Professional Documents
Culture Documents
01. Anterior longitudinal ligament - attached to body and intervertebral disc. More strongly to body.
Extend from base of skull to anterior of sacrum
02. Posterior longitudinal ligament - attached to body and intervertebral disc. More strongly to disc.
Starts from axis. Lines part of anterior surface of vertebral canal
03. ligamentum flavum - connects laminae. Lines the posterior surface of vertebral canal
04. Interspinous ligament - unites spinous processes along adjacent borders. Well developed in
lumbar region
05. Supraspinous ligament - joins tips of spinous processes up to spine of C7
06. Intertansverse ligament - joins transverse processes along adjacent borders
07. ligamentum nuchae – extends from C7 spine to the external occipital protuberance.
T9 ●inferior costal
facet missing
T10 ●superior costal
facet complete
Thoracic spines
T1, T2—horizontal
T3, T4—oblique
T5-T8—vertical
T9, T10—oblique
I. Intervertebral joints
a) Zygapophyseal joints - between superior & inferior articular facets
Synovial joint
Cervical region: articular facets lie obliquely
Thoracic region: articular facets lie in an arc
In lumbar region: articular facets interlock
b) intervertebral discs -
between vertebral bodies
secondary cartilaginous
thickest in lumbar region
outer: annulus fibrosus - fine meshwork of collagen & fibrocartilage
- Weak posterolaterally
inner: nucleus pulposus – semiliquid gelatinous substance
- Remnant of notochord
Transverse ligament
a broad, strong band which arches across the atlantal ring behind the dens
attached on each side to the medial surface of the lateral mass of the atlas
in the median plane prolonged upwards to basiocciput and downwards to body of
axis forming cruciform ligament
prevent dislocation of dens
apical ligament – from tip of dens to foramen magnum
apical ligament – from sides of dens to sides of foramen magnum. Resists rotation.
Clinicals
Death in execution is due to the rupture of the transverse ligament of dens, which then
compress the medulla oblongata & spinal cord
Cervical spondylosis
Due to the horizontal position of articular facets, dislocation occurs without fracture
Anterior margin - intervertebral disc & adjacent bodies of vertebra above & below
Vertebral canal
Formed by continuation of vertebral foramina
Boundaries - anterior wall: vertebral bodies, intervertebral discs & posterior longitudinal
ligament
-posterior wall: ligamentum flavum & vertebral arches.
Contents – spinal cord
Meninges
Internal vertebral venous plexus
Epidural/extradural space – a potential space containing extradural fat, connective tissue & internal
vertebral venous plexus
Clinical
• 1/5 of height of vertebral column – Intervertebral disc
01. Disc prolapse [slip disc]
Trauma Degenerative disease Sudden stress
04. Spondylolysis
• Inf. articular processes, spine & laminae vertebra separate from rest of body due to
fracture of pars interarticularis (loss of scotty dog appearance)
Common in L5
05. Spondylolisthesis
• Forward slippage of vertebral body
08. Epidural anaesthesia – anaesthetics can be injected into epidural space for surgical
requirements
09. Spread of cancers – prostatic, breast & cervical cancers can spread into external vertebral
venous plexus via valveless connections & then into any part in the body
Clavicle
Special features
- Only long bone which lies horizontally
- Subcutaneous throughout
- 1st bone to start ossifying
- Only long bone which has a membranous ossification
- Only long bone which has 2 primary centers of
ossification
- Generally, has no medullary cavity
- The supraclavicular nerves crossing it can be rolled
against the bone
Shaft
o Lateral 1/3
Flattened from above downwards
Anterior border concave forwards, posterior
border convex backwards
Superior surface is subcutaneous, inferior
surface has an elevation – conoid tubercle, and
a ridge- trapezoid ridge
o Medial 2/3
Rounded
Anterior surface convex forwards
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Posterior surface smooth
Superior surface rough in the medial part
Inferior surface has a rough oval impression at the medial end for costoclavicular
ligament
Lateral half of the inferior surface has a longitudinal subclavian groove. The nutrient
foramen lies in the lateral part of the groove
The ends
o Medial
Sternal end
Quadrangular
Articulates with the clavicular notch of the manubrium to form the sternoclavicular
joint
Articular surface extends up to the inferior aspect to articulate with the 1 st costal
cartilage
o Lateral
Acromial end
Flatten from above downwards
Has a facet for the acromion and forms the acromioclavicular joint
Attachments
Margins of the lateral and medial articular surfaces give attachment to the joint capsules
Clinical
Fracture
- Commonest site – junction between medial 2/3 & lat. 1/3 (weakest point) between
costoclavicular and coracoclavicular ligament
- Caused by falling on the outstretched hand
- Lat. fragment – displaces downwards by the weight of the upper limb
- Med. fragment – displaces upwards by the action of sternocleidomastoid
- Adductor muscles spasm – adduction of the arm
Dislocation
Weight transmission
1. Scapula
2. Coracoclavicular ligament
3. Clavicle
4. Sternoclavicular joint to sternum or
5. Costoclavicular ligament to first rib
Side determination
2 surfaces
1. Costal – subscapular fossa. Directed medially and forwards. Have three longitudinal ridges.
2. Dorsal – spine of scapula is present. It divides the surface into supraspinous and infraspinous
fossae. Two fossae connected through spinoglenoid notch laterally.
3 borders
1. Superior- thin and short. Suprascapular notch present at the root of coracoid process
2. Lateral- thick. At the upper end the infraglenoid tubercle is present
3. Medial- thin.
3 processes
1. Spine- triangular. Has 3 borders and 2 surfaces. The posterior border is called the crest of
spine which has upper and lower lips.
2. Acromion- has medial and lateral borders. Has superior and inferior surfaces. Has an oval
facet for clavicle.
3. Coracoid- directed forwards and slightly laterally. Directly inferior to lateral part of the
clavicle. Bent. Has an atavistic type of epiphysis.
Muscle attachments
Clinical
Winging of scapula
Due to paralysis of serratus anterior
Medial border becomes unduly prominent.
Arm cannot be abducted beyond 90 degrees.
Scaphoid scapula
Development anomaly.
Medial border is concave.
Fracture
Rare.
Strong thick covering of muscles protects it.
Only by direct and severe violence.
Suprascapular nerve and vessels
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Navy under the bridge (superior transverse scapular ligament), Army over the bridge
Movements
Humerus
Side determination:
Upper end
Shaft
Lower end
Inferior surface- area for scaphoid and lunate which take part in forming the wrist joint
Clinical – Radius
Side determination
The upper end is hook like with its concavity directed forwards
Lateral border is sharp and crest like
Pointed styloid process lies posteromedial to the rounded head of ulna at its lower end
Upper end
Presents :
Olecranon process- projects up from the shaft
Coronoid process- just below olecranon process
Trochlear notch-articular surface for trochlear of humerus to form the elbow joint
Radial notch- for head of radius
Shaft
3 borders
Lateral border is the sharpest
Posterior border is subcutaneous and is not crossed and therefore can be exposed surgically
Anterior border terminates at the medial side of styloid process
Clinical-
Dislocation of the elbow by a fall on the outstretched hand with the elbow slightly flexed. -
Fracture of the olecranon is common and is caused by fall on the point of the elbow
Miner’s elbow / Student’s elbow
Green stick fractures (common in children)-one side of bone is broken &other side only bent
Extensor compartment
Superficial layer
Muscle Origin Insertion Innervation Function
Flexor Humeral head-medial Pisiform bone and then Ulnar nerve (C7, Flexes and adducts the
carpi epicondyle of via pisohamate and C8, T1) wrist joint
ulnaris humerus; pisometacarpal
ulnar head-olecranon ligaments into the
and posterior border hamate and base of
of ulna metacarpal 5
Palmaris Medial epicondyle of Palmar aponeurosis of Flexes wrist joint;
longus humerus hand because the palmar
aponeurosis anchors skin
of the hand, contraction
of the muscle resists
shearing forces when
gripping
Flexor Medial epicondyle of Base of metacarpals 2 Flexes and abducts the
carpi humerus and 3 Median nerve wrist
radialis
Pronator Humeral head-medial Roughening on lateral Pronation
teres epicondyle and surface, midshaft of
adjacent supra- radius
epicondylar ridge;
ulnar head-medial
side of coronoid
process
Intermediate layer
Extensor compartment
Superficial layer
Muscle Origin Insertion Innervation Function
Brachioradial Proximal part of Lateral surface of Radial nerve (C5, Accessory flexor of elbow
is lateral supra- distal end of C6) before division joint when forearm is
epicondylar ridge of radius into superficial and midpronated
humerus and deep branches
adjacent
intermuscular septum
Extensor Distal part of lateral Dorsal surface of Radial nerve (C6, Extends and abducts the
carpi radialis supra-epicondylar base of C7) before division wrist
longus ridge of humerus and metacarpal 2 into superficial and
adjacent deep branches
intermuscular septum
Extensor Lateral epicondyle of Dorsal surface of Deep branch of Extends and abducts the
carpi radialis humerus and base of radial nerve (C7, wrist
brevis adjacent metacarpals 2 C8) before
intermuscular septum and 3 penetrating
supinator muscle
Extensor Lateral epicondyle of Four tendons Extends the index, middle,
digitorum humerus and which insert via ring and little fingers
adjacent extensor hoods Can also extend the wrist
intermuscular septum into the dorsal Posterior
and deep fascia aspects of the interosseous nerve
bases of the (C7, C8)
middle and distal
phalanges of the
index, middle,
Deep layer
1) Pectoralis Major-
clavicular head - the arm is abducted to 90
degrees or more
The patient pushes the arm forwards against
resistance.
sternocostal head- the arm is abducted to 60
degrees
Adduct against resistance.
The contracting heads can be seen and felt.
3) Latissimus Dorsi-
The arm is abducted to a right angle
Adducted, extended and medially rotated
against resistance
The lateral part of the muscle below the
posterior axillary fold can be seen and felt
contracting.
The muscle can also be felt to contract here when the patient coughs.
B. Muscles of shoulder
2) Deltoid- The arm is abducted against resistance and the muscle is seen and
felt.
1) Biceps Brachii- With the forearm supinated the elbow is flexed against
resistance. The contracted muscle in the arm, and the tendon and
aponeurosis at the elbow are easily palpable.
1) Triceps- The flexed forearm is extended against resistance and the muscle
seen and felt.
1) Pronator Teres- From the supine position the forearm is pronated against
resistance and the muscle palpated at the medial margin of the cubital fossa.
2) Flexor Carpi Radialis- The wrist is flexed and abducted against resistance and
the tendon is easily seen and felt.
4) Flexor Carpi Ulnaris- The wrist is flexed and adducted against resistance and
the tendon palpated.
1) Flexor Digitorum Profundus- With the fingers extended and the hand lying
supine on the table, the distal interphalangeal joints are flexed against
resistance with the middle phalanx held in extension.
2) Flexor Pollicis Longus- With the proximal phalanx of the thumb held steady,
the distal phalanx is flexed against resistance.
1) Brachioradialis- With the forearm in the midprone position the elbow is flexed
against resistance; the muscle can be seen and felt
Synovial joints
Articular surfaces
Plane- inter metatarsal
Hinge- humero-ulnar, interphalangeal
Pivot- atlanto-axial
Bicondylar- knee, TM joint
Ellipsoid- metacarpo-phalangeal
Saddle- thumb carpo-metacarpal
Ball and socket- shoulder
Articular surfaces – Shallow, too small glenoid fossa (deepened by glenoidal labrum)
Head of humerus (1/3 of a sphere) covered by hyaline cartilage
Capsule – Collagen
Pain sensitive
Strong but lax (doesn’t strengthen the joint enough)
Attachment
Proximal – proximal margins of glenoidal labrum (margin of the glenoid fossa)
Distal – anatomical neck of humerus except inferiorly upto surgical neck
Superiorly allows the passage of biceps tendon
Supported by rotator cuff muscles SITS (least supported inferiorly – anteroinferior
dislocation is common)
Ligaments Extracapsular
*Transverse humeral ligament (bridges bicipital groove)
*Coracoacromial ligament
Superior
Intracapsular
*Glenohumeral lig. Middle
Inferior
Stability-
Muscular factors
1.Rotator cuff - Tendons of Supraspinatus, Infraspinatus, Subscapularis, Teres minor
blends with each other & joint capsule (doesn’t cover inferiorly)
2. Long heads of biceps and triceps- Only support inferiorly is tendon of long head of triceps
Ligamentous factors
3. coracoacromial arch- superiorly secondary socket for the head of the humerus
4. Glenoid labrum Deepning the glenoid cavity
Bony stability is less.
Mobility -
1. 4:1 disproportion between head of humerus and glenoid fossa
2. Strong yet lax capsule
Movements - Abduction
*initiated by Supraspinatus (1st 15o)
*up to 90o - Deltoid
*up to 180o - Serratus anterior & Trapezius
After 30° of abduction, Scapula starts to rotate (Humerus : Scapula = 2 : 1 ) SITS also plays
a role here by providing stability to head of humerus
Clinicals
More prone to dislocation than any other joint
Dislocation – inferiorly (usually occurs in abducted
position)
No rotator cuff inferiorly therefore less
supported.
Reduced by Kocher’s method
Axillary nerve can be damaged,
o Deltoid is paralyzed loss of abduction
o Sensory loss over badge area
o Rounded contour is lost. Acromion becomes
prominent
Supra spinatus tendinitis - Painful arch – 60° - 120°
Subacromial bursitis - Tenderness over greater tuberosity beneath the Deltoid, disappears when
the arm is abducted
Shoulder tip pain – due to irritation of respective dome of diaphragm (phrenic nerve carrying
impulses from peritoneum and supraclavicular nerves from skin above shoulder have common
C3 and C4 roots)
Osteomyelitis of upper end of humerus can spread to shoulder joint by direct spread due to the
capsule attachment
Frozen shoulder – Common occurrence
Two layers of synovial membrane adhere together
Usually in patients aged 40-60
Complaints: Stiffness of SJ/Increasing pain/restriction of movement
Spontaneous healing or physiotherapy done
Elbow Joint
Clinicals
Interrosseus membrane
Interrosseus membrane – downwards and medially from radius to ulnar
Superior aperture- posterior interosseous vessels
Inferior aperture- anterior interosseous vessels
Other than providing attachments for muscles and binding bones, transmits forces from radius to
ulna.
Wrist Joint
Biaxial, synovial, ellipsoid
Between lower end of radius (+articular disc
of inferior radioulnar joint), scaphoid,
lunate,
triquetral (SLT)
Sternoclavicular Joint
Type - Atypical Synovial, ball and socket
Articular facets – covered by fibrocartilage
Has complete articular disc
Ligaments
1) Costoclavicular ligament
- Main stabilising factor
- It transmits the weight from clavicle to axial skeleton
2) Anterior and posterior sternoclavicular ligaments
3) Interclavicular ligament
Clinical
Paralysis of Serratus anterior causes ‘winging’ of the Scapula
- Medial border of scapula – unduly prominent
- Arm can’t be abducted beyond 90
Pec. Major testing (Pec. Major is the only muscle of the upper limb to be supplied by all 5 segments
of brachial plexus)
- Clavicular head - attempt to lift a heavy table
- flex arm to a 90 against resistance
- sternocostal head – try to depress a heavy table
- extend the flexed arm against resistance
press fists against each other
Blood Supply
Arterial supply
1) Branches of axillary artery
I. Superior thoracic
II. Acromiothoracic - Pectoral branch
III. Lateral thoracic- Main
2) Branches of internal thoracic artery – Those of 2nd & 3rd
spaces are the largest
3) Branches of posterior intercostal arteries
Developmental abnormalities
Amastia
Athelia
Polymastia
Polythelia
Gynecomastia (XXY- Klinefelter)
Clinical
-Superficial lymphatics communicate across the midline Cancer can spread from one breast
to another
SCAPULAR REGION
Muscle Origin (Scapula) Insertion Nerve Supply Action
(Humerus)
CLINICALS
Intramuscular injections -- to lower part of the deltoid muscle (avoid injury to axillary nerve)
Muscle testing --- ask to abduct against resistance
INTERMUSCULAR SPACES
Quadrangular space
TERES MINOR # Axillary nerve
# Post. Circumflex humeral
vessels
TERES MAJOR (Surgical neck)
(shaft)
M Lower triangular space L
# Radial nerve
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TRICEPS-LONG HEAD
Scapular movements
Protraction- Serratus anterior
Retraction- Rhomboids, Trapezius middle fibers
Medial rotation- Weight of upper limb, Levator scapulae, Rhomboids
Lateral rotation- Serratus anterior, Trapezius
Elevation- Trapezius, Levator scapulae
Depression- Weight of upper limb, Pec. Minor, Latissimus dorsi, Trapezius
Scapular Anastomosis
Fracture of Scaphoid
- Caused by falling on the palm with the hand abducted
(There the scaphoid lies directly facing the radius)
- May cause tenderness of anatomical snuff box (floor is
formed by scaphoid)
- 1/3 of cases – blood supply enters distally along waist
- Dislocated carpus may then reduce spontaneously and tilt it over; its distal surface facing
forwards (dislocation of the lunate)
Superficial fascia
Dense fibrous bands
Bind skin to palmar aponeurosis
Contains a subcutaneous muscle, Palmaris brevis
Deep fascia
Wrist - flexor retinaculum
Palm - palmar aponeurosis
Palmar aponeurosis
The deep fascia in the central region of the palm, reinforced by a superficial layer of longitudinal
fibers continuous with the tendon of the palmaris longus muscle and by deeper transverse fibers
Triangular in shape
Proximal apex blends with flexor retinaculum & continuous with the tendon of palmaris longus
Distally divides into 4 strips; 1 for each finger
Distally divides into 2 layers
Superficial layer – blends with skin
Deep layer – 4 slips- blends with fibrous flexor sheaths
No slip for thumb – more mobile (but plantar aponeurosis has)
Fingers fibrous flexor sheaths (see grants pic)
Forms a blind fibro-osseous tunnel – tendons of FDS and
FDP and synovial sheath lie there.
2) Volkmann’s contracture
Follows ischemia and subsequent fibrosis and contraction of the long flexor and extensor muscles of
the forearm
Deformities
Flexion at the wrist - since the flexors of the wrist are bulkier than the extensors,
their fibrous contraction is greater
Extension at the metacarpophalangeal joints - due to the contracture of the long
flexors inserted into the proximal phalanges
Flexion at the interphalangeal joints - due to the contracture of long flexors;
inserted into the distal and middle phalanges
Extrinsic muscles
Intrinsic muscles
Thenar muscles
Muscle Nerve Action
Abductor pollicis median nerve (recurrent abduction of thumb C/M & M/P joints
brevis branch) [associated with medial rotation]
Flexor pollicis superficial - median flexion of thumb
brevis nerve deep head may be
by ulnar nerve
Opponens pollicis median nerve (recurrent opposition - thumb [flexion, medial rotation]
branch)
Hypothenar muscles
Muscle Nerve Action
Opponens digiti minimi ulnar nerve deep branch opposition with thumb,
lat. rotation
Flexor digiti minimi flexion of M/P joints
brevis
Abductor digiti minimi abduction of M/P joints
1) Flexion at the metacarpophalangeal and interphalangeal joints - by flexor pollicis longus and
brevis
2) Extension at the metacarpophalangeal and interphalangeal joints - by extensor pollicis
longus and brevis
3) Palmar abduction (abduction) - by abductor pollicis brevis; thumb moves away from the
index finger in a plane perpendicular to the palm
4) Radial abduction (extension) - by abductor pollicis longus and extensor pollicis brevis
5) Adduction - by adductor pollicis; further transpalmar adduction is by flexor pollicis brevis
6) Opposition - a composite movement making the thumbnail lie parallel with the nail of the
opposed finger
6) The lumbricals and interossei are tested by asking the subject to flex the fingers at the
metacarpophalangeal joints against resistance
After exiting the carpal tunnel, the tendons of the flexor digitorum superficialis & profundus cross the
palm & enter fibrous sheaths on the palmar aspect of the digits.
These fibrous sheaths
Begin proximally, anterior to the MP joints, and extend to the distal phalanges
Are formed by annular ligaments & cruciate ligaments, which are attached posteriorly to the
margins of the phalanges and to the palmar ligaments associated with the MP & IP joints
Hold the tendons to the bony plane & prevent the tendons from bowing when the digits are flexed
is a common synovial sheath, enclosing the flexor tendons of fingers (FDS& FDP)
pass deep to flexor retinaculum
extent upwards -2”-3” into forearm
Downwards –upto middle of shafts of metacarpal bones into palm
Lower medial end- continuous with digital synovial sheath of the little finger
Seems like tendons have invaginated the bursa laterally.
Clinical:
Infection of little finger infection of ulnar bursa forearm space of parona Hour glass swelling
2. Radial bursa
Synovial sheath of flexor pollicis longus tendon
Extent – Upwards – 2”-3” into forearm
Downwards – up to distal phalanx of thumb
Cinical:
Whitlow
infection of the pulp space rising pressure in space (not much space) severe pain
If neglected
Occlusion of vessels by pressure
At each of the skin crease of the fingers, the skin is bound down to the underlying
flexor sheath so that the pulp over each phalanx is in a separate compartment cut off
from its neighbors. So usually infection doesn’t spread much. Infection may however track from one space to another
along the neurovascular digital bundles if the infection is not treated well.
Midpalmar space
Tenosynovitis of middle & ring fingers Web infection
(spread proximally
through lumbrical canal)
Thenar space infection (usually the infection in the web of thumb or untreated infection in the
pulp space of thumb or index finger)
Rectangular
Just above the wrist
In front of pronator quadratus deep to long flexor tendons
Extent
Proximal - oblique origin of flexor digitorum superficialis
Distal - Flexor retinaculum
communicates with
- Midpalmar space
- Thenar space
proximal part of ulnar & radial bursae protrudes into forearm space
3 web spaces lie in the distal part of the palm between the bases of proximal phalanges of four fingers
Bounded by superficial transverse metacarpal ligament above & deep transverse metacarpal ligament
below.
Extend proximally up to the metacarpophalangeal joint.
Contents from superficial to deep
- Superficial transverse metacarpal ligament
- Proper palmar digital nerves
- Proper palmar digital arteries
- Digital slips of palmar aponeurosis
- Lumbricals
- Deep transverse metacarpal ligament
Incised to drain palmar space infections
Web of thumb
- Lacks both superficial & deep transverse metacarpal ligaments
- Contain the heads of adductor pollicis & 1st dorsal interosseous
- Princeps pollicis & radialis indicis arteries
- Sensory loss over the skin in radial nerve palsy
Clinical:
02)T/F
a) In whitlow distal 1/5th may get necrosed
b) In infections of mid palmar spaces swelling can be seen in the dorsal surface
c) Severe throbbing pain in pulp space infections is due to tight compartments formed by
subcutaneous fat
Plexus of nerves formed by the ant. Primary rami of the C 5, C6, C7, C8, T1 nerve roots with
contributions from the C4 and T2 nerve roots.
Musculocutaneous Nerve
Root values are C5, C6, C7 anterior primary rami.
Main nerve of the front of the arm & cutaneous supply to lateral side of forearm.
Originates from the lateral cord of the brachial plexus at the lower border of Pect Minor.
In the axilla lies lateral to the 3rd part of the axillary artery & lateral root of median nerve.
It supplies the Coracobrachialis.
Then pierces the Coracobrachialis and leaves the axilla.
Enters the anterior compartment of the arm, runs between Brachialis & Biceps brachii.
Gives motor branches to Biceps brachii & Brachialis.
At the level of the elbow, becomes superficial by piercing the deep fascia lateral to the tendon of
biceps and continues as the lateral cutaneous nerve of forearm.
Gives articular branches to the elbow joint through the motor branch to brachialis.
It also gives articular branches to shoulder joint.
Axillary Nerve
Root values are C5, C6 anterior primary rami.
Origin in axilla from posterior cord of brachial plexus, posterior to the axillary artery.
Leaves axilla through the quadrangular space. (supplies no structure within axilla)
Below the capsule of shoulder joint.
Gives articular branches to shoulder joint.
Accompanied by posterior circumflex humeral vessels.
Passes behind the surgical neck of humerus.
Divides into anterior and posterior divisions.
Anterior division – Winds around the surgical neck of humerus with posterior circumflex
humeral vessels.
Supplies Deltoid.
Posterior division – Supplies Teres Minor.
Cutaneous supply to skin over lower half of deltoid via Upper lateral cutaneous nerve of arm.
Damaged in inferior dislocation of shoulder, Fracture of the surgical neck of the humerus & Misplaced
injection into deltoid.
Paralysis of deltoid.
Arm can’t be abducted beyond 15 degrees.
Sensory loss over lower half of deltoid. (regimental badge sign)
Greater tubercle becomes prominent. (atrophy of the deltoid) - flattened contour of shoulder.
Clinical
Cutaneous loss-
Vasomotor changes-
Oedema
Pigmentation of skin
Friable nails
Dryness of skin
1) Unable to pick a pin with thumb & index finger. (Due to inability to oppose thumb)
2) Pen test for abductor pollicis brevis.
Lay the hand flat on a table, palm directed upwards. Patient is unable to touch a pen held in
front of the palm by a thumb.
Clinical
Damage at wrist
Commonest.
Produces Ulnar claw hand. (Claw hand - Hyperextension at m/p
joints due to paralysis of interossei & lumbricals, Flexion at I/p
joints)
Sensory loss – medial 1/3rd of palm & medial 1 ½ fingers including
nail beds.
Vasomotor & trophic changes.
Ulnar nerve gets entrapped between two heads of FCU leading to ulnar claw
hand, loss of hypothenar eminence and muscle paralysis.
Ulnar paradox
If injured @elbow, clawing of fingers is less, because medial half of FDP is also paralysed.
If injured @wrist, clawing is more, because intact FDP flexes digits more.
Distal more clawing; Proximal less clawing.
Complete claw hand – both ulnar and median nerves get paralysed.
Clinical Testing
C6, C7, C8
C7, C8
2nd part
Branches
SALSAP
1st part -skin -serratus ant. -lateral & pos. -Axillary vein
-superf. fascia -medial cord of cords of brachial
-deep fascia brachial plexus plexus
-pec major with medial
- clavipectoral pectoral nerve
fascia -1st intercostal sp.
2nd part -skin -post. Cord of -lateral cord of -Axillary vein
-superf. fascia brachial plexus brachial plexus -medial cord of
-deep fascia -subscapularis -coracobrachialis brachial plexus
-pec major -medial pectoral
-pec minor nerve
Clinicals
These are anastomosis between -1st part of Subclavian artery
-3rd part of Axillary Artery
They provide a collateral circulation when distal part of subclavian A. or proximal part of Axillary A. is blocked
Important in coarctation of the Aorta
2) Brachial Artery
Continuation of the Axillary Artery.
Extends from the lower border of Teres Major to neck of the radius.
In the proximal arm, lies on medial side.
In the distal arm, it moves laterally to assume a position midway between lateral epicondyle and the
medial epicondyle of the humerus.
It crosses anteriorly to the elbow joint, lies immediately medial to the tendon of biceps brachii muscle.
Surface marking – Arm abducted to eight angle, line from middle of clavicle to the midpoint between
the humeral epicondyle. Readily palpable.
4) Ulnar Artery
Main artery of forearm.
Starts at the level of neck of Radius.
Oblique in upper 1/3 & vertical in lower 2/3.
Runs on medial side of forearm with ulnar nerve (in lower
part) under flexor carpi ulnaris muscle upon flexor
digitorum profundus.
Median nerve crosses superficially to ulnar artery
seperated by deep head of Pronator teres.
Leaves forearm superficial to flexor retinaculum deep to
volar capal ligament
It ends by dividing into superficial palmar branch, which is the main continuation of the artery, and
deep palmar branch
Superficial branch continues as superficial palmar arch in the hand.
Superficial
Deep to palmar Superficial
arch
- Palmaris brevis - Flexor digiti minimi
- Palmar - Flexor tendons of fingers
aponeurosis - Lumbricals
- Median nerve- digital branches
Branches – - to medial 3 ½ finger
3 common digital branches –joined to palmer metacarpal arteries from deep palmer arch
1 proper digital branch
5) Radial Artery
DEEP
PALMAR
Deep to Superficial to
ARCH
-Metacarpals-shafts-proximal parts
-adductor pollicis- oblique head -interossei
-long flexor tendons of fingers
-lumbricals
Deep branch of ulnar nerve lies within the concavity of arch
Branches
1. 3 palmar metacarpal arteries – join with lateral 3 digital branches to form
common digital branches,
Each common digital branch divides into proper digital branches & supply digits
Clinical
Allen’s test
To test the patency of each ulnar & radial arteries, related to blood supply of the hand
Clench fist occlude radial & ulnar arteries fist is released skin of palm pale release one artery
Elbow Anastomosis
Wrist – radius (ant. Border) laterally Junction – upper 1/3 & lower 2/3 of
Flexor carpi radialis tendon medially forearm medial border
(Radial pulse felt) Lateral to pisiform
Medial end
Basilic vein Lateral end
(Post axial) Cephalic vein
(preaxial)
-runs along medial side of arm & forearm -lies in the roof of anatomical snuff box
-Pierces deep fascia at the middle of arm -Lateral border of upper limb
-continues as axillary Vein at the lower -Most of the blood drains into basilic vein via
border of teres major median cubital vein
-Can be used for emergency venous cut
down at the deltopectoral groove.
-It pierces clavipectoral fascia and drains
into axillary vein
There's a constant valve where cephalic vein drains into axillary vein.
Pyramidal shaped region situated between the upper part of arm and side of chest wall.
Boundaries
1)Anterior (Pectoral) group •Along the lateral thoracic •Upper ½ of the anterior wall
vessels of the trunk
•Along lower border of pec •Major part of the breast
minor
2)Posterior (Scapular) group •Along subscapular vessels •upper ½ of the posterior
•On the posterior fold of wall of the trunk
Axilla •Axillary tail of the breast
3)Lateral group •Along the upper part of the •Upper limb
humerus
•Medial to axillary vein
4)Central group •Lie in the fat of the upper •Anterior, posterior & lateral
Axilla groups
•Floor of axilla
5)Apical (infraclavicular) •Lie deep to clavipectoral •Central group
group fascia •Upper part of the breast
•along the axillary vessels •The thumb and its web
Anterior, posterior, lateral groups drain into the central group which in turn drains
into the apical group.
Long thoracic and intercostobrachial (supplies skin of upper medial side of arm and axilla) nerves
(These two nerves and thoracodorsal nerve can get damaged in surgeries of the axilla)
*T2 dermatome
Axillary fat and areolar tissue
Clavipectoral fascia
Fibrous sheet situated deep to the clavicular portion of the Pectoralis Major muscle.
Extends- From clavicle (above) to the axillary fascia (below)
Upper part- Encloses subclavius
Lower part- Encloses pec.minor
Below pec minor->suspensory ligament
C- Cephalic vein
A- Acromiothoracic artery
L- Lateral pectoral nerve
L- Lymphatics
Axillary Sheath
Continuation of prevertebral fascia
Encloses brachial plexus, axillary artery. But NOT axillary vein.
Clinical
CUBITAL FOSSA
-Triangular, hollow space
-in front of elbow
Boundaries
Deep fascia
Bicipital aponeurosis
Content (MBBS)
M to L-Median nerve N
-Bicipital tendon T
Median nerve- Supply flexor carpi radialis, palmaris longus, flexor digitorum superficialis
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Leaves fossa between the two heads of pronator teres
Radial Nerve
-Supinator
Clinicals
2.most superficial
Distal row
Flexor Retinaculum
Clinical
Carpal tunnel syndrome
Symptoms caused by compression of the median nerve within the carpal tunnel due to any lesion
diminishing the size of the compartment
Symptoms
1. Motor changes - ape like thumb deformity/wasting of thenar eminence
loss of opposition
Extensor Retinaculum
Attachment – Laterally – Lower part of sharp anterior border of the radius
Triquetral
Pisiform
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Anatomical Snuffbox
Boundaries
Contents
Radial artery
Superficial branch of radial nerve
Cephalic vein
Pubis
The body of the pubis projects laterally as a superior ramus which joins the ilium and ischium at
the acetabulum
Inferior ramus fuses with the ischial ramus medial to the obturator foramen.
The symphyseal surface of the body forms the secondary cartilaginous joint that constitutes the
pubic symphysis
The upper border of the body is the pubic crest.
It is marked laterally by a prominence – the pubic tubercle.
From the pubic tubercle two ridges diverge laterally onto the superior ramus.
The upper ridge, sharp, is the pectineal line; it forms part of the pelvic brim and joins the arcuate
line of the ilium.
Pectineus arises from the pectineal line and the adjacent surface of the superior ramus.
The lower ridge, more rounded, is the obturator crest.
Below the obturator crest on the pubic ramus is the obturator groove, which lodges the
obturator nerve.
The pubic tubercle receives the attachment of the inguinal ligament,
Ischium
The ischium is an L-shaped bone
The body joins with pubis and ilium at the acetabulum and extends down to the ischial
tuberosity; it supports the sitting weight.
The obturator membrane is attached to the margin of the foramen.
Outer surface - obturator externus inner surface – obturator internus
The spine of the ischium projects medially to divide the greater from the lesser sciatic notch
below it.
The sacrospinous ligament is attached to it, contributing to conversion of the greater sciatic
notch into the greater sciatic foramen
The lesser sciatic notch lies between the spine and the ischial tuberosity.
It is bridged by the sacrotuberous ligament, which with the sacrospinous ligament converts the
notch into the lesser sciatic foramen
Obturator internus emerges through this foramen into the buttock, and the internal pudendal
vessels and nerve pass forward into the perineum.
The ischial tuberosity
Sex determination
Upper end
Consists of head, neck, greater and lesser trochanters
Head
More than half a sphere
Articulates with acetabulum to form hip
joint
Contains a roughened pit behind and
below the center of the head called
fovea
Neck
Connects head with shaft
Upper border is concave, horizontal and
meets shaft at greater trochanter
Lower border is straight, oblique and
meets shaft near lesser trochanter
Anterior surface is flat and meets shaft
at intertrochanteric line and is entirely
intracapsular
Posterior surface is convex vertically
and concave horizontally and meets
shaft at intertrochanteric crest. Medial half is intracapsular
Makes an angle with the shaft (125° in adults)
Angle larger in males
Angle facilitates movement of hip joint
Calcar femorale is a thickening of bone present along its concavity which strengthens it
Intertrochanteric line
Prominent roughened ridge
Continuous below with spiral line
Intertrochanteric crest
Smooth rounded ridge
Ends at lesser trochanter
Rounded elevation present a little above the crest’s middle – quadrate tubercle
Shaft
Cylindrical (middle part triangular)
Directed obliquely downwards and medially – therefore brings knees closer to center of gravity
Lower end
Widely expanded to form 2 large condyles
Anteriorly the 2 condyles are united and are in line with the front of the shaft
Posteriorly separated by a deep gap – Intercondylar fossa
Walls of intercondylar fossa
Lateral surface of medial condyle – large oval facet for posterior cruciate ligament
Medial surface of lateral condyle – small oval facet for anterior cruciate ligament
Articular surface partially covers 2 condyles
Articular surface for patella
Covers the anterior surface of both condyles
Extends more on the lateral condyle than the medial condyle
Tibial surface
Covers the inferior and posterior surfaces of the 2 condyles
Merge anteriorly with patellar surface
Lateral condyle Medial condyle
Surfaces of the medial and lateral condyles that articulate with the patella form a V-shaped trench
which faces anteriorly. Lateral surface of trench is larger and steeper
Pertrochanteric – Extracapsular
Basal
Cervical. Intracapsular
Subcapital
2.Midshaft fractures
Considerable shortening occurs
Due to longitudinal contracture of surrounding muscles
Proximal segment flexed by iliacus and psoas and
abducted by gluteus medius and minimus
Distal segment pulled medially by adductors
Patella (Kneecap)
Triangular in shape with its apex downwards
Posterior surface is divided by a vertical ridge
Largest sesamoid bone of the body
Lies in the tendon of quadriceps tendon. Continues as ligamentum patellae
from apex
When set on a table it rests on the larger lateral surface (side
determination)
Posterior surface is articular in its upper three-fourths and covered with
hyaline cartilage
Separated from the skin by prepatellar bursa
Clinical
Has a natural tendency to dislocate laterally
(Patellar ligament vertical, but pull of quadriceps is oblique)
But it is prevented by,
1. Bony factors: prominent articular surface of the lateral femoral condyle
2. Muscular factors: medial pull of the lower most fibres of vastus medialis which
insert almost horizontally along medial margin
3. Ligamentous factors: tension of medial patella retinaculum
UPPER END
Expanded side to side by 2 massive condyles
1)Medial condyle
Larger
Superior articular surface is oval, longer anteroposteriorly, concave
with medial femoral condyle(central) and medial meniscus(peripheral)
Lateral margin of articular surface is raised to cover the medial intercondylar tubercle
Groove on back Semimembranosus tendon
2)Lateral condyle
Superior articular surface is nearly circular
With lateral femoral condyle(centre) and lateral meniscus(peripheral)
Medial margin of articular surface is raised to cover the lateral Intercondylar tubercle
Postero-inferior aspect articulates with the fibula. Fibula facet is flat, circular
Superior to fibular facet groove for popliteus
tendon
Anterior aspect Smooth ‘Gerdy’s tubercle’
ITT
3)Intercondylar area
Tibial plateau rough and elevated between
condylar surfaces Intercondylar eminence
Intercondylar eminence grooved antero-
4)Tuberosity
Upper Smooth Quadrate tubercle via patella ligament
Lower Rough Subcutaneous Subcutaneous infrapatellar bursa
Inferior Continuous with anterior border of shaft
SHAFT
Triangular in Cross section
1)Borders
Anterior Sharp, crest-like, subcutaneous & forms shin
Tibial tubercle anterior border of medial malleolus
Medial convexity above behind it Tibialis anterior on upper 2/3 of ext/lateral
surface
Lower smooth deep fascia of leg
Posterior Oblique line in upper part Soleal line run to lateral border
Soleus Soleal line and mid 1/3 of posterior surface
Above soleal line Popliteus(medial)
Below soleal line Divided by vertical ridge into lateral and medial parts
Lateral Tibialis Posterior Medial FDL
Upper end of ridge Nutrient foramen Branch of Posterior tibial artery
LOWER END
Rectangular in cross section
Medially elongated Medial malleolus GSV and Saphenous nerve in front
Anterior bare Crossed by TA, EHL, Anterior tibial artery, Deep peroneal nerve, EDL, PT
Lateral Fibular notch(triangular) Inter tibiofibular ligament
Posterior Tibialis Posterior (which lies in a groove), FDL, FHL
Inferior Saddle shape articular surface from talus up to medial malleolus
Medial malleolus posterior sup and deep deltoid ligament
Upper end of the shaft most common site for acute osteomyelitis.
(upper extremity of the tibial diaphysis is extracapsular; involvement of the knee
joint therefore only occurs in the late and neglected case.)
Tibia-mostly fractured at - junction of upper 2/3 and lower 1/3
- poor blood supply Union is slow / nonunion
commonest long bone to be fractured and to suffer compound injury. (Ellis)
anteromedial surface- subcutaneous therefore a donor site for bone graft
Fibula
Fibula is shorter than tibia.
Head
-has a styloid process
-Tendon of biceps femoris insertion and fibular collateral ligament attachment
Neck- Common peroneal nerve can be rolled against the neck
of the fibula, where it is commonly damaged (Foot drop)
Shaft
Lower end
-The fibula is subcutaneous for its terminal
above the lateral malleolus, which extends
more distally than the stumpier medial
malleolus of the tibia.
-Groove for peroneus longus and brevis on
posterior aspect of malleolus
side determination - by the position of malleolar fossa behind triangular articular area
1.T/F
a) The common peroneal nerve turns around the medial surface of the
neck of the fibula.
b) The shaft of the tibia unprotected posterolaterally
c) Patella has a tendency to dislocate laterally
d) Patella is developed in the tendon of quadratus femoris.
e) The posterior surface of patella contains a large medial surface.
2.T/F
a) Subcapital fractures are known to cause avascular
necrosis of femur head.
b) Fractures of femoral shaft are accompanied by
Superficial
Deep
Fascia lata
1. Iliotibial tract
Thigh – lateral side
Thickened band of fascia lata
Attachments
Superiorly 2 slips superficial lamina iliac crest – tubercle
2. Saphenous openings
knee joint
or ant. Division
All hamstrings,
- originate from ischial tuberosity
- inserted into leg bones (except adductor magnus)
- supplied by sciatic nerve - tibial part
Long head of biceps femoris & semitendinosus have a common origin in medial facet of
ischial tuberosity
Semimembranosus originates from the lateral facet of ischial tuberosity
6.T/F
a) Semimembranosus is inserted into posteromedial surface of
medial condyle of tibia
b) Reflected head of rectus femoris arises from a groove immediately
below the acetabulum
c) Semimembranosus is inserted posterior to gracilis & Sartorius into
the medial surface of tibia
d) Sciatic nerve innervates only the hamstring muscles
e) Hamstring muscles all arise from ischial tuberosity
Leg muscles are inserted to the bones of the leg
f) All hamstring
g) All the hamstrings are innervated by the tibial nerve
*pes anserinus
Loss of dorsifexion
Foot drop
*Can occur due to damage of sciatic nerve as well
5) Ligaments-
* iliofemoral ligament (strongest, anteriorly) – limits extension
Inverted “Y” shape, arise from anterior inferior iliac spine, inserted to each end of
trochanteric line
*pubofemoral ligament (inferiorly)
Arise from iliopubic junction
blend with capsule
*ischiofemoral ligament(posteriorly)(weakest)
Arise from ischium inserted onto the greater trochanter
*round ligament (ligamentum teres)
Attached to the fovea capitis.
Medial & lateral rotation – vertical axis passes through head of femur and condyle
Shaft doesn’t rotate around its own axis
8) Blood supply:
Through ligamentum teres of femur- from obturator artery
Retinacular arteries- from trochanteric anastomosis (main in adults)
Trochanteric anastomosis – medial & lateral circumflex femoral arteries, inferior gluteal &
ascending branch of 1st perforating artery
Nutrient artery of femur
10) Clinical:
*Dislocation-
# head of femur slips upwards onto the gluteal surface---lead to lurching gait (positive
Trendelenburg test)
Trendelenburg’s test-
positive when abductors (gluteus medius & minimus) of opposite side are paralyzed (eg:- in
poliomyelitis) , dislocation, fracture of head of femur
Normally when body weight is supported on one limb, the glutei of the supported side rise the
opposite unsupported side of the pelvis.
1. T/F
a) Axis of gravity passes anterior to the hip joint.
b) Tensor fascia lata stabilizes the knee joint in the extended position
c) Acetabulum has both articular and non-articular surfaces
d) Trendelenburg test is positive when the normal side is raised
e) Capsule of the hip joint extends up to the trochanteric crest.
f) A fracture of the trochanteric neck of the femur leads to avascular necrosis
g) A disease of the hip joint may cause pain in the knee because of their common
nerve supply by the femoral nerve.
3) Capsule: attached little beyond the margin of articular surface of tibia & femur. Attached to
the sides of patella and anteriorly deficient and replaced by
patella
quadriceps femoris
ligament of patella
5) Relations:
Ant- prepatellar, subpatellar, infra patellar bursae and patellar plexus
Pos- muscle forming borders of popliteal fossa and contents of popliteal fossa
Medial- semitendinosus, tendon of Sartorius and gracilis, great saphenous vein
with saphenous nerve
Laterally- biceps femoris, common peroneal nerve, tendon of origin of popliteus
Bursae: 12 bursae.
capsule communicates –
7) Stability–
Locking andstraighten
Factors----- unlocking the
mechanism
knee joint
Locking of the knee joint – result of medial rotation of femur at
the last stage of extension
Knee remains in full extension. ligaments are taut. Not much
muscular effort against gravity.
Unlocking of the knee joint-lat rotation produced by popliteus
Menisci
Ligaments
1. Intracapsular
Cruciate Ligament
Strong fibrous connection between femur and tibia
Determines Antero-posterior stability
Intra-capsular extra-synovial
2. Extracapsular ligaments
Stability continued…
Cruciate ligaments maintain anteroposterior stability
Collateral ligaments maintain side to side stability
Factors strengthening the capsule
8) Blood supply:
*From thigh- descending genicular branch of femoral,
popliteal and lateral circumflex femoral
* From leg- circumflex fibular artery
recurrent branch of ant. Tibial artery
9) Nerve supply:
* obturator *Femoral *Tibial *Common Peroneal
Clinical: C1- Collateral ligaments- Taut in full extension Medial C.L- Damaged
so liable to injury in in violent abduction
this position(less common) Lateral C.L- Damaged
in violent adduction
Ankle joint
-A Hinge joint formed between mortise formed by two malleoli and between lower end of tibia and
body of talus.
Clinical
01. Pott’s fracture
Pott’s fracture
03. posterior margin of the lower end of the tibia shears of against
02. Sprains of the ankle are almost always abduction sprains of subtalar joints. True sprains are
caused by forced plantarflexion
Collateral ligaments of ankle joint can be sprained or completely torn by forcible abduction
or adduction
Lateral collateral ligament is the most affected, because medial collateral ligament is
stronger.
**Avascular necrosis of the Talus- Occur due to forced dorsiflexion causing fracture of the neck of
talus. If arteries to body of talus go through neck only as in some cases, the body will get avascular
necrosis.
03. Dislocation of ankle joint is rare. Most stable when foot is dorsiflexed
FEMORAL ARTERY
- Chief artery of L.L
- Continuation of external iliac artery as the vessel passes under the inguinal
ligament
Surface marking
Course
Enters the thigh behind inguinal ligament at midinguinal point (Pubic symphysis & ASIS)
Just below the inguinal ligament artery is lateral to vein
Lies in lateral compartment of the femoral sheath
Passes downwards & medially
-femoral triangle
-adductor canal (deep to Sartorius)
Vein gradually crosses medial to lateral deep to artery
Saphenous nerve crosses to medial superficially
through adductor hiatus (at junction of upper 2/3rd & lower 1/3rd of thigh)
continues as popliteal artery
1. Superficial epigastric
emerges through the saphenous opening.
runs towards the umbilicus.
2. Superficial circumflex iliac
pierces the fascia lata
to the anastomosis at the anterior superior iliac spine.
3. Deep external pudendal
pierces the fascia lata
behind the spermatic cord (round ligament)
to supply the skin of the scrotum (labium majus).
4. Superficial external pudendal
emerges from the saphenous opening
in front of the spermatic cord (round ligament)
to the penis and scrotum (labium majus).
-2 deep-
1. Profunda femoris
2. Muscular branches
In adductor canal -
1. Muscular
2. Descending genicular
Lateral circumflex femoral artery Transverse: Cruciate anastomosis, pierce Vastus lateralis
4 perforating arteries
Clinical:
Ascending branch
Ascending branch
Trochanteric
OBTURATOR ARTERY
divides into anterior and posterior branches that encircle the foramen.
anastomose with each other and with the medial circumflex artery
Abnormal obturator artery replaces the pubic branch of inferior epigastric artery
Branches –
5 genicular branches
1. Medial superior genicular artery
2. Lateral superior genicular artery
3. Medial inferior genicular artery
4. Lateral inferior genicular artery
These four contribute to genicular anastomoses
Course
Branches
Branches
Anastomosis
* 4th perforating artery popliteal artery (upper muscular branch)
Arteries of foot
Posterior tibial
Runs to 1st intermetatarsal space & passes down into the sole where it joins the lateral
plantar artery to complete plantar arch
Palpated between tendons of extensor digitorum longus & extensor hallucis longus
3 branches
- 1st dorsal metatarsal artery
- Arcuate artery- 2, 3, 4 dorsal metatarsal arteries
- Lateral tarsal artery
a) The popliteal artery divides into anterior & posterior tibial arteries at the distal
border of popliteus.
b) The anterior tibial artery passes to the anterior compartment of the leg by piercing
the interosseous membrane.
c) The posterior tibial artery is the main artery of the foot.
d) The main blood supply of both tibia & fibula is from posterior tibial artery.
3 types deep
veins Superficial Veins
Perforating veins
Deep veins
Ant. Tibial
Post. Tibial
Peroneal
Popliteal
Femoral
Valves-more numerous
Supported by surrounding
powerful muscles
Accompany major arteries
More efficient
Most of the venous return
happens through the deep
vein system.
Superficial veins
Great (long) saphenous vein
Small (short) saphenous vein
- Drains into deep veins via
perforating veins
Less valves
Starts by union of medial marginal vein & the medial end of dorsal
venous arch
Runs upwards in front of medial malleolus (constant position)
Crosses the lower third of the medial surface of the tibia obliquely along
with the saphenous nerve (In varicose surgery sensory loss in medial
side of leg)
Along medial side of leg
To Posteromedial aspect of knee (hand’s breadth behind the medial border
of the patella)
Spirals forwards around the medial convexity of the thigh
Course
Starts – drains the lateral side of the dorsal venous arch of the foot and lateral margin of the foot.
Ascends behind the lateral malleolus, accompanied by the Sural nerve. (lateral to the vein)
Ascends in the subcutaneous fat along post. Aspect of leg up to midcalf level
Pierces deep fascia (anywhere between midcalf to roof of the popliteal fossa)
Drains into popliteal vein.
It communicates by several channels with the great saphenous vein.
Perforating veins
Indirect direct
Through muscles 1) Hand’s breath above knee
Superficial veins deep veins Great saphenous vein femoral vein
2) Hand’s breath below knee
Great saphenous vein post. Tibial v.
3) Hand’s breath above ankle
Medially- great saphenous post. Tibial v.
Laterally- small saphenous peroneal v.
General factors
Local factors
Clinicals
Muscle pump
Soleus (peripheral heart)
Varicose veins & ulcers
incompetence of
o valves of perforators or deep veins
o valves at termination of superficial
veins
Deep vein thrombosis – may occur in deep veins of lower limb and pelvic veins
Valves of Lower limb may be destroyed leading to varicose veins
Superficial Deep
Superficial inguinal lymph nodes
1.Deep inguinal lymph nodes
About 10 nodes, T shaped arrangement
Proximal group – Just distal to the ¾ nodes
inguinal ligament
Medial to femoral vein
Distal group – Lies vertically along the
eg:- lymph nodes of
terminal great saphenous vein
Cloquet/Rosenmuller
Efferent – Pierce cribriform fascia and
terminate in deep inguinal nodes - afferents from
* Superficial inguinal nodes
* Popliteal nodes
* Glans penis / clitoris (→Cloquet)
Upper medial – Umbilicus and anterior
abdominal wall. * deep lymphatics – L.L.
Below it, - efferent to
External genitalia, lower anal * external iliac nodes
canal and perineum, uterus
Upper lateral – buttock, flanking back 2. Popliteal lymph nodes
below the waist - near small saphenous vein termination
Lower vertical (distal group) – Superficial - afferents from
lymphatics of the lower limb except * territory of small saphenous vein
posterolateral calf * leg – deep parts
* heel of foot
* knee joint
-efferents to
Lower part of anterior abdominal wall *deep inguinal nodes
below the level of umbilicus
Superficial
Popliteal
Femoral nerve
Nerve of the extensor compartment of thigh
Root value - Posterior Divisions of Ant. Primary rami L2, L3, L4
Course
Starts from the lumbar plexus
Emerges at the lateral border of psoas major in abdomen then lies in the iliac fossa
between psoas and iliacus.
Enters thigh by passing deep to inguinal ligament, at the lateral edge of the femoral
sheath, which separates it from the femoral artery. (Lies behind iliacus fascia)
Lies between iliacus and psoas tendons in the femoral triangle
Not a content of the femoral sheath
Divides into branches immediately (~4cm distal to the inguinal lig)
Branches
Iliacus is supplied by the nerve in the abdomen.
As it enters the femoral triangle, it gives off the branch to Pectineus, which passes behind
the femoral sheath to reach the muscle.
Femoral nerve supplying quadriceps femoris is tested by patellar jerk (L3, L4)
(Separated by
Anterior division lateral circumflex artery) Posterior division
Anterior division Posterior division
Muscular 2 nerves to Sartorius Rectus femoris
(usually double)
Intermediate, medial,
lateral vasti
(medial – lat side of femoral
artery enter the adductor
canal)
(lateral- with descending
branch of lat circumflex
femoral)
Largest branch – Vastus medialis
Cutaneous Intermediate Saphenous nerve – leaves
cutaneous nerve (one femoral triangle at its apex
of Sartorius) and enters the adductor canal
medial cutaneous then run across the femoral
nerve artery. leaves the canal
between Sartorius and
gracilis)
Largest branch. Accompany
great saphenous vein, anterior
to the vein.
Hip joint (nerve to rectus
Articular femoris)
Knee joint (nerves to all 3 vasti )
Anterior Division
Passes above and anterior to the obturator externus
Then behind pectineus and adductor longus
Over the ant. surface of adductor brevis
After supplying gracilis, enters the subsartorial plexus ends by
supplying femoral artery (supplies skin over the medial side of thigh)
Posterior division
Enters thigh, piercing obturator externus
Passes vertically downwards on adductor magnus, deep to the other
adductor muscles.
Clinical
Both femoral and obturator nerves supply knee joint and hip joint. Pain in the knee can be
referred to hip joint
Due to deep position, damage due to trauma is rare, but may be involved in obstetrics processes and
pelvic disease. (Ovarian tumour causes pain referred to medial side of thigh)
Subsartorial plexus
Medial cutaneous nerve of thigh
Saphenous nerve
Obturator nerve- anterior division
Supplies the overlying fascia lata and an area of skin above the medial side of the knee
Sciatic Nerve
Nerve of the flexor compartment
Thickest nerve in the body.
Main Branch of sacral plexus
Root values - ventral divisions of anterior primary rami L4, L5, S1, S2, S3 (tibial Part),
- dorsal divisions of anterior primary rami L4, L5, S1, S2 (common peroneal part)
Course
In the pelvis
Lies in front of piriformis
Undercover of fascia
In the gluteal region
Enters through the greater sciatic foramen below piriformis (more laterally than the
inferior gluteal and pudendal nerves and vessels)
Posteriorly related to the capsule of hip joint
Passes vertically downwards on the posterior surface of Superior Gemellus, Obturator
Internus, Inferior Gemellus, Quadratus femoris.
Pass midway between the ischial tuberosity and greater trochanter. No branches given in
this region
Enters back of thigh at the lower border of gluteus maximus.
Nerve to quadratus femoris is deep to the sciatic nerve.
Superficially lies the posterior cutaneous nerve of thigh.
In the thigh
Lies under cover of the Gluteus Maximus, crossed posteriorly by
the long head of Biceps Femoris.
Runs vertically downwards up to the superior angle of popliteal
fossa on the posterior surface of the adductor magnus, where it
Clinical
Sciatica
- Shooting pain over cutaneous distributions of sciatic nerve and its terminal branches
- Due to compression and irritation of nerve roots forming sciatic nerve (osteoarthritis, lumbar disc
prolapse, spondylolisthesis
Foot drop
Intramuscular injections
Gluteal region is a typical site for intramuscular injections. Sciatic nerve passes through this
region and it needs to be avoided. Safest place to inject is the upper outer region of the gluteal
region.
Sleeping foot
- Compression of sciatic nerve (Since sciatic nerve lies on femur between quadratus femoris
and adductor magnus)
- Unusual stretching after sitting for a long time
Tibial Nerve
Nerve of the flexor compartment of the leg
Larger subdivision of sciatic nerve
Root values - ventral division of ventral rami L4 ,
L5 , S1 , S2, S 3
Course
Descends vertically in the popliteal fossa
Crosses popliteal vessels from lateral to medial side superficially
Descends as the neurovascular bundle with post. tibial vessels (Post. Tibial artery first lies lateral
to it then passes ant. to it and continues down on its medial side.
Lies superficial to tibialis posterior and deep to flexor digitorum longus
Passes deep to the middle of the flexor retinaculum and
terminates by dividing into medial and lateral plantar nerves
Clinical Commonest nerve to be damaged in the lower limb. (fracture of neck of fibula, compression of
the nerve by a plaster on the leg)
- Site- as it winds around the neck of the fibula
Effects of injury (talipes equinovarus)
o Paralysis of dorsiflexors of the foot ------- foot drop (unopposed action of plantar flexors)
o Paralysis of evertors -------- inversion of the foot
Sensory loss
Back of leg
Lateral side of leg
Most of dorsum of foot
Branches
Muscular -Tibialis Anterior (Muscles of the extensor compartment of leg)
-Extensor Hallucis longus
-Peroneus tertius
-Extensor digitorum brevis & longus
Cutaneous -dorsal digital nerves for the adjacent sides of the big toe and second toe
Branches
Relations to piriformis
region
Internal pudendal vessels
PIN Nerve to obturator internus
Inferior gluteal vessels
Inferior gluteal nerve
Posterior cutaneous nerve of thigh
Nerve to quadratus femoris
Sciatic nerve
Lesser sciatic foramen
Obturator internus muscle tendon
Pudendal nerve
Internal pudendal vessels Pass into perineum from gluteal region
Nerves
Posterior femoral cutaneous nerve / posterior cutaneous nerve of the thigh (S1, S2, S3)
Runs medial or posterior to sciatic nerve
Immediately deep to the deep fascia
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Branches
Perineal branch
o Crosses the ischial tuberosity
o Enters the urogenital triangle
Gluteal branches
o Supplies skin of posteroinferior quadrant of gluteal region
Arteries
Muscles
Gluteus maximus
Gluteus medius
Gluteus minimus
Ligaments
Sacrotuberous ligament
Between ischial tuberosity and posterior iliac spines
Sacrospinous ligament
Deep to sacrotuberous ligament
Attached to, laterally – ischial spine
Medially – sacrococcygeal junction
Clinical
Intramuscular injection- upper outer quadrant of buttock
Contents - 01. Femoral artery and branches [midinguinal point to the apex -6 Branches-3 superficial and 3 deep
-superficial branches-superficial external pudendal
-superficial epigastric
-superficial circumflex iliac
-deep branches -profunda femoris
-deep external pudendal
-muscular branches]
02. Femoral vein and tributaries
[At base - medial to artery] Great saphenous vein
[At apex - post. to artery] Veins corresponding to branches of artery
(Receives greater saphenous vein, circumflex veins and corresponding branches of femoral artery)
03. Femoral sheath
04. Nerves
A) Femoral nerve (in the groove between iliacus & psoas muscles outside the femoral sheath)
B)Nerve to the pectineus (branch of femoral nerve)
C) Femoral branch of genitofemoral nerve
D) Lateral cutaneous nerve of the thigh
05. Deep inguinal lymph nodes
Femoral artery lies in front of psoas major tendon
Femoral vein lies in front of pectineus
Femoral nerve lies in the groove between iliacus and psoas muscles
4 © 2017 A/L Repeat Campaign
Femoral sheath
● Funnel shape sleeve of fascia
● It is asymmetrical
● Enclose upper 4cm of femoral vessels
Prolongation of
o Fascia transversalis=>Ant. wall
o Iliacus fascia=>Pos. wall
Inferiorly merges with adventitia of femoral vessels
Femoral vein
Nerve to pectineus
Femoral Canal
-Medial compartment of femoral sheath
-Conical
-wide above at the base and narrow below
-Base is also known as Femoral ring
Clinical
Femoral Hernia
➢ Abdominal contents bulge out through femoral canal
➢ More common in female
Wider pelvis
Smaller size of femoral vessels
In strangulation, have to enlarge femoral ring => By incising lacunar ligament
Normally => No Danger
Abnormal(accessory) obturator artery => Alarming hemorrhage
usually sometimes
Passes lateral to lies along the medial
femoral canal border of femoral ring
Definition - Intermuscular space, triangular in cross section, on medial side of middle 1/3 of thigh
Extent - From - Apex of femoral triangle above
To - Tendinous opening in adductor magnus below
Boundaries - Ant.lateral wall – Vastus medialis
Post.medial wall - Adductor longus[above]
- Adductor magnus [below]
Medial wall - Fibrous sheath joining ant. & pos. wall
Overlapped by Sartorius [Subsartorial plexus --between fibrous sheath & Sartorius, Formed by
saphenous nerve, medial cutaneous nerve of thigh Anterior division of obturator nerve]
Contents=>01. Femoral artery & branches
o Muscular
o Descending genicular
Femoral artery leaves the adductor canal through the opening in adductor magnus
At all levels in the thigh, the femoral artery lies between saphenous nerve and femoral vein
02. Femoral vein => Upper - posterior to artery
Lower - lateral to artery
03. Saphenous nerve=>pierces roof to leave canal (Crosses anterior to femoral artery from lateral to medial side)
04. Obturator nerve =>Ant.& Pos. divisions
05.Nerve to vastus medialis
Clinical
Exposure and ligature of femoral artery in this canal for aneurysm of the popliteal artery
T/F
Saphenous nerve crosses femoral artery medial to lateral in the adductor canal
Superolateral
*Biceps femoris
Inferomedial
*Gastrocnemius medial head
Inferolateral
* Gastrocnemius lateral head
* Plantains
Roof
Skin, superficial fascia
Contains
01. Short saphenous vein
02. Cutaneous nerves – 3
Medial cutaneous N. of thigh
Posterior cutaneous N. of thigh
Sural communicating N.
Floor
Above
01.Femur popliteal surface
02. Knee joint – capsule & oblique popliteal ligament below
03.Popliteal fascia covering popliteus
Contents
01. Popliteal artery &branches 05. Pos.cutaneous nerve of thigh
02. Popliteal vein & tributaries 06. Obturator nerve - genicular branch
03. Tibial nerve & branches [Sural N.] 07. Popliteal lymph nodes
04. Common peroneal nerve & branches 08. Fat
Superficial to deep- N, V, A
Medial to lateral- above- A, V, N
below- N, V, A
(popliteal vessels cross the tibial nerve anteriorly in the middle of fossa. Arrangement @ middle is N, V, A
behind forwards)
Tibial nerve crosses fossa vertically downwards.
Popliteal artery runs downwards and slightly laterally, divides at the lower border of popliteus
Common peroneal nerve crosses the fossa obliquely along the medial border of biceps femoris.
Clinical
Pulsation of popliteal artery – in aneurysms
2. base of the 5th metatarsal - easily felt on the lateral side of the foot and is
the site of insertion of peroneus brevis.
3. If the calcaneus carefully palpated→ the peroneal tubercle can be felt below
the tip of the lateral malleolus
Talonavicular & calcaneocuboid joints lie in one line and together called “Transverse
tarsal joint” (mid tarsal joint) here pronation and supination take place as hidden
movements for plantigrade contact (gripping) – reinforced by the bifurcate ligament
Cuboideonavicular joint - Fibrous joint. No movement (All other joints are synovial)
Cuneonavicular joint - Continue with 2nd and 3rd intermetatarsal joints
Calcaneocuboid joint - long and short plantar ligaments on its plantar surface
Tarso-metatarsal joints - Gliding and aid in pronation and supination. Synovial
**The tendon to the great toe is different from others and is named extensor hallucis brevis
1st layer
2nd layer
02) Flexor digitorum -lateral plantar nerve -straigthens the pull of long flexor
accessorius main trunk tendons
3rd layer
02) Adductor hallucis -lat. plantar nerve-deep branch -adduction-- great toe
03) Flexor digiti minimi lat. Plantar nerve-superf. Bran. -flexion of little toe
4th layer
atlanto-occipital joint
knee joint
ankle joint
four vertebral curvatures
Except the hip joint – posterior to the hip joint. Tendency to extend is
prevented by iliofemoral ligament
*Erector Spinae
*Gluteus maximus
*Soleus
*Quadriceps femoris
Standing
Clinical: In wearing high heels the spine is pushed forward, knees excessively bent, soleus & gluteus
maximus in contraction, toes in extreme flexion, forward tilting of pelvis, cervical extension, lumbar
lordosis
Gait
The gait cycle consists of one cycle of swing and stance by one limb.
o Begins with heel strike, when the heel strikes the ground and begins to assume the
body’s full weight
o Ends with push off, from the forefoot – a result of plantar flexion
o Occupy 60% of walking cycle
o Contains two periods
Double stance period -- when both feet are on the ground
Single stance period – when one foot is on the ground
In running there is no period of double stance
o After the heel strikes, the forefoot must be lowered to the ground via plantar flexion
As one foot is raised from the ground, pelvis of the unsupported side drops
This is corrected by the gluteus medius and minimus of the opposite side
When these muscles are paralyzed
In one side – lurching gait
Both sides – waddling gait
(+ve Trendelenburg test)
Rising up
o Hip extension
o Knee extension
Walking up stairs
o Extension of the hip & knee joint in the leading limb to pull up the trunk to the
Step above
Internal Environment
In a multicellular organism, it is the interstitial fluid or tissue fluid.
There are various physiological arrangements which serve to restore the normal state once it is
disturbed.
Eg: Plasma [H+]
Plasma [H+]
There are various Control Systems to make this happen. They maintain a variable at a particular set
point.
-Gets inputs from set point & feedback
from the sensor. If the set point changes with
Set point
-Detects the error
time of the system is called
-Output to effector.
a “servo mechanism”.
Controller
Inputs Set point-
Output
Feedback
Feedback =error
signals
Sensor
Effector
-Continuous
monitoring of the -Receives output of the
variable controller
-Detects disturbance -Applies necessary correction
-Sends feedback to
controller Response
Controlled
variable
Correction
Disturbance(s)
In each case positive feedback is useful, the positive feedback itself is part of an overall
negative feedback process.
4. A 25-year-old person was admitted to the hospital after a road traffic accident. He has lost blood.
His systolic pressure was 90mmHg at the time of admission (normal systolic point is 120mmHg).
Deviation of blood pressure from the set point would,
A) Be due to decreased volume in the intra vascular compartment
B) Larger in the absence of a regulatory system
C) Be detected by the sensors in the circulatory system
D) Blood pressure can be normal by positive feedback
E) Can be normal 100% by negative feedback
ECF ICF
1/3 of TBW or 20% of 2/3 of TBW or 40% of
BW BW
Transcellular fluid belongs to ECF & includes CSF, secretions in gut, fluids in joints and eye.
Blood-8% of the BW
Water Balance
In a healthy person,
Water gain = water output
3L/day = 3L/day
Distribution of electrolytes
Measurement of electrolytes
SI unit - mmol/L
Traditional unit- mEq/L
100
TBV -
100−𝐻𝑎𝑒𝑚𝑜𝑡𝑜𝑐𝑟𝑖𝑡
× 𝑝𝑙𝑎𝑠𝑚𝑎 𝑣𝑜𝑙𝑢𝑚𝑒
Interstitial fluid - ECF - plasma
Mechanisms
Filtration
Glomerular Solvent Drag
filtration 1.Transport of
nutrients
2.RBCs in blood
Diffusion
1. Simple :
Gases-O2, CO2
Lipid Soluble Substances Active Transport
2.Facilitated : Glucose 1. Primary : Na+ /K+ ATPase
Mechanisms 2. Secandary :
Na+/glucose (SGLT)
Na+ /bile salt co-transporters
Exocytosis
Nerve Impulse Endocytosis
Transmission Osmosis
Phagocytocis
Pinocytosis
1) Diffusion
The process by which
-a gas or
-a substance in solution
-expands
-because of the continuous random movements of particles
-to fill all of the available volume
Net flux of
-solute particles
-from areas of high
-to areas of low concentrations
3. Membrane permeability
i. thickness of membrane (d)
ii. lipid solubility
iii. no. of protein channels per unit area
iv. Temperature
v. Molecular weight of substance
4. Donnan Effect
Presence of a non-diffusible ion
-on one side of a membrane
-affects the
-distribution of
-diffusible ion
-across that membrane
In a predictable manner.
Types of diffusion
a. Simple Diffusion
b. Facilitated Diffusion
HA H+ + A-
H+ X
A- X
3) Filtration
Movement of fluid due to difference in pressure on two sides
4) Osmosis
Diffusion of solvent from a region of low solute [conc.]/ low osmotic pressure to a region of high
solute [conc.]/ high osmotic pressure across a semi permeable membrane.
Pressure necessary to be applied to a solution to prevent the inward flow of solvent across a
semipermeable membrane by osmosis
Depends on no. of dissolved particles
Osmole = amount of solute that dissociates in solution to form 1 mole
Glucose 1 mol/L =1osmol / L
NaCl 1mol/L = 2 osmol/L
Tonicity
Osmolality of a solution relative to plasma
Isotonic - same as plasma
{0.9% Saline, 5% Dextrose, king coconut water}
Hypertonic - greater than plasma
Hypotonic - lesser than plasma
2. Assuming complete dissociation into Na+ & Cl- a solution of 5.85 g NaCl in litre of water
a) will have an osmolality of 0.1 osmole
b) will contain 0.1 mole of Na+ per litre
c) would be more concentrated than ECF
d) would have higher H+ concentration than ECF
e) will cause hemolysis of a normal red cells added to the solution in a few seconds
This suggests capillary walls acts like semi permeable membranes. Impermeable to colloids.
So, COP develops. COP due to plasma colloids is called the oncotic pressure.
Capillary permeability
Available surface area
Hydrostatic P =
∆P = ↓(11-9) mmHg
= ↓ 2 mmHg
Odema
Generalized Localized
1. ↑ venous pressure 1. ↑ venous pressure in local obstruction
In right heart failure -Late pregnancy (IVC)
↑ R atrial pressure.
2. lymphatic obstruction (lymphoedema)
2. hypoalbuminemia -cancers
+ protein malnutrition -filariasis
+liver disease
+nephrotic syndrome 3. ↑ capillary permeability
+Hypoproteinemia -insect bites
-Inflammation & allergy
-Substance P, histamine, kinins
2. Capillary filtration
a) decreases if interstitial oncotic pressure increases
b) is normally smaller in magnitude than capillary reabsorption
c) is the main mechanism of cerebro-spinal fluid formation
d) will decrease if the capillary hydrostatic pressure decreases
e) is increased in protein malnutrition
Neurones Muscles
Neurones
Structural Classification
1. Unipolar
2. Bipolar – retina
3. Pseudounipolar – Sensory
neurone
4. Multipolar – motor
Functional components of a
neurone
A receptor zone - Dendrites or
the cell body integration of
multiple local potentials
generated by synaptic
connections
Cell body
Generator of propagated
impulse - Initial segment or the
1st node of Ranvier
Pathway to transmit the
impulse - axon
Nerve endings to release the
neurotransmitters – axon
terminal
Glial cells
Microglia – Derived from macrophages Removes debris resulting from infection + diseases
Macroglia
1. Oligodendrocytes – Forms myelin sheath in CNS. A single cell can form myelin sheaths of multiple neurones
by emitting branches.
2. Schwann cells – forms myelin sheath in PNS. A single cell contributes only to one neurone.
3. Astrocytes
a. Only found in blood brain barrier
b. Trophic to nerves (produce neutrophins)
c. Take up K+ and neurotransmitters
Macroglia also secrete nerve growth factors.
Multiple sclerosis – Myelin destruction in CNS
Guillain barre syndrome – Myelin destruction in PNS
Membrane potential is the electrical potential energy difference between the inside and outside of a cell
Resting membrane potential (RMP) is the membrane potential when not transmitting an impulse
In neurons its value is usually -70 mV (inside the cell membrane compared to outside)
– Due to different concentrations of ions across the membrane
– Different permeability for different ions
The bulk solution inside and outside is electrically neutral
The potential difference exists only across the cell membrane
Main determinant of RMP is the movement of K+ through K+ leak channels
Therefore, changes in extracellular [K+] have major effects on RMP
Negativity inside is maintained by Na+/K+ ATPase pump Ion concentrations when R.M.P is -70 mV
– An electrogenic pump
– Inhibited by Ouabain and Digitalis Extracellular Intracellular
At rest the membrane is impermeable to proteins Na + - 150 Na+ - 15
Due to leak channels, the membrane is K - 5.5
+ K+ - 150
– Slightly permeable to Na+ Cl- - 125 Cl- - 9
– Highly permeable to K+ (impermeable
to proteins)
– Freely permeable to Cl- (No net movement as Electrical responses of nerve to a
its equilibrium potential is -70 mV) stimulus
+
K diffuses “out” of the cell along its
concentration gradient Propagated action Local, non-propagated
potential potential
Na+ diffuses “in” to the cell along its
concentration gradient
Receptor potential
If ion leakage across the membrane continues unopposed, it would proceed
until concentration gradients are balanced by the electrical gradient
But, Na+/K+ ATPase pumps 3Na+ out & brings 2K+ in, per turn End plate potential
(Na+/K+ ATPase pump act as an electrogenic pump because it generates
electronegative potential Synaptic potential
+
This maintains the concentration gradients of K and Na +
(but contribution of Na+/K+ ATPase pump for RMP is a very small value of -5mV)
Therefore, the membrane potential is maintained at RMP
Changes in membrane potential that reach the threshold level can be propagated along a nerve fibre
Threshold is usually 15 to 20 mV above RMP (about -55 mV)
Action Potential
B. Repolarization
Resistance for Na+ influx
increases as membrane
potential becomes more positive, reversing the electrical gradient for Na+.
Voltage gated Na+ channels close 1/104 s after they open.
Na+ INFLUX stops.
When MP rises from -70mV to 0mV, voltage gated K+ channels open.
– They are slow to open and slow to close.
Opening of K+ channels coincide with the closure of Na+ channels.
Resulting K+ EFFLUX makes the membrane potential negative again.
After depolarization, K+ voltage gated channels close via a negative feedback mechanism
C. Hyperpolarization
K+ efflux lasts longer than needed to restore membrane potential to RMP.
Therefore, the membrane is hyperpolarized.
When K+ channels close, K+ EFFLUX stops.
Membrane stops becoming more negative.
RMP is restored. But a large amount of Na+ remains within the cell & a large amount of K+ has escaped.
Na+ / K+ ATPase corrects the ionic distribution.
Absolute Relative
• Time period from reaching the firing level to the first • Time period from the last 2/3 of repolarization to
1/3 of repolarization the beginning of after-depolarization
• Does not respond to any stimuli • Only suprathreshold stimuli can evoke an AP
1. In a nerve cell
a) K+ efflux contributes to repolarization.
b) Initial rapid depolarization is due to opening of Na+ channels.
c) High Na+ concentration in ECF increases the magnitude of action potential.
d) Conductance of fibre type A is faster than type C.
e) Slightly higher cation concentration in the interstitial space affects the RMP of the cell.
Longer the time of application of the stimulus Smaller the required minimum strength of the stimulus
Shorter the time of application of the stimulus Greater the required minimum strength of the stimulus
Very slowly increasing current No AP
o Slow opening of voltage gated Na+ channels and slow opening of voltage gated K+ channels coincide.
Na+ influx is balanced by K+ efflux.
Clinical relevance
Demyelination (Eg: Multiple sclerosis) – Conduction velocity is decreased
Axonopathy – Reduction of amplitude. Later the velocity also reduced.
Injury to nerves – PNS likely to regenerate, CNS mostly degenerated.
Local anaesthesia – Blocks only C fibres
Neutrophins
Nerve growth factor (NGF)
Necessary for the growth & maintenance of sympathetic and other sensory neurones
Reduce apoptosis of neurons
Produced in structures innervated by them. Eg: muscles. In the CNS, produced by astrocytes
Transported retrogradely to the nerve cell body
Local potentials
Can be subdivided into,
1. Receptor potential
2. End-plate potential
3. Synaptic potential
When stimulus act on the unmyelinated nerve end or receptor changes occur in
receptor membrane
Opening of Na+/Ca2+ channels, inhibition of K+ channels or inhibition of Na+/K+
ATPase pump leads to produce non-propagated receptor potential
When this receptor potential reaches the threshold, An AP is generated in the 1st
node of Ranvier
Ach binds to the muscle type nicotinic-cholinergic receptors in the motor end
Local plate
This opens a gate within the ligand gated channels which are equally permeable
Potentials to Na+ & K+
Depolarization & causes a local graded potential on the end plate
Synaptic potential
Synaptic Potentials
Single stimulus does not produce an action potential in postsynaptic membrane, instead it produces a transient
depolarization or transient hyperpolarization
1. Summation
Summation of synaptic
potentials
Spatial Temporal
Many presynaptic terminals are stimulated at the same Successive discharges from a single presynaptic
time. terminal,
The depolarization induced at several points on the neuron If they occur rapidly enough, can add to one-
spread to trigger zone before decaying out another and summate
The potentials summate to elicit an AP
4. Inhibition
a. Presynaptic b. Postsynaptic
Inhibitory interneuron-GABA
Motor neurone
Synaptic Plasticity
Changes in the function of synapses due to past experience
Basis of learning and memory
1. T/F
a) Decrease in ECF [K+] hyperpolarize the nerve axons
b) Chronaxie is a time measurement
c) Rheobase the minimum strength of a stimulus to initiate an action potential
d) A slight increase in extracellular Na+ is enough to depolarize the membrane
e) Increased extra cellular Ca2+ increases the excitability of the nerve membrane
4. Saltatory conduction
a) Occurs only in myelinated fibres.
b) Does not depend on depolarization of the nerve cell membrane.
c) Velocity decreases as the temperature rises.
d) Transmits impulses with a velocity proportionate to fibre diameter.
e) Produces a great voltage change in the membrane than in non-saltatory conduction
Acetylcholine receptors
Z lines move closer. ‘A’ band remain constant. All others get shorter.
Functional unit of muscle – motor unit (=single motor neurone and all the muscle fibers innervated by it)
Neurone All the muscle fibers in one motor unit are innervated by one
motor neuron.
Relaxation
Ca2+ pumped in to SR by Ca2+ - Mg2+ ATPase pump (SERCA) (this pump needs ATP, therefore ATP dependent
process)
Release of Ca2+ from troponin C
Interaction between actin-myosin stops.
If Ca2+ transport into reticulum is inhibited, relaxation does not occur, resulting in sustained contraction called
contracture.
Electrical response
Mechanical response-
Starts 2ms after the onset of depolarization
before repolarization is complete
Muscle twitch – a single action potential causes a brief contraction followed by relaxation
Summation of Contraction
a) Tetanus - when there are repeated stimulations with a high frequency, individual responses fuse into a
single continuous contraction.
b) Treppe (Staircase phenomenon) – Maximal stimuli given at a frequency just below the tetanizing frequency
Increase in tension develop in each twitch. After a few contractions uniform tension per contraction is
reached (due to progressive increase in Ca2+ in the sarcoplasm)
E.g.- when muscle begins to contract after a long period of rest initial strength is little, after strength of
contraction increase to a plateau.
Tension
Time
In isometric contraction,
Tension α cross linkages between actin & myosin
Too shortened – distance thin filaments can more reduced
Too stretched – overlap of thin & 2 thick filaments reduced
Results of denervation
Muscle atrophy
Fibrillation – Fine irregular contractions of individual fibers, cannot be seen by naked eye but can be
observed by electromyography
Denervation hypersensitivity – due to increased sensitivity to circulating Ach
Fasciculations – Jerky, visible contractions of groups of muscle fibers that occur as a result of pathological discharge
of spinal motor neurones
CARDIAC MUSCLE
Visceral smooth muscle/ Single unit smooth muscles Multi-unit smooth muscle
Tunica media of blood vessels has both visceral and multi-unit smooth muscle types.
Lacks visible cross striations as actin and myosin filaments are not arranged in regular arrays.
Troponin is absent, but tropomyosin is present
Poorly developed sarcoplasmic reticulum
Few mitochondria
Depends mostly on glycolysis
Spikes
Ionic fluxes
Binding of Ach. muscarinic receptor
Increased influx of Ca2+ into cells from ECF through voltage gated Ca2+ channels
Activation of calmodulin dependent myosin light chain kinase
Phosphorylation of myosin light chains
Binding of myosin to actin and increased myosin ATPase activity
Contraction
Dephosphorylation of myosin by various phosphatases
Relaxation or sustained contraction due to latch bridge mechanism
E.g.: - vascular smooth muscles
Varicosities - Dilated areas of nerve fibers innervating smooth muscles that release neurotransmitters.
Dephosphorylated myosin cross-bridges remain attached to actin for some time after the cytoplasmic Ca 2+
concentration falls. This produces sustained contraction with little expenditure of energy.
Important in vascular smooth muscle.
Action of catecholamines and acetylcholine on smooth muscle (Reverse happens in some smooth
muscles.)
Catecholamines Acetylcholine
Membrane potential become more negative Membrane potential becomes less negative
Spikes decrease in frequency Spikes more frequent
Muscle relaxes Muscle tone increases
α action – increased Ca2+ efflux from cells By phospholipase C and IP3, increase intracellular Ca2+
β action – via cAMP increased intracellular binding of Ca2+ concentration
Function of the nerve supply to smooth muscle is not to initiate activity but to modify it.
Mysthenia gravis – Autoimmune disorder that destroys muscle type nicotinic Ach receptors. What happens?
Lambert-Eaton syndrome – Autoimmune disease. Patients develop antibodies against voltage gated Ca 2+
channels in the nerve endings.
To head arise in superior, middle and stellate To Head - cranial nerves III, VII, IX
ganglion & travel with blood vessels
To Thorax and upper abdomen - Cranial nerve X
Parts of uterus and male genital tract from
To sacral region S2-S4 spinal nerves
collateral ganglia
Short preganglionic and long postganglionic fibers Long preganglionic and short postganglionic fibers
Ganglion in sympathetic chain and superior, middle Near the viscera/ inside the viscera
& stellate ganglion
ACETYLCOLINE NOADRENALINE
Effects are localized and short term Spread further than Ach more prolonged &
(Acetylcholinesterase) diffuse action
Receptors Receptors
Nicotinic Alpha receptors-α1, α2
muscarinic Beta receptors-β1, β2
Receptors
Most of the organs are supplied by both divisions of The ANS but few organs are supplied only by
one division of ANS
Exclusively by sympathetic-blood vessels, sweat glands, pilomotor muscles
Exclusively by parasympathetic-lacrimal glands, ciliary muscles, sublingual glands
Parasympathetic action
Acetylcholine - Muscarinic receptor
01. Decrease heart rate
02. Bronchoconstriction and increase
mucous secretion
03. Increase motility and secretion and decrease sphincter tone in GIT
04. Increase gastric acid secretion (M3)
2. Submucosal plexus
Located between circular & luminal mucosa
Regulate the blood flow & epithelial cell functions
Although the enteric NS can function autonomously, normal digestive function often requires
communication between the CNS & the enteric NS
Prokaryotic Eukaryotic
High S/V ratio Low S/V ratio
Single membrane surrounded by rigid cell Lipid bilayer membrane with proteins.
wall.
(Membrane - phospholipid
Cell wall - heteropolysaccharides )
No membrane bound organelles Contains membrane bound organelles
Ribosomes are 70S with 50S and 30S subunits Ribosomes are 80S with 60S and 40S
subunits
A Prokaryotic cell
1. Lysosomes
Contains hydrolytic enzymes for intracellular digestion.
2. Peroxisomes
β oxidation of excess fatty acids.
Removal of H2O2. Catalase converts to H2O and O2.
Participate in synthesis of cholesterol, bile acids.
Breakdown of excess purine nucleotides to uric acid.
Synthesis of lipids used to make myelin.
Detoxify toxic molecules.
3. Mitochondria
Aerobic respiration and ATP production.
Certain heme synthesis reactions, urea cycle.
β-Oxidation of fatty acids.
5. SER
Synthesis of lipids and steroids
Detoxification of drugs and chemicals
Stores Ca2+ ions
6. Golgi
Receive, modify, sorts and package of proteins (secretory)
Creation of lysosomes.
7. Cell membrane
Permeable to water, carbon dioxide, and oxygen
Acts as a gate for different substances/semipermeable
Forms vesicles and participate in exocytosis and endocytosis.
Epimer
Different configuration around 1
specific ‘C’ except Carbonyl C
Mutarotation
OH
OH
α anomer β anomer
b) Inulin
polymer of fructose furanose
to measure GFR by inulin clearance test
d) Glycoproteins
Used in blood group analysis (in ABO system)
e) D-glucose
Used as a parenteral source of calories & water for parenteral nutrition & hydration
Hypertonic dextrose injections (>5%) are used to provide adequate calories in minimal
volume of water
10-25% dextrose injections are used to restore blood glucose concentration in treatment of
acute symptomatic hypoglycemia
Reviving unconscious patients who have consumed too much alcohol
May be admixed with amino acid injections or other compatible IV fluids to provide
parenteral nutrition
Classification of carbohydrates
Monosaccharides Disaccharides
Cannot hydrolyze
Can be hydrolyzed.
reducing sugars (Benedict’s Test) reducing sugars (except sucrose)
cyclization (become stable) sugars prefer contains glycosidic bonds
cyclic structures to linear structures
6-member ring- pyranoses (Eg: glu & gal) E.g.
5-member ring- furanoses (Eg: fructose) Maltose (from hydrolysis of starch)
derivatives; Glu+Glu
Eg: α-1-4 glycosidic bond
1. Phosphate esters (Eg: - glu. 6. Phosphate, Sucrose
glu. 1. Phosphate) Glu+fru
2. Sugar amines (Eg: - D- glucosamine, α-1-2 glycosidic bond
N-acetyl glucosamine) Lactose
3. Sugar sulphates - biological tissues Glu+ gal
4. Deoxy Sugars - component of nucleic acids β-1-4 glycosidic -galactosidic type
5. Sugar alcohols (Eg: - sorbitol)
6. Sugar acids (Eg: - glucuronic acid – in urine N- glycosidic(nucleotides)
Simplest carb. & bile; proteoglycans) O- Glycosidic(sugar)
Glycosidic Bond
(Classified according to carbonyl C)
1)No.: Designate C atom that forms the bond.
2) α / β: Bond up or down
3)Type;
Digestible
Eg: Lactose - β-1-4 galactosidic type of glycosidic
Indigestible
Eg: cellulose - β-1-4 glucosidic type of glycosidic
Salivary α amylase catalyzes the hydrolysis of
α-1-4 glycosidic bond
Complex carbohydrates
Oligosaccharides Polysaccharides
3-10 mono. (>10 mono.)
components of cell membrane
and human milk
Eg: Raffinose, Stachyose
Polysaccharides
Unbranched Branched
1.Cellulose 1.Glycogen
Group of plant Animal polysaccharide for
polysaccharides glucose storage
β-1-4 glucosidic type of Highly branched – rapid
glycosidic bond breakdown (more branched
not hydrolyzed in humans than amylopectin)
α-1-4 & α-1-6 glycosidic Bond
2.Amylose 2.Amylopectin
20% in starch α-1-4 & α-1-6 glycosidic bonds
α-1-4 glycosidic bond Difficult to digest.
Blue-black colour with iodine Most abundant in Starch
Easy to digest.
Starch types
(Plant polysaccharide
for glucose storage)
Conjugated
Pure
GAGs
Pectin
With Lipids With Proteins Gums
glycolipids proteoglycans
glycoproteins
02.Hyaluronic acid
03.Keratan sulphate
04.Chondroitin sulphate
Conjugated (Glycoconjugates)
Glycoproteins
O linked N linked
O linked Glycoproteins
Eg-
Glycophorin, a protein in erythrocyte cell membranes
Mucin, a protein in saliva involved in formation of dental plaque
Notch, a transmembrane receptor involved in development and cell fate decisions
Thrombospondin
Factor VII, Factor IX
Urinary type Plasminogen Activator
Functions- recognition, interaction and enzyme regulation
Glycoproteins Proteoglycans
Length of CHO chain relatively shorter. Relatively longer
CHO do not have serial repeats GAGs present. Have repeating disaccharides.
CHO chain often branched. Unbranched
CHO may/may not be negatively charged. Negatively charged.
Less CHO More CHO
Tests
Benedict’s test Test for reducing Brick red Here anomeric C form enediols
sugars precipitate (intermediate) in alkaline medium
Barfoed test Specific for Red precipitate Oxidation of monosaccharides
monosaccharides (carbonyl group to carboxylic group)
Iodine Test For starch Blue black I2 + I- -------- I2-
colour
Diseases
Diabetes mellitus
GAGs – mucopolysaccharidosis
Mucopolysaccharidosis
Hereditary disease caused by a deficiency of any one of the lysosomal hydrolases normally
involved in degradation of Heparan sulphate or dermatan sulphate.
Characterized by lysosomal accumulation of GAGs in various tissues.
All are autosomal recessive. (except Hunter syndrome- x linked)
Incomplete lysosomal degradation of GAG- presence of oligosaccharides in urine.
Saturated Unsaturated
No / bonds Has 1 / many / bonds
Strong interactions between FA chains Monounsaturated (only 1 = bond)
Abundant in animals Poly unsaturated (more than 1 / bond)
Eg: palmitic, stearic Eg: linoleic (sunflower/olive/gingerly)
( except palmitic and stearic all other examples α- linoleic
given for FAs on lecture note are unsaturated ) Lauric (coconut)
Arachidonic
If there is more than 1 double bond, they
are separated by a methylene (-CH2) group
Week attractions between FA chains, chain length, presence, number, position and
confirmation of double bonds affect the melting point. (length melting point - due to
number of vanderwaals interactions)
Most naturally occurring unsaturated fatty acids have cis double bonds. Nearly all the FA s in
mammals have even number of carbon atoms
Trans double bonds increase the melting point of unsaturated fatty acids.
Eg: margarine, elaidic acid (natural trans unsaturated)
16:1ω9 first carbon with double e.g. –C-C-C=C-C=C-COOH in this example it is a ω-3 FA
bond 1 2 3 4
(counting from the end) ω carbon doesn’t change in metabolism so can trace.
No. of double bonds
No. of carbons e.g. Arachidonic ω-6 (20:2ω6)
Linoleic ω-6 (18:2ω6) Sounds the same
α Linolenic ω-3 (18:3ω3) but different
Parental FA
α Linolenic - ω 3 series
Linoleic - ω 6 series
TAG
(triglycerides) Sphingolipids Steroid Phosphoglycerolipids
(glycerophopholipds)
sphingosine
Glycerol
FA X
Cholesterol
Sphingosine + FA = ceramide FA FA phosphoric
alcohol
Lecithin
Phosphosphingolipids Glycosphingolipids Choline alcohol - neural
transmission
sphingosine sphingosine Most abundant phospho lipid
in cell membrane
FA phosphoric FA Sugar (one or more) Lung surfactant - dipalmytoyl
lecithin
alcohol Blood group antigens Cardiliopin
Cerebrosides Only in mitochondria
Galactosyl ceramide - brain Inositol
Sphingomyaline Precursor of 2nd messengers
Glucosyl ceramide - extra
Myaline sheath in
neural tissue
brain and nervous
Gangliosides - receptor
system (no glycerol)
Cell surface receptors for
cholera and tetanus
Major glycolipids in animal
tissue
Common in cell membrane
(outer leaflet)
Storage lipids
1) TAG
storage lipids
neutral fat
hydrophobic / non polar
not components of bio membranes
high energy molecule
anhydrous
C1 & C2 of glycerol is not identical & they are enzyme specific
3) Cholesteryl ester
Hydrophobic
Cholesterol FA
Eicosanoids
Eicosanoids
Phospholipase A2
Arachidonic acid
NSAIDs - - Inhibited in
COX 1 lipoxygenase asthma
Ex: - aspirin COX 2 treatment
Amino acids
Amino acids are classified according the properties of the side chain (R group)
Some AA are not found in proteins but found in the free state in cells or as derivatives.
Eg: - epinephrine, norepinephrine
Ketogenic AA
Amino acids that only yield acetyl CoA & they can’t be used for gluconeogenesis.
But can be used for ketogenesis
Eg: - Lysine & Leucine
Amino acids that yield both acetyl CoA & TCA cycle intermediates
Eg: - trypsine, tyronine, Phe, Ile
Metabolism of all AA except branched chain AA (Val, Leu, Ile) takes place in Liver
Isoelectric pH (pI)
pH at which zwitter ion predominates with equal but very small amounts of cationic &
anionic forms.
A zwitter ion is a dipolar ion with two or more functional groups one is (+) charged and
other one is (-) charged. (At pI - no net charge)
not move in an electric field
solubility is least
Cystinuria
Proteins An inherited abnormality in
reabsorption of Cystine, Orn, Arg,
Ninhydrin reaction
Lys (COAL) in kidney tubule.
T
AA + Ninhydrin Bluish Purple It leads to increased excretion of
these AA in urine.
But Pro & OH-Pro gives a yellow colour Clinical features due to precipitation
Useful in detecting and qualifying amount of of Cystein in renal tracts
AA in plasma and urine
1) Glutathione
Antioxidant
AA transporter
Glutamine, Cysteine, Glycine
Protein structure
2) Secondary
Structure that arises as a result of interactions between backbone groups that are close to one
another in protein
Helix and alpha chain are not same
3) Tertiary
Fibrous Globular
Structural
proteins functional
Insoluble compact, tight
Long half life packing in core
Secondary structure Secondary, tertiary &
quaternary structure
Intermediate structure
Eg: - α keratin, Soluble in water
collagen, elastin Eg: - Hb, myoglobin,
lysosome,
Eg: - fibrinogen ribonuclease
Some globular proteins have both α helical and B pleated sheet (higher amount of B
pleated sheet) structures in the same molecule
Lysozyme
Domains
Distinct 3-dimensional structural units of a polypeptide chain which may have separate
functions.
Often encoded by different exons
A chain with a domain folds independently of others
Each domain has a characteristic of a small compact globular protein structurally
independent of the others.
Core of domain is composed of super secondary structures(motifs).
In functional molecule
2 types
a) Monomeric
b) Oligomeric
Individual polypeptide chain – protomers / monomers / sub units
Quaternary structure; characteristic manner in which individual polypeptide chains held
together by weak non covalent
H bonds
Ionic linkage
Hydrophobic interactions
Sub units may function independently of each other or may work cooperatively as in Hb
Prion diseases
Natural non infectious form is alpha helical found in human brain cells
Prion protein is a causative agent of transmissible spongiform encephalopathies
Infectious beta pleated sheet act as a template and convert naturally occurring non infectious
prion protein alpha helical structure to beta pleated sheet
Insoluble aggregates of fibrils
Amyloidosis
Collagen
Synthesis of collagen
Collagen diseases
Properties of Proteins
1. Charged nature
Mainly from charged R groups and to a lesser extent COOH or NH2, can exist as cations,
anions or zwitter ions, depending on pH
IpH depending on nature of R groups
At IpH solubility and osmotic pressure are minimum
Alkaline medium negative ions react with Zn2+/Ba2+ deproteinising body fluid
2. Buffering action
pH = pK buffering is maximum
Imidazole of His important in buffering action of Hb (Globin is rich in His, pka = 7)
4. Solubility
Most need small amount of salt to solubilisation
Eg: globulins in plasma
6. Denaturation Denaturants
II, III, IVry structures altered Heat
Iry structure unchanged Organic solvents
Loss of biological activity Mechanical mixing
Solubility decreased Strong acids/bases
Eg: heat coagulation test Detergents
Digestibility increased Heavy metal ions
Irreversible (refolding uncommon) Urea 8M
Functions
1. Control of fluid distribution - albumin maintains colloid osmotic pressure
2. Transport (albumin, others) - bilirubin, free FA, Ca2+, Zn2+, fat soluble vitamins &
hormones (others - thyroid hormones, lipids, irons)
3. Haemostasis (enzymatic activity)
4. Defense - Immunoglobulins (γ globulins), acute phase proteins (inflammatory
responses in severe conditions)
Proteins Simple
Electrophoresis
Plasma lipoprotein
Separate as for serum proteins but stain for lipids (Eg: - Sudan red)
Thinnest (7 nm)
Helical polymer
Has polarity
Dynamic structure
Flexible
Functions
Mechanical strength
Maintains cell shape
Cell Motility
Pseudopodia - actin reorganizes/ weakens to form a pseudopodium
Cell streaming - cytoplasm cycles over a carpet of actin filaments within the cell.
Myosin also contributes
Cell division - cytokinesis (Division of cytoplasm by forming Cleavage furrow)
Contractile structures (with Myosin)
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Involvement in cell adhesion - Tight junctions, Adherent junctions
Any process which involves a change in the shape of the cell needs microfilaments.
Eg: -
platelet aggregation, phagocytosis, development of embryo, immune response, cell crawling,
angiogenesis, extension of neurons, muscle contraction, cell division
RBC Cytoskeleton has no Microtubules or intermediate filaments. Structural support.
Biconcave Shape
Hereditary Spherocytosis
Defective Cytoskeleton (Ankyrin, Spectrin)
Production of Sphere shaped RBCs.
Leads to breakdown of RBCs. Haemolysis in spleen.
Microtubules
Functions
Structural support of cilia / flagella
Forms mitotic spindle (moves chromosomes during mitosis)
Determines position of organelles
Provide “tracks” for movement of organelles / vesicles (Dynein, Kinesin)
Polarize cells. Eg: cell division, T-cells (positioning of Golgi apparatus)
Centrioles
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Motor proteins interact with & move along microtubules
Energy dependent process
Cilia
Clinical
Cancer treatment by targeting microtubules
Drugs bind with Microtubules and stabilize them.
Mitotic Spindles cannot form.
Taxol - binds & stabilizes microtubules
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Intermediate filaments
Apolar
More stable. Not involved in movement
Different subunits
8 tetramers twisted into a rope-like filament
Various globular protein subunits are incorporated into IF filaments
Heterogeneous group of proteins
Assembly & disassembly is controlled by phosphorylation.
Functions
Maintains cell shape (specialized for tension bearing)
Anchorage of nucleus and other organelles
Formation of nuclear laminar
Involvement in cell adhesion - Desmosomes (cell-cell), Hemi desmosomes(cell-BM)
Disorders
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Overall Functions
1) Structural support
acts as scaffolding (stabilize cell shape)
provides shape to sub-structures of cells
anchorage for cells / organelles
2) Movement
movement of whole cells
provides “tracks” for movement of cellular components
cell division
3) Regulation
organizers structures and activities of the cell
regulation of cytoskeleton dynamics
Key Functions
Anchorage for cells
Structural support for tissues
Barrier functions for segregation of tissues from one another
Lubrication of joints
Regulates cell migration and intercellular communication
Local store for growth factors
Important for growth, wound healing and fibrosis.
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Composition of ECM
1) Polysaccharides
Properties of GAGs
Proteoglycans
Aggrecan - cartilage
Syndecan - cell surface Na+
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When compressed,
the water is 'squeezed out'. Molecules ‘slip' past each other due to repulsion.
Ehler-Danlos Syndrome
Defects in collagen processing enzymes and mutations in collagen genes.
Abnormally stretchy skin.
Osteogenesis Imperfecta
Defect in synthesis of collagen. Often type I collagen.
Defective ∝ chains. Inadequate bone mineralization
Brittle bones - High frequency of fractures
2) Proteins
Fibrous proteins
Bone Matrix
Proteins (Organic matrix) are synthesized first and then the minerals are added.
The vast majority of the organic matrix is collagen which provides tensile strength.
Type of mineralized ECM embedded with bone cells, blood vessels and nerves.
ECM↑, Cells ↓
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Polysaccharide ↓
Elastin
Rich in Pro & Gly, little OH-Pro Emphysema due to α 1 - antitrypsin deficiency
hydrophobic Neutrophils secrete elastase
Non-glycosylated
Elastase breakdown Elastin in lung tissue
Permits deformability and
passive recoil α 1 - antitrypsin inhibits Elastase
Smoking – oxidize Methionine of active site
of Antitrypsin
Marphan’s syndrome Leading to Emphysema (Chronic obstructive
Mutations in fibrillin gene pulmonary disease)
Elongated bones in fingers and
arms
Adhesive proteins
Fibronectin Laminin
(widespread) (In Basal Laminar)
Epidermolysis Bullosa
Cartilage
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ECM
Proteoglycan aggregates (Chondroitin sulphate, Keratin sulphate)
Collagen (Type II), Elastin
Osteoarthritis
Proteoglycans autoantigens
Destruction of the cartilage
Replacement by bones
Fibrosis
Excessive collagen production - over expression of collagen gene
Decreased activity of removing enzymes - decreased ECM degradation
Cancer
ECM barrier to cancer metastasis
Invasion requires cell adhesion, migration and protease activity
Wound healing
Mechanical support for cells and tissues
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Integration of cells into tissues. Provide framework for cell adhesion
Binds tissue to each other
Influence cell shape and movements.
Influence growth, proliferation and migration of cells
Influences cell development and differentiation. (Embryogenesis)
Serving as a medium for exchange
Aiding in defense and protection
Coordinates cellular functions through signaling with cellular adhesion receptors
Reservoir for extracellular signaling molecules
Regulation of filtration (Kidney glomerulus)
Regulation of blood clotting
(Damage to blood vessels Exposure of ECM Interaction of platelets with ECM)
Scaffolding for tissue renewal
ECM binding many growth factors and hormones
Migratory cells bind to ECM via - focal adhesions
Stationary cells bind to ECM via - hemi desmosomes
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BIO MEMBRANES
The composition of the membrane is dynamic
Structure
Lipid bilayer
Held together by non-covalent interactions
Components proteins
Carbohydrates covalently linked to proteins (glycoproteins)
Lipids (glycolipids)
Only in outer leaflet.
1. Lipids
Cholesterol
Hydrophilic head →
PI - minor phospholipid critical for signaling
Cardiolipin - a constituent of MC membrane exposed to water
Hydrophobic tails →
Lipids are amphipathic in interior
Enzymes
Used in DNA to target
delivery of Anticancer tissues.
drugs
2. Membrane proteins.
Transporter
Enzyme binding site Outside
Cell surface receptor
Cell surface identity marker
Cell adhesion Inside
Attachment to cytoskeleton Glycophorin
1) Asymmetry
2) Fluidity
3) Flexibility
4) Dynamic
5) Self-sealing
6) Selectively permeable
Flippase actively maintains the concentrations of PS and PE in inner membrane. Cell damage
leads to loss of membrane asymmetry
Carbohydrates mainly in outer leaflet
Phosphatidylserine
Anionic-Gives negative charge to cytoplasmic side of the membrane.
Their polar heads are small and hydrocarbons are more spread out and more suited for the
curvature
Cofactor for membrane bound enzymes
Eg: - Protein Kinase C, Na+/K+ ATPase
2) Fluidity
Amount of cholesterol
(Fluidity Buffer)
Type of phospholipids
a) Saturation
Unsaturated - high fluidity
b) Chain length
shorter the length-more fluid
Amount of cholesterol
Q. Briefly explain the role of cholesterol in maintaining the fluidity of the bio membranes.
The steroid cholesterol is wedged between phospholipid molecules in plasma membrane of
animal cells.
- OH groups of cholesterol are aligned with the polar head of phospholipids in the
membrane
It acts as fluidity buffer
At warm temperatures it controls the movement of phospholipids and reduces fluidity
At cool temperatures it maintains fluidity by preventing tight packing
3) Flexibility
4) Dynamic
1. Rotational mobility
2. Lateral diffusion
MEMBRANE TRANSPORT
Ion channels - allow passage of ions which are associated with water
Gap junctions
Transport ions connect the cytoplasm of two cells by 2 CONNEXONS
A connexon is made by 6 connexin proteins
Opening of gap junctions is inhibited by intracellular Ca2+.
Aquaporin
Transport water (too narrow for ion transportation)
Tetrameric transmembrane protein
Uniport
Transport single solute
Eg- GLUT 1 glucose carrier
Symport / cotransport
Two different solutes to be
transported
Gradient of one substrate drive
uphill transport of co-substance
Eg: - Glucose-Na+ symport
Antiport
Exchange one solute for another
Eg: -
Na+- H+ exchanger,
Cl-/HCO- exchanger
bands protein in RBC membrane
Symport and antiport are secondary active
transport methods
2) Active transport
Na+ / K+ ATPase
Na+/K+ ATPase binds 3 intracellular Na+
ATP phosphorylates protein with bound sodium
Phosphorylation causes conformational changes reducing its affinity to Na+, then 3 Na+
diffuses out
New conformation has higher affinity to extracellular K+
Binding of 2 K+ facilitates dephosphorylation of protein
Required to maintain osmotic balance and cell volume
Cell contain high concentration of solutes
Digitalis inhibits this pump, Careful use as a therapeutic benefit for heart patients
Q. Explain the molecular mechanism of acidification of the stomach lumen by parietal cells in the
gastric lining
Omeprazole inhibits the H+/K+
ATPase pump and used for gastric
ulcers
In the healthy state there are glucose-dependent and glucose independent methods of
absorbing Na+ in the gut
In diarrhoea glucose independent method is inactivated
The gene defective in cystic fibrosis codes for CFTR (cystic fibrosis transmembrane conductance
regulator)
Mobile Carriers(Ionophores)
Ions may be carried across by ionophores, small molecules that mask the charge of the ions and
allow them to diffuse through the lipid bilayer.
They transport ions down the concentration gradient to equilibrium,
Number of antibiotics function as ionophores
Eg: - Valinomycin
Two types
1) endocytosis
2) exocytosis
2) Exocytosis
Structure
DHF reductase
Dietary folate (DHF) THF
Homocysteine
N5 Methyl THF
Vit. B12
Methionine
Deficiency
Active form
Function
1. Methylation
2. Isomerization
Vit. B12
Methyl malonyl CoA Succinyl CoA
Bioavailability
Binding protein
In blood
Stored in liver B12+B12 binding protein
Causes,
Decreased intake (take several years to develop).
Impaired absorption (quicker).
Reduced secretion of gastric acid.
Reduced secretion of IF (autoimmune destruction of parietal cells).
Effects of deficiencies,
Pernicious anaemia;
Neuropsychiatric
symptoms
Need to give folic acid
throughout the life
Folic acid can partially reverse the haematological abnormalities of B12 deficiency, and therefore
Folic acid can partially reverse the hematological abnormalities of B12 deficiency, and therefore can
can mask the B12 deficiency. So treatment initiated with both folic acid and B12 until the cause of
mask the B12 deficiency. So treatment initiated with both folic acid and B12 until the cause of the
the anaemia is diagnosed
anaemia is diagnosed.
Functions
Other functions
Carnitine biosynthesis
Degradation of tyrosine
Tyrosine epinephrine, synthesis
Bile acid formation
Inhibit nitrosamine formation during digestion
Deficiency
4) Vitamin B1 (Thiamine)
Functions
5) Vitamin B2 (Riboflavin)
Active form
Functions
FAD/FMN FADH2/FMNH2
6) Vitamin B3 (Niacin)
Active forms
Functions
NAD+/NADP++ H + NADH/NADPH
Pellagra
8) Vitamin B6 (Pyridoxine)
Active form
Function
Function
Carboxylation reactions
Substrate product
Carboxylase-biotin-COO-
1) Vitamin A (retinoid)
Structure
Retinol
Retinal
Retinoic Acid
Visual Cycle
opsin
Rhodopsin
Importance of carotenoids
Deficiency To prevent retinol and carotenoid precursor are used as dietary supplement
Conjunctival xerosis
Night blindness is the earliest sign
Large bitot spot
2) Vitamin D
Functions of vitamin D
Functions as a hormone
Main function - Ca absorption and homeostasis
Maintains adequate plasma levels of calcium
When necessary, calcitriol can:
increase uptake of calcium by the intestine: by increasing the gene expression of calcium-
binding proteins
minimize loss of calcium by the kidney by increasing reabsorption
stimulate bone resorption (demineralization), synthesis and secretion of parathyroid and
thyroid hormone
Act like a steroid hormone - binds to nuclear receptor protein
Deficiency
Toxicity
Hyper vitaminosis D
enhanced calcium absorption and bone resorption → hypercalcemia
3) Vitamin E (Tocopherol)
β-Carotene as an antioxidant
Traps peroxy free radicals formed in tissues
Functions at low PO2
Complements vitamin E function in the body
vitamin E and β carotene compete with each other for antioxidant properties
Active form
Functions
ϒ carboxy glutamate
DNA
Stability
Denaturation
H bonding of the duplex DNA can be broken, and the two strands can be separated by
increasing the temperature
increasing the pH
specific enzymes.
Denaturation is a reversible process.
The temperature where half the duplex DNA is unwound is called melting point.
Process where the denatured complementary strands of DNA forms the duplex DNA.
Slow cooling of denatured DNA allows renaturation.
Hybridization
Denatured DNA when cooled in the presence of exogenous DNA, strand of DNA forms the
duplex DNA.
Depends on
Favourable temperature of the solution
Salt-ion concentration
Even if two sequences do not match perfectly, they can be hybridized. Used in disease diagnosis
(DNA annealing)
DNA PACKAGING
Supercoiling of DNA
Bending, twisting of the DNA helix(coil)
DNA ------- coil of DNA ----------- supercoil
Topoisomerases
Topoisomerase I Topoisomerase II
1) Cleaves one DNA strand 1) Cleaves both DNA strands
2) No energy required 2) Energy required (ATP)
3) Present in both prokaryotes and 3) Present in both prokaryotes and Eukaryotes
Eukaryotes 4) DNA gyrase (bacterial) - introduce (-ve) supercoils
Prokaryotes: Relaxes (-ve) supercoils Remove (+ve) supercoils
only 5) Eukaryotic topo 2 cannot introduce supercoils. It
Eukaryotes: can work on both (-ve) can only relax them.
and (+ve) supercoils 6) Linear daughter chromatids are separated by
Type II topoisomerases following replication.
DNA Gyrase
Euchromatin Heterochromatin
Poorly stained Darkly stained
Loosely packed Densely packed
Transcriptionally active Transcriptionally inactive
ds-DNA (2nm)
Chromosomes(700nm)
Histone acetylation/deacetylation
In bacteria
Key features of DNA Replication, (DNA – only molecule that can duplicate itself)
Semi-conservative - new strand built on parent strand, so, each DNA molecule consists of
one old (parental) strand and one new (daughter) strand. (Advantage – Replication errors
can be repaired)
Bi-directional - The two replication forks move in opposite directions.
Semi-discontinuous
Concept of Template
If the sequence on one strand is given, then the sequence of the other strand is
automatically determined. (complementary base pairing)
Uses DNA as a template to synthesize new DNA by catalyzing chain growth (phosphodiester
bonds) in 5´ to 3´direction.
This requires,
A template
A primer with a free 3´ OH
Deoxynucleotides in the form of tri-Phosphates (PP released in reaction)
1. 3´ to 5´exonuclease activity
Proofreading activity replication fidelity
(Removing wrong nucleotides & replace)
2. 5´ to 3´exonuclease activity
Removes nucleotides from 5´end.
This is used in removal of RNA primer and DNA repair.
3’ to 5’ exonuclease 5’ to 3’ exonuclease
Important for proof reading function Important for removal of “RNA
of DNA polymerase I primers”
Can remove wrong nucleotides and Removes nucleotides from 5’ end
replace
Removes only mismatching points Removes matching pairs also
Removes only one nucleotide Can remove a large part
Only remove deoxyribonucleotides Remove both deoxyribo and
ribonucleotides
Primase
Initiate the DNA replication.
DNA polymerases require a free 3 OH group, so, DNA polymerases can’t initiate the
replication.
Primase is a RNA polymerase, that synthesize a short sequence of RNA in a template
dependent manner known as the primer.
Then DNA polymerases, extends from the 3’ OH of that short RNA strand to form DNA.
Topoisomerases
DNA ligase
1) Initiation
Occurs at a single specific site called ‘origin of replication’ (oriC). It is a highly conserved A:T
rich repeat sequence.
a) DnaA (Initiation factor) binds to ‘oriC’ and induces melting of DNA strands.
b) DnaB (Helicase) binds and begins further unwinding of DNA strands – requires ATP.
c) SSB binds and stabilize ssDNA. Also protect ss from inappropriate attacks from nucleases.
d) Primase binds and synthesizes RNA primer. Separate two single strands.
e) Topoisomerases relieve topological strain.
f) DNA pol III binds and begins to add dNTPs – deoxy nucleotide triphosphates, to the
primer.
2) Elongation
Leading strand
Continuous synthesis
Chain elongation in the same direction as replication fork movement.
Lagging strand
DNA polymerase - I,
DNA Ligase
3) Termination
Replication forks from bi-directional replication run into each other and terminates Or One fork
STOPS and WAITS for the other.
Events that occur at the terminus that result in separation of daughter strands.
In the lagging strand, synthesis at the 5’ end cannot be completely done because the
primer cannot be laid down at the very end of the chromosome.
Therefore, each time cell divides, a small part of the 5’ end will be lost from the
chromosome end, making the chromosome shorter.
This end replication problem is overcome by addition of G+T nucleotides at the 3’ end of
parental strand
These added sequences are known as “Telomeres”, which are special DNA sequences
found at the ends of eukaryotic chromosomes. They are essential for genome stability.
Telomeres are several thousand bases of tandem repeats. The G T rich region at the
3’end of one strand extends as a single stranded G rich overhang (G tail) and fold back
on itself.
Addition of the bases at the 3´ end is done by the “Telomerase”
Ribonucleoprotein complex
Has an RNA template
Has Reverse Transcriptase activity.
Has other proteins for binding of DNA.
Telomerase recognizes the G rich single stranded 3´ end of the parent strand and elongates it by
copying its RNA template. It contains both template and enzyme activity.
Retroviruses
During replication
HIV Reverse transcriptase is 10 times less accurate than other reverse transcriptase
enzymes, therefore they have very high rate of evolution
RNA
1. RNA – Translated into proteins
mRNA 5%
2. Structural / Functional RNA - Not translated
rRNA - An integral component of ribosome 80% [Some rRNAs functions as catalysts
(rybozymes)]
tRNA - Involve in translation 15%
snRNA - Involve in RNA splicing
scRNA - Involve in protein trafficking
Transcription
The synthesis of RNA molecules using DNA strands as templates so that the genetic information
is transferred from DNA to RNA.
Promoter - The nucleotide sequence upstream of a gene, that acts as a signal for RNA
Polymerase binding
Exons - coding DNA segments of eukaryotic genes.
Introns - non-coding DNA segments of eukaryotic genes. (intervening sequences)
(Transcripted but not translated. They are removed to produce mature mRNA)
The enzyme responsible for the RNA synthesis is DNA dependent RNA polymerase.
But RNA polymerase is 100% processive.
Multiple subunit protein.
3 types
Enzyme Transcription
RNA Polymerase I rRNA
RNA Polymerase II mRNA, some SnRNAs
RNA Polymerase III tRNA, SnRNA, ScRNA
Unlike prokaryotic RNA polymerases eukaryotic RNA polymerase 2 can’t recognize the
promoter.
Therefore, transcription factors do it
Eg: TF II D
1) Initiation
2) Elongation
3) Termination
Bubble moves forwards by unwinding in front & rewinding behind the DNA strand.
DNA-RNA base pairing CG GC TA AU
Promoters
Transcription Bubble
PROKARYOTES EUKARYOTES
Transcription & Translation occurs Transcription in the Nucleus
simultaneously Translation in the cytosol
One type of RNA polymerase 3 types of RNA polymerase
Polycistronic - mRNA codes for more Monocistronic - mRNA codes only for one
than one gene gene
Most part of DNA is accessible to Only small amounts are accessible
transcription
mRNA doesn’t show post All mRNA, tRNA, rRNA undergo post
transcriptional modification transcriptional modification
INHIBITOR EFFECT
Rifampicin(on prokaryotes) Inhibit transcription by binding to
RNA polymerase (prevent chain
extension beyond 8 nucleotides)
Blocks initiation
Actinomycin D (on both Intercalate between DNA base pairs.
prokaryotes and eukaryotes) – Stop movement of RNA polymerase.
Cancer drugs RNA elongation inhibitor.
Both prokaryotes & eukaryotes
α amanitin (on eukaryotes) – poisonous Eukaryotic RNA polymerase II inhibitor
mushrooms
1) mRNA
Modification Function
1) Addition of the 7-methylguanosinecap at the Prevent nucleases from destroying the
5’position (5’capping) transcript
Occur at the beginning of transcription Ribosome recognition
Enzyme - Guanylyl transferase Transfer of the transcript to the cytoplasm
2) Adding the poly A tail to the 3’ position Stability
At the end of transcription Transfer of RNA to the cytoplasm
Enzyme - Poly A polymerase
3) Splicing – Removal of Introns & joining Make exon intron boundaries recognizable by
together off exons by SNURP SNURP
Catalyze the removal of introns, based on
conserved sequences
2) tRNA
Remove introns
3’ end is cut off and replaces by a CCA sequence
Removal of the leader sequence
Some base modifications
Replication Transcription
Template Both strands Single strand
Substrate dNTP NTP
Primer Yes No
Enzyme DNA Polymerase RN Polymerase
Product dsDNA ssRNA
Base Pairs A-T, G-C A-U, T-A, G-C
THE GENE
Genetic code-information in the cell is stored in the form of linear sequence of nucleotides in
DNA
The code has 4 different letters- A, C, G & T (4 bases)
The code is composed of triplet codes/codons. eg - AGC, CTC, TGG
Each codon codes for one amino acid.
There are 64 different codons. ( 𝟒𝟑 = 𝟔𝟒 )
But only 61 of them code for amino acids. (rest of them are stop codons) (61 codons-->20 AAs)
A series of codons in DNA that coding for a protein is a GENE.
Universal (almost) - The code is almost the same for all the living organisms.
wobble hypothesis
Pairing of 3rd base in codon (wobble base) with 1st base of anticodon isn’t strong, but
other 2 base pairs follow strong Watson & crick pairs.
Genetic Code 61 codons Coding for 20 amino acids
All 61 codons do not have individual tRNA to pair.
Therefore, more than one tRNA can bring one amino acid, because non tradition base pair
can occur.
e.g. - anticodon- (3’) XYU (5’)
codon - (5’) YXA (3’) or (5’) YXG (3’)
So the 1 base of the anticodon determines the number of codons read by a given tRNA
st
tRNA
Ribosomes
Small subunit
mRNA binding site
Large subunit
A site (Aminoacyl tRNA binding site)
P site (Peptidyl tRNA binding site)
E site (tRNA exit site)
1) Initiation
Ribosome binds to mRNA and 1st AA, attach to its tRNA
Involves the assembly of 2 ribosomal subunits, Aminoacyl tRNA, GTP & initiation factors
2 subunits of ribosome separate
30S subunit joins mRNA near 5’ end, the P site opposite the initiation codon.
Shine-Delgano sequence
Shine Delgano sequence is a ribosomal binding site which located, just upstream of the start
codon (AUG) in the prokaryotic mRNA. It base pairs with the end of rRNA of 30s small subunit
& helps to position & recruit the ribosome.
But eukaryotic mRNA doesn’t contain a ‘shine delgano sequence’, so in eukaryotes 40 s
small subunit binds to the 5’cap region of the mRNA & scan for the start codon (AUG).
This process requires ATP.
fMet-tRNA binds to AUG forming 30S initiation complex (fMet-tRNA is the only tRNA which
goes into the P site)
50S subunit binds to 30S initiation complex forming 70S initiation complex.
Ribosomes add 1 AA at a time to carboxylic end of growing polypeptide chain, GTP required
Ribosome translocates by 3 bases after peptide bond formed.
New charged tRNA aligns in the A site.
Peptide bond between amino acids in A and P sites is formed by peptidyl-transferase.
Ribosome translocates by three more bases.
The uncharged tRNA in the P site is moved to the E site.
Translocation: translocation of the new peptidyl t-RNA with its mRNA codon in the A site
into the free P site occurs.
Now the A site is free for another cycle of Aminoacyl tRNA codon recognition and
elongation. Each translocation event moves mRNA one codon length through the
ribosomes.
3) Termination
Prokaryotes Eukaryotes
70s ribosomes 80s ribosome
Prokaryotic mRNA is polycistronic. Eukaryotic mRNA is monocistronic.
Initiator Met-tRNAi or Met-tRNAf Initiating tRNA carries methionine
carries formyl- methionine
Prokaryotic mRNA has specific purine rich No specific purine-rich sequence.40s subunit
‘Shine Delgano sequence’ on the mRNA. binds to 5’ cap region and scan for the first AUG
Fewer translation factors Many translation factors
Elongation GTP driven translocation Similar to prokaryotes but specific elongation
factors
Termination carries out by 2 release Termination in eukaryotes is carried out by a
factors single released factor eRF 1
Chaperones
Proteins in the cell which assist the covalent folding or unfolding
They guide folding of proteins present in cytosol, lumen of RER, mitochondria, etc.
Chaperones promote the assembly of protein complexes from subunits.
Prevent the aggregation of unfolded proteins.
Protein folding
BiP (hsp) helps to fold protein correctly.
ATP
Open state confirmation, BiP-ATP
BiP weakly binds to target protein
hsp 40;
helps to hydrolyze ATP to ADP
conformational changes that causes BiP-ADP
BiP to clamp tightly to hydrophobic
region of the protein
This process is repeated over and over until protein is folded into its final form.
PTMs in Prokaryotes,
Protein folding
Removal of the Signal Peptide
Removal of Formyl – Methionine from the N terminal
PTMs in Eukaryotes,
Protein folding
Removal of the Signal Peptide
Removal of Methionine from the N terminal (initial Amino Acid)
1) Proteolytic cleavage
2) Disulphide bond formation
3) Glycosylation
4) Methylation
5) Phosphorylation
6) Lysosomal targeting of enzymes
7) Ubiquitination
8) S-Nitrosylation
9) Acylation
10) Sulfation
11) Vitamin C- dependent modification (Hydroxylation)
12) Vitamin K dependent modifications
2) Covalent attachments
a) Hydroxylation
Eg: In collagen synthesis; hydroxylation of selected proline and lysine residues of pro α chains.
Prolyl hydroxylase
Proline Hydroxy proline
Vit C= Ascorbic acid
Lysyl hydroxylase
Lysine Hydroxy Lysine
Vit.C = Ascorbic acid
Ascorbic acid is required for this process. So, Vit.C deficiency leads to scurvy.
b) Glycosylation
Enzymatic addition of oligosaccharide molecules into the peptide chain about 50% of
eukaryotic proteins are glycosylated
Attached glycosyl residue determines the function of the glycoprotein
predominated by mannose, glucose, galactose, GALNAC, GLCNAC, NANA
Eg:
In collagen synthesis
Glycation of Hb
[Fructosamine] α Average blood glucose concentration over the previous 1-2 weeks
Fructosamine
c) Phosphorylation
Selected serine side chains of Histone proteins are phosphorylated DNA packaging is
altered.
Glycogen synthase Glycogen synthase
(Active) (Inactive)
Eg:
Insulin – 2 interchain S-S bonds
1 intrachain S-S bonds
S-Nitrosylation
NO is a chemical messenger. It reacts with free cysteine residues to form
S-nitro thiols (SNOs).
S-Nitrosylation is a critical PTM used by cells to;
stabilize proteins
regulate gene expression
provide NO donors
Lysosomal enzymes are synthesized in RER and modified in the Golgi apparatus.
A carbohydrate moiety, mannose-6-phosphate label (man 6-PO4) is tagged to direct these
hydrolytic enzymes to lysosomes.
Man 6-PO4 is bound by a specific glycosyltransferase or phosphotransferase.
Man 6-PO4 acts as a Targeting signal that is identified by receptor that target the protein into
lysosomes.
Defective phosphotransferase in the Golgi → cannot add PO43-to the mannose residue.
Enzymes are not targeted to direct it to lysosome but excreted outside the cell.
Partly digested materials (oligosaccharides, lipids, GAGs, etc.) accumulated within lysosomes.
Defective lysosomal enzymes are found in high concentrations in the blood and urine.
(lysosomal enzymes are normally found only within lysosomes.)
Signal hypothesis
This explains how proteins destined for secretion are synthesized.
Free ribosomes in the cytosol are directed to the ER by the presence of a signal peptide in the
protein being synthesized.
Signal peptide; ~18-36 AAs near the N-terminal of the chain
Absent in the mature protein
Direct the ribosome to ER
Protein synthesis in ER
ER synthesize proteins which are to be exported out of the cell (Eg: Insulin, Collagen)
Signal hypothesis Explains how proteins destined for secretion, are synthesized
Signal sequence,
Free ribosomes in the cytosol are directed to the ER by the presence of a signal
peptide in the protein being synthesized.
Absent in the mature protein.
DNA
DNA Damage
Repaired DNA
DNA replication
Normal DNA DNA mutations
Different types of mutations
DNA damage
DNA damages can occur due to various reasons, but they can be mainly categorized into,
1) Endogenous damages
2) Exogenous damages
If these damages occur in germ cells, they are inherited by offspring if not repaired, but
unrepaired damages in somatic cells affects individual only.
a) Base damage
Modification of bases
2. Adenine Hypoxanthine
Deaminated A pairs with C
2. Cytosine
Amino form Imino form
Tautomerized C pairs with A
Loss of bases
b) Replication errors
Replication errors are the main source of mutations because DNA polymerase is not
perfect.
Replication errors can be due to,
Base pair mismatch - a wrong base can be added by DNA polymerase during replication.
Insertions or deletions - repeat sequence regions are more prone due to strand slippage
by DNA polymerase
Eg: - Single nucleotide repeat
c) Recombination errors
d) By products of metabolism
e) Alkylation
a) Chemicals (mutagens)
Natural
in food - (Aflatoxin)
Food preservatives
Benzopyrene
Polycyclic aromatic hydrocarbons, which alters the DNA structure, from coal, cigars & etc.
Bulky lesions
Intercalating agents
Alkylating agents
UV radiation
cannot penetrate beyond the outer layer of the skin, so it mainly leads to
formation of pyrimidine (Thymine - Thymine) dimers.
Ionizing radiation
penetrate the whole body, so they can cause both somatic & germ line mutations.
Eg: -
α, β, γ particles
X rays
2) Indirect damage
water dissociates to H* & OH* (radiolysis of water) under α radiation
free radicals cause DNA / RNA damage
Process which enables the link between DNA damages & the relevant Damage repair mechanisms.
Activation of a cell cycle checkpoint
Carrying out DNA repair mechanisms
Initiation of cell apoptosis when the damage is severe
Damage Reversal
Damage Removal
Repair double strand breaks caused by high energy radiation and oxygen free radicals
Few bases lost, if wrong ends are joined, Crossing over/strand exchange
mutations can happen
Resulting gap in sister chromatid filled by
polymerase
Triplet expansion
Missense Nonsense
Base pair substitutions Net change result in stop codon Increasing the number of
Eg: β globin gene – Forms truncated proteins triplets in sequence
substitution of Premature termination Eg:
Valine in 6th place of translocation of Huntingdon’s disease
instead of Glutamate proteins accumulation of protein
Causing change of cell Eg: aggregates
shape Cystic fibrosis neuro-degenerative disease
Leads to sickle cell Duchene muscular dystrophy Fragile X syndrome
anaemia β thalassemia
Prokaryotes
are unicellular or colonial
evolved to quickly exploit transient resources
gene regulation is to allow cells to adjust to changing conditions
different genes are active in the same cell at different times
Eukaryotes
are multicellular organisms
evolved the ability to maintain a stable internal environment -Homeostasis
gene regulation is to allow specialization / differentiation & division of labor among the cells
different genes are active in different cells at the same time
c) Inducible genes
genes that are transcribed & translated at higher levels in response to an inducible factor
d) Repressible genes
genes whose transcription & translation decreases in response to a repressing signal
Induction or repression can be due to,
1. environmental change
2. position of the cell cycle
Chromatin Structure
2) Heterochromatin
highly condensed regions which contain the transcriptionally inactive genes
difficult to access by RNA Polymerase
two forms of Heterochromatin,
1. Constitutive Heterochromatin
permanent organization
contain no genes
Eg: Centromeric & Telomeric regions of human Y chromosome
2. Facultative Heterochromatin
not permanent
contain genes that are inactive in some cells or at some periods of the cell cycle
Eg: Barr body formation in females (X inactivation)
Chromatin Modifications
Histone modifications
Histone proteins in a nucleosome should move (rearrange) to express or depress a gene, but
this movement is dependent on signals found on both the histone proteins & on the DNA.
These tags do not alter the DNA base sequence, but they alter the gene expression by changing
the arrangement of histone proteins
DNA Methylation
Methylation occurs within very specific regions called CpG islands. These are stretches with
a high frequency of Cytosine (C) & Guanine (G) dinucleotide DNA pairs found in the
Promoter regions of genes (~ 56 % of human genes).
2) Hypo methylation
Eg: Proto oncogenes leads to cancer
Non-communicable diseases
epigenetic modifications occur in response to cellular environment, such modifications
occurring at key stages in fetal development are now thought to play a role in subsequent
development of Obesity, Diabetes & etc. later in life.
Eg: Exposure of fetus to high glucose environment in mother with Gestational Diabetes
Mellitus (GDM).
Genomic imprinting
epigenetic mechanism, where one allele of a gene is silenced by methylation, in a parent of
origin specific manner.
Mutations to unimprinted (expressed) allele, may lead to diseases.
Eg: Prader-Willi Syndrome
Angelman Syndrome
Enhancers/silencers
Cis acting sequences
Distal control element act on more than one
promotor
Regulatory DNA sequences that
increase/decrease transcription of genes in
vicinity
15-25 bp
promoters Upstream/downstream or within the gene
Bind with transcription factors
Found upstream
Enhancers/silencers for regulatory proteins or
Proximal control element
specific transcription factor s are called as
Determines the strength of the promoter
response elements
Activators Co-activators
Bind to enhancers & stimulate transcription Proteins, which serve as a physical bridge
2 domains between the activator & the RNA
DNA binding domain polymerase.
Eg: Zn finger motif They consist of 2 types of binding sites
leucine zipper 1) polymerase binding sites
homeodomain, 2) Activator binding sites
basic helix-turn-helix Eg: Histone Acetyl Transferases(HATs)
Transcription factor binding domain
Binding sites for Coactivators
Variable
Increase transcription by 100-fold
HRE is a common cis acting regulatory element present in genes, which need to coordinate their
expression, to affect a particular response.
HREs bound by particular trans-acting factors under particular conditions to effect gene
expression.
Eg: lipid soluble hormones bind to specific soluble intracellular receptors, which functions as
trans-acting factors to a particular HRE.
Steroid hormones, thyroid hormones, retinoic acid, calcitriol
Post transcriptional regulation, allow a cell to fine-tune gene expression. There are various
regulatory mechanisms of gene expression at this level.
RNA editing
modification of nucleotide sequence after transcription.
Eg:
mRNA stability
length of time an mRNA remains in the cytosol before it is degraded, influences how much
proteins are produced from that mRNA.
binding of proteins called RNA binding proteins (RBPs) to the regions of the RNA just
upstream or downstream of the protein coding region, can influence its’ stability.
These regions in the RNA that are not translated into proteins, are called the Untranslated
regions (UTRs).
They are not introns, but these are the regions that regulate,
mRNA localization
stability
protein translation
Excess free Iron (Fe) in cell causes cell damage, so cellular iron uptake & storage must be
tightly regulated, because there is no proper excretory method of Iron, in humans.
Mechanism of gene silencing mediated by short non-coding micro RNAs. They decrease
expression of mRNA by,
Repression of translation
Increased degradation
Micro RNAs are derived from longer dsRNAs, which are cleaved by an endonuclease (Dicer) &
associate with cytosolic protein complex (RISC).
They bind to complementary sequences in target mRNAs to exert their silencing effect.
The use of short regulatory RNAs to block the translation appears to be important for
developmental regulation.
Increase or decrease in miRNAs play a role in diseases by altering gene expression.
In prokaryotes, regulation of gene expression mainly done via operons, but eukaryotes lack
operons.
Operon is a functioning unit of DNA containing a cluster of genes which are acting together &
expressed under the control of a single promoter.
Eg: Lac Operon - contains 3 genes
Try Operon - contains 5 genes
Definitions:
Recombinant DNA – Creation of a new combination of DNA not found naturally
DNA Cloning – making genetically identical copies of DNA/genes using a cellular process
Amplification – making lots of copies of a selected fragment of a genome using either DNA
cloning or PCR
Restriction Enzymes
Isolated from bacteria (bacteria uses to kill viruses)
Not affect to bacterial DNA, their DNA has methylated sequences
Recognize specific DNA sequences (palindromes)
Does not cleave RNA, only dsDNA
Cleave at specific sites, within/close to recognition sequence.
Cleave both strands at a specific site – Endonuclease activity
produce Blunt Ends (Hae III) or Sticky Ends (Eco RI/TAQI)
5’
5’
CCGG3’ 5’
CC3’ 5’
GG3’ 5’
GAATTC3’ 5’
G3’ AATTC3’
3’GGCC5’ 3’GG5’ 3’CC5’ 3’CTTAAG5’ 3’CTTAA5’ 3’G5’
DNA Ligation
Joins DNA fragments of compatible termini via phosphodiester bonds (ATP needed)
Enzyme – DNA Ligase
Cloning Vector
Extraction and
Purification of Insulin protein
Collection of DNA Clones (transformed bacteria) that together represents the entire genome
of an organism
cDNA Library
Collection of DNA clones (transformed bacteria) that represents the expressed genes in an
organism
cDNA libraries,
Are smaller than a genomic library
May vary according to
Particular tissue
Particular developmental stage
Particular conditions (e.g. disease states)
Can be used to synthesize eukaryotic proteins as cDNA has no intervening sequences (i.e.
no introns, only the expressed exons)
Library Screening – Finding the gene of interest in a DNA Library. Can use the following
techniques:
Extraction of plasmid DNA
Restriction enzyme digestion
Agarose gel electrophoresis
Southern blotting
Hybridization
DNA sequencing
Denaturation
Probe: A short piece of ssDNA or RNA labeled with radio isotope (eg: - 32 P) or a non-
radioactive molecule (eg: - Biotin, Fluorescent dye)
Temperature
Salt concentration
Denaturing agents (urea, formamide)
High molecular weight polymers (dextran sulphate)
Shear forces
Southern Blotting
DNA Sequencing
Sanger’s method – use dideoxynucleotides
Used to identify the nucleotide sequence in a DNA fragment
Steps involved
1. Denaturation of dsDNA
2. Annealing ssDNA with a primer
3. Extension by a DNA polymerase and 4 types of deoxynucleotides
4. Termination due to ddNTP
ddNTP lacks a 3’-OH, therefore chain elongation stops
4 different types of dideoxynucleotides are added to 4 different samples
5. So bands with same terminal nucleotide can be separated and the sequence can be read by
6 © 2017 A/L Repeat Campaign
Agarose gel electrophoresis
Autoradiography
(Refer page 487, Lippincott)
Amplification of specific DNA fragments in vitro (i.e. a cell-free DNA amplification system)
Requirements:
Template DNA
DNA primers (×2) – specify target DNA fragment (3’OH end should be pointed towards
target sequence)
DNA polymerase – Thermostable DNA polymerase (e.g. Taq polymerase)
Deoxynucleotide triphosphates (dATP, dGTP, dCTP, dTTP)
Buffer
Applications of PCR:
1. Genetic disease diagnosis
2. Detection of infectious diseases – Dengue, Malaria, Tuberculosis
(Using primers specific to pathogen’s DNA)
3. DNA fingerprinting (DNA typing/ DNA profiling)
DNA Fingerprinting
The variability of the size of fragments obtained from the same restriction
enzyme digestion
Digest DNA with restriction enzymes
↓
Gel electrophoresis
(Separate DNA fragments by size)
↓
Southern blotting
(Obtain ssDNA copy in nitrocellulose)
↓
Hybridize with a radio-labelled probe & Wash the blot to remove excess probes
↓
Autoradiography (Expose to X-ray film and develop)
Specific examples are given later on in this note (see below).
The variability of the size of the PCR products obtained with the same random primers
(Use of PCR on the genomic DNA with an arbitrary oligonucleotide primer results in
amplification of several discreet DNA products)
RAPD technique is not used that much. Instead, we use the AFLP technique given below.
AFLP uses a combination of features of RFLP and RAPD for the amplification of a set of
fragments using selective primers.
Since PCR is efficient at amplifying only small fragments,
Example for use of AFLP for analyzing SSRs/STRs to identify two people:
A B
Rohini
CACACACACA
A B
Rohan
CACACACACACACACACACAC
A and B are the primers for PCR – by using 2 primers the selected region can be
specifically amplified (microsatellite marker – PCR primers designed from unique
flanking DNA)
PCR products differ in length, depending on the number of repeat units (copy number)
Since the PCR product is a single amplified segment, the use of Southern blotting and
hybridization is not needed
Rohan
1) In analysis of SNPs
Features of SNPs:
A single base pair is changed
Leads to creation or removal of a restriction endonuclease site
Examples:
In sickle cell anaemia → single base pair subs tu ons in β-globin gene removes an
existing site
DMD (deletions in dystrophin gene)
Cancers (various mutations)
Using a radio-labelled probe that binds to sequence in the larger fragment in a normal person, after
gel electrophoresis:
1 2 3
2) In analysis of VNTRs
3) In Paternity Testing
Paternity testing using RFLP uses analysis of VNTRs of the child, mother and the suspected
fathers
The corresponding alleles of a child come from the father and the mother
A couple complained to the police that their male infant war lost from the maternity ward. The
police investigations detected a suspected woman with a male infant. Outline a DNA typing
method to prove beyond a reasonable doubt that the complainant couple is the true parents of
the infant. (50)
Method used here is (VNTR analysis) using RFLP
DNA is extracted from infant, couple and suspected woman
All four DNA samples are cleaved using same restriction endonuclease enzyme
Restriction fragments are subjected to gel electrophoresis on an agarose gel/
polyacrylamide gel
Restriction fragment pattern is transferred from gel into a nitro cellulose paper by southern
blotting
In that procedure dsDNA is made single strand DNA and immobilized
A suitable radiolabeled probe is added to the filter paper and hybridization is allowed
Excess probes are washed out
Autoradiography is performed using X-ray film
X-ray film is developed
Each DNA band of the infant must correspond to either the mother’s or father’s DNA bands.
If such correspondence is found when comparing the infant’s DNA band pattern and if such
correspondence is not found with the suspect woman, the couple’s DNA band pattern then
the complainant couple are the true parents of the infant
12 © 2017 A/L Repeat Campaign
CELL CYCLE
Features,
Composed of orderly sequence of biochemical events.
Directional
Leads to the production of two daughter cells containing chromosomes that identical to
parental cells.
Eukaryotic cell cycle take place in a highly coordinated fashion. It consists of several phases &
gaps.
Cyclin-dependent Cyclins;
Protein kinases (CDK) - the regulatory subunits
- catalytic subunits of CDK
Cyclins
Serves as regulatory subunits of CDKs. It binds and activates its specific CDK.
Important in cell cycle control & that depends on their concentration. Concentrations
fluctuate with the phases of the cycle, due to changes in synthesis & degradation.
Cyclin-CDK complex phosphorylates other proteins to control cell activities.
Differential synthesis of CDKs & cyclins → The levels of kinases present are constant. Levels of
cyclin proteins fluctuate cyclically. So activity of one
cyclin-CDK complex is proportional to corresponding
cyclin concentration.
Sense problems that may occur during DNA synthesis & chromosomal segregation.
Minimize the occurrence of mistakes in cell cycle events.
Ensures that;
chromosomes are intact
each stages of the cell cycle are completed before the following stage is initiated.
Mdm2-p53 p53
Causes of cancer
5) Angiogenesis
Formation of new blood vessels
Cancer cells secrete angiogenic factors - VEGF (Vascular Endothelial Growth Factor)
VEGF stimulate endothelial cells to grow, divide, proliferate & survival
Bind to receptors on endothelial tissue
Endothelial cells become activated
Release enzymes for proteolytic degradation (Metalloproteinases & Plasminogen
activators)
Metalloproteinases digest the ECM
Plasminogen system is activated &
Break down basal lamina
Cells migrate through basal lamina into surrounding tissue
Express integrins to attach to new locations
Divide and develop into a mature blood vessel network
Steps in metastasis,
Contact inhibition
Contact with the cells inhibits cell proliferation and movement.
Limited proliferation capacity
Normal somatic cells have a limited number of divisions they can do. (telomeres wear out)
Loss of telomeres which occurs normally during DNA replication limits the number of cell
divisions.
Normal tissues
Rate of new cell growth = Old cell death rate
The balance between cell apoptosis & survival signals, allow the controlled homeostasis of
the tissue
But in cancer cells survival signals triggered by oncogenic transformation favors
uncontrolled growth
Epigenetic Genetic
Occurs outside the coding sequence Occurs inside the coding sequence
Eg: Promoter/enhancer silencing
Mutations of DNA
2) Amplification
resulting in many copies of same gene in the genome which lead to
overproduction of the same normal protein.
Normal function - inhibit cell proliferation when necessary & regulates the cell cycle.
Eg: P53 gene, Rb gene
They become oncogenes by loss of function mutations
Mutated gene acts recessively
So both gene copies should be defective for the action to be lost.
Absence/ inhibition of inhibitor uncontrolled cell proliferation
P53 is a key enzyme of cell cycle regulation & most frequently mutated gene
P53 exists in a normal cell at low concentrations
During stress conditions it accumulates and the concentration increases (DNA damage,
Hypoxia & etc.)
Protein kinases and acetyl-transferases are activated
Results in stabilization and activation of P53 within nucleus
Phosphorylated or acetylated P53 interacts with DNA at P53 response elements of target genes
Induce transcription of genes involved in DNA repair
Arrests cell cycle till repair is complete
Once complete P53 is degraded and cell cycle restarts
If damage is extensive, cell apoptosis is started
If P53 is Inactive, a damaged or mutated cell will continue to proliferate instead of
starting to apoptosis & mutated P53 is often associated with resistance to anti-cancer
drugs.
Some cancers are caused by epigenetic changes. This refers to heritable changes in gene
expression that occur without alteration in DNA sequence.
2 mechanisms
Arrangement of genes
Repeat sequences
Interspersed Repeats
2) Tandem repeats
Tandem Repeats
Mutation - differences in DNA sequence in an individual that are rare, may be unique to the
individual or family line, occur in coding/ regulatory region. (<1% in population)
Importance of SNPs
𝐸 + 𝑆 → 𝐸 − 𝑆 𝐶𝑜𝑚𝑝𝑙𝑒𝑥 → 𝐸 − 𝑃 𝐶𝑜𝑚𝑝𝑙𝑒𝑥 → 𝐸 + 𝑃
Enzyme Classification
Cosubstrate
Only transiently
associated with enzyme.
Dissociate in an altered
state.
Coenzyme
Eg: - NAD+
Small Organic
molecules Derived from
Vitamins
Prosthetic Group
Non protein moiety
Permanently associate
Cofactor with the Enzyme.
Metal Ion Eg: - FAD+
Eg: - Zn2+/Fe2+
Cu2+/Mn2+
Catalyze same reaction, but has different primary structures, therefore different
kinetic properties.
Eg: Creatine kinase CK-1, CK-2, CK-3
LDH
→ (Refer Medical Diagnostics)
Creatine kinase ;
𝑉𝑚𝑎𝑥 [𝑆]
𝑉𝑜 =
𝐾𝑚 + [𝑆]
V0 = Initial Velocity
[S] = Substrate Concentration
Km = Substrate Concentration at half Vmax
Vmax = Maximum Velocity
Km changes with
1. Temperature
2. pH
3. Structure of Substrate
1) Substrate Concentration.
Velocity = No. of substrate molecules converted to product per unit time (μmol/min)
3) Effects of Temperature
vo
Enzyme Concentration
Enzyme inhibitors
Any substrate that can diminish the velocity of an enzyme catalyzed reaction is called “inhibitor”.
Enzyme
inhibitor
E+I EI
Ki affinity of I
Ki affinity of I
Competitive Non-Competitive
Active Site Active on active site Not on Active site
Structure of inhibitor Structural analogues. Unrelated molecules
Substrate and inhibitor are
chemically similar and have
similar shapes
Effect on Active site Inhibitor does not change Inhibitor changes the
active site shape of the active site
Inhibition Reversible Generally irreversible
Excess of Substrate Inhibition relieved No effect
E+S ⇌ ES ⇌ E+P E+S ⇌ ES ⇌ E+P
+I +I +I
EI EI ESI
Inhibitor binds with Enzyme Enzyme or ES complex
Km ↑ Unchanged
Affinity ↓ Unchanged
Vmax Unchanged ↓
1) Statins
2) Sulfa drugs
Alcohol dehydrogenase
Methanol Formic acid → Metabolic acidosis and tissue injury
-
Ethanol
Uncompetitive Inhibitors
ESI
1. Suicide inhibitors
Allopurinol- blocks the actions of Xanthine Oxidase by substrate competition and is also
metabolized by it to form Alloxanthine. (Suicide Inhibition)
Alloxanthine – A non-competitive Xanthine Oxidase inhibitor
2. Proteinase inhibitors
c) Proteinases and their inhibitors play a major role in cancer metastasis. (E.g.: Genetic
deficiency of α1 proteinase inhibitors)
Suicide inhibitors
Substrate inactive
Product is the inhibitor non-dissociable complex with the enzyme
Protease inhibitors
Inhibitor analogue of substrate and forms a non-dissociable complex with the enzyme
Allosteric
Enzymes
Short Term
Covalent
Regulatory Modification
Enzymes
Regulation of
Long Term
Enzyme Synthesis
A. Allosteric enzymes
Enzymes
Effectors
bind with Have active and
modulatory modulatory site
site non
covalently
Frequently
catalyze Activated by
the Substrate
committed and other
step in a positive
pathway Allosteric modulators
Enzymes
Do not
obey
Michaelis Inhibited by
end products
Menten
Kinetics
Normally
composed of
Catalyse an multiple
irreversible
subunits
reaction
(Identical/
different)
Negative Effector->
Inhibits enzyme
(Km↑ Vmax↓)
Effectors of By Activity
Allosteric Positive Effector->
(Km↓ Vmax↑)
Enzymes
Changes
Km Homotropic Effector->
Vmax Effector = Substrate
By Type of
Both Substance
Heterotropic Effector->
Effector ≠ Substrate
I. Homotropic effectors
Effector ≠ substrate
i.e. feedback inhibition
Glycogen phosphorylase
B. Covalent modification
Addition/removal of groups
Phosphorylation and dephosphorylation
Phosphorylation by protein kinases
Dephosphorylation by phosphoprotein Phosphatases
Some Enzymes are active when phosphorylated
Some are inactive
Cells can regulate not just the activity of an enzyme, but the synthesis or degradation
Increase in synthesis -> Induction
Decrease in synthesis -> repression
Eg – Effect of Insulin Glucagon on enzyme activity during fasting
1) As therapeutic reagents
2) Enzyme activity in body fluids (serum and urine) in diagnosis and prognosis
3) As analytical reagents in measurements of non-enzyme substances (Drugs, Proteins)
1) As therapeutic reagents
Asparagine is an amino acid which is incorporates into proteins and helps in cell growth.
It is important for healthy cells and lymphoblasts (lymphoblasts show malignant growth in
leukemia)
Lymphoblasts do not have L-asparagine synthetase. Therefore, asparagine is required for
lymphocytes.
In leukemia, Asparaginase is given to reduce malignant cell growth
b) Fibrolytic enzymes
c) Digestive enzymes
Rhodonase
2- 2-
S2O3 + CN --------------------------> SO3 + SCN-
2) Enzymes in Plasma
a) Constituent enzymes
b) Non-constituent enzymes
Non-plasma enzymes
No functional role
Generally present in low concentration
Present in bile
ALP
Enzyme Assays
Serum is used
Hemolyzed samples cannot be used
Unit of enzyme activity:
μ moles of substrate converted/min at a given pH and temperature
Unit - μ moles/min
Measured by termination of reaction or pH/temperature changes
Photometric methods
Eg: –
1. ALT activity
ALT
α – KG + Alanine Pyruvate + Glutamate
NAD+
Lactate
2. ELISA
Antibody is added
Standard free energy change (ΔG) for aerobic respiration is negative. The standard free energy
change for phosphorylation of ATP is positive. The energy released in respiration (in ETC) is
coupled to phosphorylation of ATP.
Aerobic respiration uses an ETC to break the fall of the electrons to oxygen into several
energy - releasing steps. (If electrons were transferred directly to oxygen, a large
proportion of the energy would be lost.)
Mitochondria
Cytochrome C
A small water-soluble mobile protein.
Shuttles electrons from complex III to IV.
Cytochromes use the ability of metal atoms to accept and release electrons.
Iron is most commonly used.
Copper and iron (as haem) are used in the Complex IV – Cytochrome c oxidase.
NADH+ H+ Succinate
Complex I Complex II
(NADH) (Succinate DH)
NAD+ Fumarate
FMNH2 FADH2
Co. Q
FADH2 FADH2
A proton concentration gradient formed as a result of electron transfer serves as the energy
reservoir for driving ATP formation.
(Flow of three H+ ions through ATP synthase complex causes a conformational change which
causes ATP synthase to synthesise ATP using ADP and Pi – this is oxidative phosphorylation)
NADH results in more net H+ movement than FADH2 because complex I pump protons but
complex II does not.
One NADH 3 ATP P: O Ratio
One FADH 2 ATP ATP count for 1 O atom (H2O) → NADH 3:1
FAD 2:1
Extra energy releases as heat
Once ATP is formed, the ATP is transported out of the matrix, in exchange for ADP,
by adenine nucleotide translocase (an antiport). The most abundant inner
membrane protein
Phosphate (as H2PO4-) is brought to the matrix by phosphate translocase which is a
symport that transports H2PO4- and H+ ions into the matrix through the inner
membrane.
Together, adenine nucleotide translocase and phosphate translocase provide substrates
and remove the product of ATP synthase. (multi-subunit enzyme)
Normally, ETC and oxidative phosphorylation are tightly coupled for ATP synthesis
Certain substances can uncouple the ETC from oxidative phosphorylation
This causes the collapse of the electro-chemical H+ gradient
The energy stored in the gradient is dissipated as heat
This leads to Non-shivering thermogenesis.
Natural uncoupling protein ‘thermogenin’ (UCP1) is found in brown adipose tissue in the
newborn. Brown adipose tissue contains many mitochondria and helps maintain body
temperature. Thermogenin (UCP1) is an important factor in heat production and in lipid
turnover.
Decrease H+ gradient by proton leakage without ATP synthesis
[Brown fat containing natural uncouplers is also important in animals – e.g. adapting to
the cold & during hibernation]
2) Synthetic uncouplers
Synthetic uncouplers such as 2,4-DNP and FCCP are hydrophobic and contain a dissociable
proton (i.e. they are hydrophobic weak acids). In their uncharged form, they can pass into
the mitochondrial matrix and release H+ in the matrix – dissipating the H+ gradient.
Drugs such as aspirin (and other salycilates) which are weak acids at high doses can act as
uncouplers.
NADH made in the cytosol (in glycolysis) cannot move into the matrix of the mitochondria.
Two mechanisms are present in cells to shuttle the cytosolic NADH to the mitochondrial
matrix:
Glycerol 3-
DHAP
phosphate
Glycerol 3-
DHAP
phosphate
Synthesize 2 ATPs for each cytosolic NADH Yields 3 ATPs for each cytosolic NADH oxidized.
oxidized
Cyanide Poisoning
2) Administration of thiosulphate
Inherited diseases of mitochondrion respiratory chain can cause lactic acidosis. Fatal
infantile mitochondrial myopathy, leber hereditary optic neuropathy (vision loss) and
renal dysfunction involves in severe deficiency/absence of most oxidoreductases of the
respiratory chain.
Also, absence of ATP/ADP translocase can cause lactic acidosis. WHY?
Thoracic cage
Borders
Anterior-sternum
Posterior-12 thoracic vertebrae &
intervening intervertebral discs
On each side- 12 ribs with their costal
cartilages+ intercostal muscles
Shape
Adult
Transverse section - kidney shape
Transverse diameter> antero-posterior diameter
Ribs - oblique ribs
Thoracic & abdominal respiration
Infant
Transverse section – circular
Transverse diameter< antero-posterior diameter
Ribs - horizontal ribs
Purely abdominal respiration
Typical rib
Anterior end
concave depression
attach with costal
cartilages
Posterior end
Head – 2 facets & a crest in between
Upper facet – body of the higher vertebra
Crest – intra articular ligament
Lower facet – body of the numerically corresponding vertebra
Neck – 2 surfaces
Anterior – smooth related to costal pleura
Posterior – rough inferior costotransverse ligament
Superior border or crest superior costotransverse ligament
Superior surface
In between insertion of scalenus anterior to
the scalene tubercle
Subclavian vein - anteriorly
Subclavian artery & the lowest trunk of
the brachial plexus - posteriorly
Medially
Apex of the lung & cervical pleura
Suprapleural membrane is attached
Neck
From Medial to Lateral
S – Sympathetic trunk
V – 1st posterior intercostal Vein
– Superior intercostal Artery
A
N – T1 Nerve (Larger portion of T1 nerve to form inferior trunk of brachial plexus)
CLINICALS
Rib fractures
Children – rare - Chest wall is highly elastic
Adult – common
By Direct or indirect violence
Indirect weakest point (at the angle) but, upper 2 ribs – protected by the clavicle
Lower 2 ribs – floating, are least commonly fractured
Pressure on
1) Lowest trunk of brachial plexus (T1) -
Parasthesia along the ulnar border of forearm -
Wasting of intrinsic muscles of the hand
B) COSTAL CARTILAGES
Hyaline cartilage
In old age – progressive ossification
Add resilience to the thoracic cage - Protects sternum & ribs
C) STERNUM
3 parts- manubrium, body, xiphoid process
Clavicle
Manubriosternal joint
Xiphoid - Cartilage
May ossify at adult life (40)
Overlies the Epigastric fossa
Ligaments
1. capsular
2. Superior, Inferior, lateral costotransverse
Vertical diameter
Contraction of the diaphragm (losing its convexity)
Piston movement
Transverse diameter
Mainly ribs 7-10 (partly 2-6)
Bucket handle movement
Replacement of a shorter rib with a longer rib
Axis of rotation- costovertebral joints
Chondrosternal joints
Antero-posterior diameter
Mainly ribs 2-6 (partly 7-10)
Pump handle movement
Forward movement of manubrio-sternum
Axis of rotation – costovertebral joints
-Costotransverse joints
Muscles
Quiet inspiration – diaphragm
External intercostals muscles
Intercostal spaces
Intercostal muscles
3 layers – external intercostals Subcostalis
Internal intercostals
Tranversus thoracis Sternocostalis
Innermost intercostals
Muscle Fibre direction Origin Insertion Extent Nerve supply Action
External Forwards Lower Outer lip of Elevate
Downwards border of the upper b From the the ribs
Medially the rib order of the tubercle to the during
above the rib below Costochondral inspiration
space Junction.
Then muscle is
replaced by
anterior
intercostals
membrane.
Internal Backwards Floor of the Inner lip of Lateral border
Downwards costal the upper of the sternum Intercostal
groove of border of the to the angle of nerves
the rib rib below the rib. depress
above the ribs in
After the angle forced
of the rib expiration
continue as post
intercostals
membrane.
Innermost Backwards Middle 2/4 Inner lip of Middle 2/4th of
Downwards of the ridge upper the rib
above border of
costal the rib
groove below
Intercostal nerves
Intercostal nerves – anterior primary rami of T1-T11 spinal nerves, after the dorsal primary rami has
been given
Subcostal nerve – anterior primary rami of T12
Typical intercostal nerve – T3-T6
Branches – lateral cutaneous, anterior cutaneous, and collateral muscular
Intercostal arteries
Each intercostal space contains
1 posterior intercostal artery
2 anterior intercostal arteries
Intercostal vein
Anterior intercostal veins
- Upper 6 spaces internal thoracic vein
- Lower 3 spaces musculophrenic vein
Lymphatic drainage
Anterior aspect Posterior aspect
Tracheobronchial nodes
Lower 4 spaces upper spaces
Brachiocephalic nodes
Cisterna chyli Right Left
Bronchomediastinal trunk right lymphatic duct thoracic duct
Right Left
Neurovascular bundle
From above downwards - V A N
Between: internal intercostal & innermost intercostal muscle layers (neurovascular plane)
Lying in the subcostal groove
intercostal nerve block – upper border of the space/ just below the rib
CLINICALS
SVC obstruction – azygos vein transmits blood from the upper half of the body to
unobstructed part of the SVC or to the IVC.
Thoracoepigastric vein (Superficial vein formed by anastomoses between lateral
thoracic vein of axillary vein and superficial epigastric vein of greater saphenous vein)
opens up.
HEMIAZYGOS VEIN
Formed by the left ascending lumbar & left subcostal
9-11 left posterior intercostal veins
DIAPHRAGM
- dome shaped fibromuscular septum
- partition between the thorax & abdomen
- chief muscle of respiration
- 2 parts: peripheral muscular
Central tendon (aponeurosis)
- Normal - Right dome upper border of the 5th rib
- left dome lower border of the 5th rib
- In forced expiration - Right dome 4th intercostal space
- Left dome 5th rib
- In forced inspiration – Right dome 6th rib
Muscular fibers (origin)
- Sternal – 2 small slips from the back of the xiphisternum
- Costal – inner aspect of lower 6 ribs & costal cartilages
- Vertebral/ lumbar – from the crura & arcuate ligaments
Right crus: anterolateral aspect of bodies of upper 3 lumbar vertebrae & intervening inter-
vertebral discs
Fibers forms a sling around esophagus.
Left crus: corresponding parts of upper 2 lumbar vertebrae
Median arcuate ligament: medial margins of 2 cruratendinous arch in front of the Aorta
Nerve supply
Entire motor supply: phrenic nerves (C3, C4, C5)
Sensory: central- phrenic
Peripheral (including crura) - lower 6 intercostal nerves
Blood supply
CLINICAL
*paradoxical movements
*referred pain
Position
- Highest in supine position
- Lowest while sitting
- Intermediate while standing
Diaphragmatic hernia
Congenital hernia– unusual to occur
1. Anteriorly – through foramen of Morgagni (retrosternal); between xiphoid & costal margin
2. Posteriorly – through the foramen of Bochdalek (pleuroperitoneal canals) - posterolateral
hernia
3. through a deficiency of the whole central tendon (central hernia)
4. congenitally large oesophageal hiatus
Irritation of diaphragm can cause referred pain in the shoulder tip (via root values C3, C4 and C5
Boundaries of mediastinum.
Anterior – Sternum
Posterior – 12 thoracic vertebrae
Superior – Superior thoracic aperture
Inferior – Inferior thoracic aperture
On each side - mediastinal pleurae
Divisions
Imaginary plane through sternal angle of Louis &
lower border of T4 divides mediastinum into
Mediastinum
Superior Inferior
Superior mediastinum
Boundaries
- anterior - manubrium sterni
- posterior- upper 4 thoracic vertebrae
- superior- superior thoracic aperture
- inferior- imaginary plane through sternal angle and lower border of T4
- on each side- mediastinal pleura
Contents:
- Trachea, oesophagus, thymus, thoracic duct
- Nerves - Vagi, phrenic, left recurrent laryngeal, cardiac nerves
- Veins - Left & right brachiocephalic, SVC, left superior intercostal veins
- Arteries - Left common carotid, left subclavian, brachiocephalic artery & arch of aorta
- Muscles - Sternothyroid, sternohyoid
- Lymph nodes – paratracheal, brachiocephalic, tracheobronchial
Mediastinitis
Little loose connective tissue
Lots of dead space – expand veins, more on the right side
Easy spread of infection
Large surface area
Toxins get absorbed
Attachment of prevertebral fascia to T4 – infections spread from the neck to the sup
mediastinum
Attachment of pretracheal fascia with arch of aorta – neck infections
spread to sup mediastinum & through it to posterior mediastinum
- Right + left brachiocephalic vein = SVC (behind the sternal end of the right fist
costal cartilage)
- *no valves
- Tributaries:
Azygos - second right costal cartilage
CLINICALS
Obstruction of SVC
Above azygos opening – through azygos
Below azygos opening – through IVC
Aorta
1.Ascending aorta
Lower border of 3rd costal cartilage
Forwards, upwards to the right
2.Arch of aorta
nd
Begins at upper border of right 2 sternochondral joint
Upwards, backwards to the left across the bifurcation of trachea
Downwards behind left bronchus- reach the body of T4 just left of midline
Arches over root of left lung(Left primary bronchus)
Ends at the sternal angle
The convexity reaches as high as midpoint of manubrium
Relations:
anteriorly to the left
Left phrenic nerve, cardiac nerves, vagus
Left superior intercostals vein-deep to phrenic nerve & superficial to
vagus
Left lung & pleura
Remains of thymus
Inferiorly
- Bifurcation of pulmonary trunk
- Left bronchus
- Ligamentum arteriosum with superior cardiac plexus on it
- Left recurrent laryngeal nerve
Branches
O 9 posterior intercostals arteries
o Subcostal artery
o 2 left bronchial arteries
o Oesophageal branches
o Pericardial branches
o Mediastinal branches
o Superior phrenic arteries
CLINICALS
Aortic aneurysm
Coarctation of aorta
RADIOGRAPHY
The diaphragm is higher on the Dome of right side (due to the liver)
Mediastinal shadow – heart & great vessels
Right border –
o Right brachiocephalic vein
o SVC
o Right atrium
o IVC
Left border –
o Aortic knuckles (arch of the aorta)
o Pulmonary trunk
o Left auricle
o Left ventricle
Inferior border –
o Centrally merge with diaphragm
o Either side forms cardiophrenic angles
Oesophagus
25cm long muscular tube
Begins – C6 – lower border of the cricoid cartilage
Traverses the superior & posterior mediastina
Curvatures-2 side to side curvatures ( to the left)
-anteroposterior curvature corresponding to the curvature of
Constrictions:
o C6 : at the beginning (cricopharyngeal sphincter) – 15cm (6’’) from upper incisor teeth `
(narrowest-commencement)
o T4 : Crossed by aortic arch – 22.5 cm (9’’)
o T5 : Crossed by left bronchus – 27.5cm (11’’)
o T10 : Pierces diaphragm – 37.5cm (15’’)
Relations:
Cervical
Anterior – trachea, thyroid gland
Posterior – C6,C7,prevertebral fascia
On each side- Common carotid arteries
Recurrent laryngeal nerves
Left subclavian artery
Terminal part of thoracic duct
Thoracic
Anterior : -Trachea
-Just below bifurcation of trachea crossed anteriorly by Left bronchus &
Right Pulmonary artery
-Pericardium with left atrium
-Diaphragm
Posterior–
Vertebral column
Thoracic duct(first on its right, At T5 crosses to left behind oesophagus)
More
posterior
Azygos vein &its tributaries
plane Right posterior intercostal arteries
Level of T7 – descending thoracic aorta pass behind to it
To the right –
o right lung & pleura
o Azygos vein – arches over Right primary bronchus
o Right vagus
To the left
Abdominal
Passes through an opening in the right crus of the diaphragm
Behind it, lies the left crus
Comes to lie in the oesophageal groove on posterior surface of left lobe of liver
Covered by peritoneum anteriorly & left
Blood supply
Arterial supply:
Cervical - inferior thyroid arteries
Thoracic - oesophageal branches of aorta
Abdominal - oesophageal branches of left gastric artery
Venous drainage:
Cervical – inf. thyroid vein/brachiocephalic veins
Thoracic – azygos vein
Abdominal – partly azygos, partly left gastric
Lymphatic drainage:
Perioesophageal lymphatic plexus
Cervical – deep cervical nodes supraclavicular
Thoracic – post. mediastinal nodes & tracheobronchial nodes
Abdominal – left gastric nodes & coeliac nodes
Nerve supply:
Parasympathetic - below the root of the lung vagi form a plexus on it
Sympathetic – middle cervical & thoracic ganglia
CLINICALS
Barium swallow
Thoracic duct
45cm long (L2 to root of neck)
Beaded appearance - presence of valves
Continuation of cisterna chyli
Ascends through the aortic opening of the diaphragm (T12)
Runs through posterior mediastinum behind oesophagus in front of vertebral bodies
Crosses from right to left (T5)
Arches laterally – C7 transverse process
Descends over – left subclavian artery
Drains – commencement of left brachiocephalic vein (confluence of internal jugular and
subclavian veins)
Drains the whole lymphatic field below the diaphragm & left half of the body above it
Right side – right subclavian + jugular trunks = right lymphatic duct
Together with mediastinal trunk drains into the origin of right brachiocephalic vein
Azygous Aorta
**Fibroserous sac which encloses heart and the roots of great vessels
Pericardium
Parietal layer
Visceral layer
Base blends with central tendon. (E
Clinical
Pericardial effusion Collection of fluid in the
(cardiac tamponade) pericardial cavity
• Drained by puncturing -
o Left 5th or 6thintercostals space just lateral to
sternum
o Left xiphicostal space
o Needle directed upward, backward and to the left
• Structures pierced by,
skin
superficial fascia
deep fascia
external intercostal muscle
internal intercostals
innermost intercostals
fibrous pericardium
parietal layer of serous pericardium
Pericarditis inflammatory condition of the pericardium.
2
© 2017 A/L Repeat Campaign
Heart
External features
b) Surfaces→
• Anterior / sternocostal surface
mainly right ventricle & right
atrium (left ventricle, left auricle)
• Posterior/base left atrium
(mainly) & small part of
right atrium
• Inferior/ diaphragmatic right
1/3 of right ventricle, left 2/3
of left ventricle, on central
tendon of diaphragm
• Left surface mainly left
ventricle, Upper end by left
auricle
c) Borders
• Right → right atrium only (acute border)
• Left → left ventricle, partly by left auricle (obtuse border)
Grooves
Chambers of Heart
Right Atrium
Right upper chamber
External features
• Sulcus terminalis→ groove from SVC to IVC along the right border
(Produced by internal muscular ridge- Crista terminalis)
• Upper part of the sulcus contains SA node
• Right atrioventricular groove → separates right atrium from right ventricle
• Right auricle → prolonged upper end
Left atrium
• Posterior surface forms the anterior wall of
the oblique sinus
• Greater part of interior is smooth walled
• Fossa lunata on the septal wall
• Two pairs of pulmonary veins open on each
side of posterior wall
• Musculi pectinati are present only in auricle
Left ventricle
2 parts interior
• Upper smooth part →aortic vestibule
gives origin to ascending aorta
• Derived from mid part of bulbus cordis
• Lower rough part with trabeculae carneae
derived from primitive ventricle
• Contains 2 well developed papillary
muscles (anterior & posterior)
• 2 orifices Left atrioventricular orifice/bicuspid (mitral) valve
Aortic orifice/semilunar valve
• Interventricular septum upper part is thin & membranous
Lower part is thick and muscular
Valves of the heart
1) Atrioventricular valves
• Fibrous ring to which the cusps are attached
• Cusps → Smooth atrial surface, Rough ventricular surface
• Rough margins to which chordae tendineae are attached
• Papillary muscles attached to the cusps
• Blood vessels only in fibrous ring
a) Tricuspid valve - between right atrium and right ventricle
b) Bicuspid valve/ -between left atrium and left ventricle
Mitral valve
5 © 2017 A/L Repeat
Campaign
The mitral valve is more prone to valvular disease
2) Semilunar valves
• 3 semilunar cusps, no chordae tendinae attached
• Nodule in the free margin & lunule extends up to the base of the cusp
• Opposite cusps vessel walls are slightly dilated to form sinuses
a) Aortic valve between left ventricle and ascending aorta
b) Pulmonary valve between right ventricle and pulmonary trunk
-Valves prevent back flow of blood -Chordae tendinae prevent eversion of cusps
-Normal heart sounds are produced by closure of heart valves
Auscultation
Valve Auscultatory area
Pulmonary Second left intercostals space near the sternum
Aortic Second right intercostal space near the sternum
Mitral Cardiac apex- left 5th intercostal space at midclavicular line
Tricuspid Just to the left of the lower part of the sternum near the 5th intercostal space
Conducting system
*Composed of specialized cardiac muscle fibres
SA node
Pacemaker of the heart, Horse shoe shaped
Situated at the atrio-caval junction in the upper
part ofthe sulcus terminalis
Supplied by right coronary artery (60%)
AV node
Situated lower posterior part of interatrial
septumJust above the opening of coronary
sinus
AV bundle of His only muscular connection
between atrial and ventricular musculatures
Right branch A large part enters moderator band (septomarginal trabecula)
Left branch
Purkinje fibres form a subendocardial plexus, pale fibres striated only at margins
Due to defects or damages to this system cardiac arrhythmias
Coronary circulation
Winds around the inferior border of the heart right marginal artery
Terminates by anastomosing with the terminal part of the left coronary artery.
• Distribution –
o Right atrium
o Right ventricle except a small area near the anterior IV groove.
o Left ventricle near posterior ventricular groove.
o Posterior 1/3 of the intervent. Septum.
o Whole conducting system except a part of left bundle branch.
Emerges between the pulmonary trunk and the left auricle. Left atrial artery
Though the pain is usually referred to the left side, it may even be referred to the right
arm, jaw, epigastrium or the back.
Cardiothoracic ratio
It is measured by taking the sum of the measurements from the midline to the furthest
point on the right side of the heart & from the midline to the furthest point on the left
side of the heart, and dividing by the transverse diameter of the thoracic wall.
Pulmonary/Visceral Pleura
From splanchnopleuric mesoderm.
Firmly adherent to the lung.
Covers the surfaces & fissures of lungs except along the pulmonary ligament & hilum of
the lung.
Pain insensitive – autonomic supply (T2-T5 sympathetic,
Vagus parasympathetic)
Supplied by – bronchial arteries
1. Costomediastinal recess
Between costal & mediastinal pleurae.
obvious in regions of cardiac notch of the
Left lung.
Filled by anterior margins of the lungs
even during quiet breathing.
2. Costodiaphragmatic Recess
Vertically 5 cm.
extends from 8-10 ribs along the
midaxillary line.
between costal & diaphragmatic pleura.
3. Pulmonary Ligament
Parietal Pleura extend downwards beyond the
root.
Provide a dead space for pulmonary veins and lung roots.
Root of lung-structures that connect lung to
mediastinum.
Hilum-site where structures enter & leave the lung
Clinicals
Paracentesis thoracis
Tube thoracostomy-chest tube insertion into plural cavity to drain air, blood, bile,
pus or other fluids.
Ex: pneumothorax
Done at safe triangle
Boundaries of safe triangle:
1…………………………………………..........................……..
…………………….……………………………………………………
2…………………………………………………………………………
..…………………………………………………………………………
3………..………………………………………………………………
………………..………………………………………………………..
Needle/Syringe insertion
During any of these procedure needle or tube pass above upper border of the rib. (lower part of the
intercostal space)
Why?
……………………………………………………………………………………………………………………………………………..……………
………………………………………………………………………………………………………………………………………………..…………
Referred pain
Diaphragmatic pleura
Fissures
Oblique fissure – Cuts into whole thickness of lung, except at hilum
Due to; lower lobe more posterior than others
o 2cm lateral to the T3 spine
o 5th rib in the mid axillary line
o 6th costal cartilage 3 inches (7.5cm) from midline
OR
Full abduction of the shoulder
o Oblique fissure corresponds to the position of the medial border of the scapula
Lingula – Tongue shaped projection of left lung below the cardiac notch.
Contents
1. Principal bronchus on the left, eparterial and hyparterial bronchi on the right.
2. One pulmonary artery.
3. Two pulmonary veins; superior and inferior.
4. Bronchial arteries; one on the right and two on the left.
5. Bronchial veins.
6. Anterior and posterior pulmonary plexuses of nerves.
7. Lymphatics of the lungs.
8. Bronchopulmonary lymph nodes.
9. Areolar tissue.
Anterior
- phrenic nerve
- pericardiophrenic vessels on both sides
- anterior pulmonary plexuses
*on the right – svc, right atrium
Posterior
- Vagus nerve
- posterior pulmonary plexus on both sides
*on the left – descending thoracic aorta
Superior
On the right – terminal part of the azygos vein
On the left – arch of aorta
Inferior
Pulmonary ligament
Hilum
Lies opposite the bodies of T5, T6, T7 vertebrae
Behind 3rd and 4th costal cartilages
Contents;
bronchial vessels
A – Right 1, left 2
V
lymphatics
bronchopulmonary lymph nodes
Pulmonary nodes
Bronchopulmonary nodes
Paratracheal nodes
Clinicals
Auscultation of lung
1. Upper lobe – 4th rib on both sides
2. Lower lobe – back
3. Middle lobe – between 4th & 6th ribs on both sides
Secondary/lobar bronchi
One for each lung lobe (2 for left & 3 for right)
Tertiary /segmental bronchi
10 for each side one for each segment
Divide repeatedly
Terminal bronchioles
Respiratory bronchioles
Alveolar ducts
Components of pulmonary unit
Atria
Air saccules
Alveoli
Bronchi Eparterial
Right principal bronchus – divides before enter lungs
Hyparterial
Wider
Shorter
More in line with trachea (More vertical) than left
2.5cm long
Nearly 5 cm
Downwards & outwards below the arch of aorta
Pulmonary artery anteriorly & above
Esophagus posteriorly
Narrower, longer, more oblique
Angle with tracheal bifurcation - 45°
Bronchopulmonary segments
Definition - a segment of lung supplied by a single segmental (IIIry) bronchus
Features
• 10 in each lung.
• Independent respiratory unit. (surgical, functional, structural)
• Each segment has its own separate artery.
• Veins lie in the intersegmental planes, can isolate a particular segment along the veins
• Bronchopulmonary segment is not a bronchovascular segment (as it doesn’t have its
own vein).
● Pyramidal, apex directs towards root.
Clinicals
Bronchoscopy
Widening and distortion of the angle between the primary bronchi
- Carina
- Carcinoma of tracheobronchial lymph nodes around the bifurcation of the trachea.
- Bronchial infections are restricted to specific bronchopulmonary segment.
Trachea
Relations
Cervical
Anterior
• Isthmus of thyroid gland
• Inf. Thyroid veins
• Sternothyroid
• Sternohyoid
Posterior
• Esophagus
• Recurrent laryngeal nerve
Laterally
• Lobes of the Thyroid gland
• Common carotid artery {carotid sheath & its contents}
Anterior
• Brachiocephalic artery
• Left carotid artery
• Left brachiocephalic vein
• Thymus
Posterior
• Esophagus
• Recurrent laryngeal nerve
To the left
• Arch of aorta
• Left common carotid artery
• Left subclavian artery
• Left recurrent laryngeal nerve
• Left lung and pleura
To the right
• Right vagus
• Azygos vein
• Right lung and pleura
Composition of Plasma
• Water - 90%
• Proteins - 8%
albumin
globulin (α,β,γ - From lymphatic tissues)
fibrinogen
• Inorganic Ions - 1% (Na+, K+, HCO3-, Cl-, Mg+, Ca+)
• Others - 1% (Hormones, gases, waste products)
Medullary Extramedullary
Growth factors
Formation of growth factors and
differentiation inducers is itself controlled by
factors outside the bone marrow
Ex; RBC production is increased
1. cell proliferation
2. differentiation
3. suppression of apoptosis
4. maturation
5. functional activation
2nd messenger
systems
Gene Activation
Less
basophilic
• No Nucleus
• Life span-120 days
• Higher concentration in males than females - sex hormones affect the rate of haemopoiesis
• Contains Hemoglobin
34% i.e. 1/3 from the weight of a RBC
• As RBCs carries the maximum amount of Hb at normal circumstances it can never become
hyperchromic
• Daily; only 25% of Pluripotent Haemopoietic stem cell (PHSC) differentiate into RBCs but high
amount of RBCs seen in blood because of its long life time
• Mature RBC - Biconcave disc shaped - High surface area: Volume ratio
Functions of RBC
• Transport of O2 and CO2
• Buffering action by Hb and proteins
• Contains Carbonic Anhydrase enzyme
Kidney and liver has O2 sensors, when there is hypoxia, erythropoietin synthesis is stimulated.
If both kidneys are affected , non- renal production of erythropoietin can compensate the RBC production
up to 33%-50% (1/3-1/2)
Hemoglobin
HbA2 = 2α 2𝛿
Glycated haemoglobin = HbAIC (increased in patients with Diabetes mellitus.So it used as clinical marker
for Diabetes mellitus )
oxygenation
Hb + 402 Hb (O2)4 oxyhaemoglobin
RBC Abnormalities
• Due to a defect in the membrane - Hereditary spherocytosis
• Due to a defect in hemoglobin production - Thalassemia , sickle cell disease
• Due to the deficiency of enzyme G6PD-Haemolysis
(Jaundice GIT)
Anaemia
Reduction in concentration Of Hb below accepted normal range (which depends on sex, age, ethnic
group, altitude)
Features - Tachycardia, palpitations, heart murmur, dyspnea, pallor
Causes of Anaemia
↓ Production
↑ Loss ↑ Destruction
*nutritional deficiency
Haemorrhages Eg: hemolytic
anaemia *↓ bone marrow erythroid cells
*renal disease
2. Megaloblastic anemia
3. Hemolytic anemia
a) Hereditary spherocytosis
Haemolyse easily
Enter a vicious cycle that may even lead to death in some cases
Rh+ RBC in the fetus are attacked by Rh- antibodies from mother
d) G6PD Deficiency
Haemolysis
Polycythemia (erythrocytosis)
Polycythemia (erythrocytosis)
Primary Secondary
pathological Physiological
-cancer ↑ erythropoiesis
*polycythemia rubra vera Hypoxic
Renal disease
❖ Comparison between Fe deficiency anemia Vit B12 deficiency anemia and physiological
anemia in pregnancy
Increased in Decreased in
Rheumatic fever
TB
Rh system
Antigens present only on RBC
• Unlike ABO antibodies Anti D antibodies do not develop without exposure of D- RBC to D+ RBC by
transfusion or pregnancy
• Cross matching Donor RBC + Recipients plasma
1. Incompatibility reactions
RBC Agglutination
Clumps
IV Hemolysis
May block blood
Release Hb
vessels
Jaundice
Renal failure
2. Fever, allergic reaction, circulatory overload, Iron overload, Air embolism, diseases (ex:- malaria,
AIDS)
• At first IgM antibodies which are pentamers are formed, they cannot cross placenta
• Secondly IgG antibodies which are monomeric are formed, so they can cross the placenta in
subsequent pregnancies
• Rhogam is administered within 72 hours after delivery, it consist of synthetic anti D antibodies,
prevent sensitization of mother to D antigen
Complications
o Death,
o severe anaemia
o jaundice
o oedema(hydrops fetalis)
o Kernicterus = destruction of neuronal cells due to deposition of bilirubin (as fetal blood brain barrier
is still underdeveloped and may be permeable to certain substances)
Neutrophils secrete
• Metalloproteinases -Facilitate the movements of other
• Elastase neutrophils by digesting collagen in the ECM
• Defensins - Antimicrobial peptide
• Thrombaxanes - Vasoconstriction
• Leukotrines - Increases vascular permeability and attraction of other
neutrophils
• Prostaglandins - Inflammatory mediator
• PAF - platelet aggregation
• Lactoferrin -Binds to iron required for bacterial growth
• Neutrophils can only ingest 3-20 bacteria whereas macrophages can about 100.
• Macrophages have the ability to ingest large particles as RBC/malaria parasites.
• Macrophages can extrude the residual products after digesting particles and can survive for
more months whereas neutrophils cannot.
• Macrophage lysosomes have large amount of lipases which can digest the thick lipid
membranes of bacteria. (specially Tuberculosis bacillus)
Acquired Immunity
Complement system
• Opsonization and facilitate phagocytosis (acts over bacteria to make them tasty)
• Chemotaxis (attract neutrophils to infected areas)
• Lyses of the cells (destruction of the cells)
• Activation of B lymphocytes
• Glycoproteins
• Present on the surface of the cells
o MHC I – PresentAll nucleated cells
o MHC II – Macrophages, dendritic cells and natural killer cells
• Polypeptide products of digested antigens are coupled to MHC on surface of cells.
Immunoglobulin
• Ig G = Monomer; complement activation, can cross placenta
• Ig A = localized protection in external secretion , Monomer/Dimer/Trimer
• Ig M = Complement activation, can't cross placenta, Pentamer
• Ig D = Antigen recognition by B cells, Monomer
• Ig E = Binds to basophiles & mast cells, Monomer
Functions of Immunoglobulin
Antigen (pathogen)
Invaded by macrophages, dendritic cells, natural killer cells and other nucleated cells
Antibodies=Immunoglobin
s
Direct Actions
Agglutination
Complement
Precipitation system activation
(classic pathway)
Neutralization of protein toxin
Lysis by enzymes
Active Immunity - Person's own body develops either antibodies or activated T cells in
response to invasion of the body by a foreign antigen
Passive Immunity - By infusing antibodies, activated T cells or both, obtained from the blood
of someone else or from some other animal that has been actively
immunized against the antigen
Immune Tolerance - Process by which the immune system does not attack an antigen.
Auto Immunity - The failure of an organism in recognizing its own constituent parts as self, which,
b allows an immune response against its own cells and tissues.
Primary Immune response : Slow, Lower level, shorter duration, IgM Main type
Secondary Immune Response : Rapid, Potent, Longer duration, IgG main type
✓ Thrombocytopenia - Decrease in platelet count below normal e.g.: HIV AIDS, dengue, Portal
hypertension (Blood is diverted to spleen → Splenomegaly →Sequestration of platelets → Reduction
of platelets → Thrombocytopenia) Leads to failure of clot retraction
✓ Thrombocytosis - Increase in platelet count above normal e.g.: splenectomy, bone marrow cancer
Thrombocytopenia
Haemorrhages) Thrombosthenic
- Loss of function
17 © 2017 A/L Repeat Campaign
Von WILLEBRAND Factor (VWF)
• Forms adhesive bridges between endothelial cells and platelets as well as in between platelets
• Extends the half-life of factor VIII (factor VIII regulation)
Haemostasis
Haemostasis is the process of forming clots in the walls of the damaged blood vessel and preventing blood
loss while maintaining blood in fluid state within vascular system
Injury to a vessel
Anticoagulants
Bleeding
Breakdown the clot once the
damage is repaired
procoagulants
Prevent intravascular
Formation of clot
coagulation or Thrombus
formation (thrombosis)
Stop bleeding
Vessel injury
Vascular response
Clotting response
Platelet response
(Formation of a definitive
(Formation of a temporary clot)
clot)
Vascular response
Platelet Response
Intraplatelet Ca2+
- Change shape
Platelet Activation - Put up pseudopodia
- Contract using contractile
protein
Platelet Plug
(Prostacyclin)
(Not Essential)
(Platelet Phospholipids)
Xa
Common Pathway
Heparin-Antithrombin III complex inhibits activated Factors IIa, IXa, Xa, XIa, XIIa
3. Tissue Factor pathway inhibitor (makes complex with Va, VIIa, Xa)
4. Interaction between TXA2 & Prostacyclin
5. Fibrinolytic system (Plasminogen System)
Plasminogen plasmin
t-PA, u-PA
Streptokinase & Human recombinant t-PA are used in treatment of myocardial infarction
Streptokinase cannot cross blood brain barrier, so recombinant t-PA is given in stroke medication
Anti-coagulants
A. In vivo
1. Low molecular Heparin weight -Facilitates the action of antithrombin ш
2. Coumarin derivatives -Dicoumarol, Warfarin
Inhibit the action of Vitamin K (by inhibiting vit K reductase enzyme) , vitamin K is necessary for
the production of Factors II (Prothrombin), VII, IX and X, protein C and protein S
* -Carboxy-glutamic acid residues increases (-) charge in the clotting factors which can then adhered to
platelet membrane phospholipids through Ca2+
B. In Vitro
1. Heparin
2. Oxalate - E.g.-Na Oxalate, K Oxalate
From insoluble salts with Ca2+
Abnormalities of hemostasis
1. Bleeding time test - for vascular response & platelet response( minor/superficial wounds)
2. Platelet count
3. Hess Test - for vascular integrity (capillary integrity) ; Checking progression of Dengue
4. Prothrombin time test/INR - For extrinsic pathway and common pathway of clotting
5. Whole blood clotting time test - for intrinsic pathway and common pathway of clotting
6. Activated Partial Thromboplastin Time Test(APTT) -For Intrinsic + common pathway of clotting
7. Thrombin time
Neutrophils secrete
Metalloproteinases -Facilitate the movements of other
Elastase neutrophils by digesting collagen in the ECM
Defensins - Antimicrobial peptide
Thromboxanes - Vasoconstriction
Leukotrienes - Increases vascular permeability and attraction of other
neutrophils
Prostaglandins - Inflammatory mediator
PAF - platelet aggregation
Lactoferrin - Binds to iron required for bacterial growth
Neutrophils can only ingest 3-20 bacteria whereas macrophages can about 100.
Macrophages have the ability to ingest large particles as RBC/malaria parasites.
Macrophages can extrude the residual products after digesting particles and can survive for
more months whereas neutrophils cannot.
Macrophage lysosomes have large amount of lipases which can digest the thick lipid
membranes of bacteria. (specially Tuberculosis bacillus)
Acquired Immunity
Complement system
Opsonization and facilitate phagocytosis (acts over bacteria to make them tasty)
Chemotaxis (attract neutrophils to infected areas)
Lyses of the cells (destruction of the cells)
Activation of B lymphocytes
Glycoproteins
Present on the surface of the cells
o MHC I – Present in all nucleated cells
o MHC II – Macrophages, dendritic cells and natural killer cells
Polypeptide products of digested antigens are coupled to MHC on surface of cells.
Immunoglobulin
Ig G = Monomer; complement activation, can cross placenta
Ig A = localized protection in external secretion , Monomer/Dimer/Trimer
Ig M = Complement activation, can't cross placenta, Pentamer
Ig D = Antigen recognition by B cells, Monomer
Ig E = Binds to basophiles & mast cells, Monomer
Functions of Immunoglobulin
Antigen (pathogen)
Invaded by macrophages, dendritic cells, natural killer cells and other nucleated cells
Antibodies=Immunoglobin
Direct Actions
Agglutination
Complement
Precipitation system activation
(classic pathway)
Neutralization of protein toxin
Lysis by enzymes
Active Immunity - Person's own body develops either antibodies or activated T cells in
response to invasion of the body by a foreign antigen
Passive Immunity - By infusing antibodies, activated T cells or both, obtained from the blood
of someone else or from some other animal that has been actively
immunized against the antigen
Immune Tolerance - Process by which the immune system does not attack an antigen.
Auto Immunity - The failure of an organism in recognizing its own constituent parts as self, which,
b allows an immune response against its own cells and tissues.
Primary Immune response : Slow, Lower level, shorter duration, IgM Main type
Secondary Immune Response : Rapid, Potent, Longer duration, IgG main type
Thrombocytopenia - Decrease in platelet count below normal e.g.: HIV AIDS, dengue, Portal
hypertension (Blood is diverted to spleen → Splenomegaly →Sequestration of platelets → Reduction
of platelets → Thrombocytopenia) Leads to failure of clot retraction
Thrombocytosis - Increase in platelet count above normal e.g.: splenectomy, bone marrow cancer
Thrombocytopenia
Haemorrhages) Thrombosthenic
- Loss of function
7 © 2017 A/L Repeat Campaign
Von Willerbrand Factor (VWF)
Forms adhesive bridges between endothelial cells and platelets as well as in between platelets
Extends the half-life of factor VIII (factor VIII regulation)
Haemostasis
Haemostasis is the process of forming clots in the walls of the damaged blood vessel and preventing blood
loss while maintaining blood in fluid state within vascular system
Injury to a vessel
Anticoagulants
Bleeding
Breakdown the clot once the
damage is repaired
procoagulants
Prevent intravascular
Formation of clot
coagulation or Thrombus
formation (thrombosis)
Stop bleeding
Vessel injury
Vascular response
Clotting response
Platelet response
(Formation of a definitive
(Formation of a temporary clot)
clot)
Vascular response
Platelet Response
Intraplatelet Ca2+
- Change shape
Platelet Activation - Put up pseudopodia
- Contract using contractile
protein
Neutrophils
Platelet release reaction Discharge granular contents Monocytes
Platelets
Platelet aggregation
Platelet Plug
(Prostaglandins)
(Not Essential)
(Platelet Phospholipids)
Xa
Common Pathway
Heparin-Antithrombin III complex inhibits activated Factors IIa, IXa, Xa, XIa, XIIa
3. Tissue Factor pathway inhibitor (makes complex with Va, VIIa, Xa)
4. Interaction between TXA2 & Prostacyclin
5. Fibrinolytic system (Plasminogen System)
Plasminogen plasmin
t-PA, u-PA
Streptokinase & Human recombinant t-PA are used in treatment of myocardial infarction
Streptokinase cannot cross blood brain barrier, so recombinant t-PA is given in stroke medication
Anti-coagulants
A. In vivo
1. Low molecular Heparin weight -Facilitates the action of antithrombin ш
2. Coumarin derivatives -Dicoumarol, Warfarin
Inhibit the action of Vitamin K (by inhibiting vit K reductase enzyme) , vitamin K is necessary for
the production of Factors II (Prothrombin), VII, IX and X, protein C and protein S
* -Carboxy-glutamic acid residues increases (-) charge in the clotting factors which can then adhered to
platelet membrane phospholipids through Ca2+
B. In Vitro
1. Heparin
2. Oxalate - E.g.-Na Oxalate, K Oxalate
Form insoluble salts with Ca2+
Abnormalities of hemostasis
1. Bleeding time test - for vascular response & platelet response( minor/superficial wounds)
2. Platelet count
3. Hess Test - for vascular integrity (capillary integrity) ; Checking progression of Dengue
4. Prothrombin time test/INR - For extrinsic pathway and common pathway of clotting
5. Whole blood clotting time test - for intrinsic pathway and common pathway of clotting
6. Activated Partial Thromboplastin Time Test(APTT) -For Intrinsic + common pathway of clotting
7. Thrombin time
Heart muscle
Pacemaker tissue/cells
No contribution from Na+ for rapid depolarization
Other features
Parasympathetic Sympathetic
Membrane hyperpolarized Slope of prepotential is
& slope of prepotential is increased
decreased By ANS+ Catecholamines
By vagi (Left-AV Right-SA)
β1 adrenaline receptor
M2 receptor-mainly in SA
present in every cell of
& AV
myocardium
Lies in atrial tissue & not in
ventricle
So Ach’s influence is to
decrease mainly
chronotropic action not
inotropic action
A
c
h
Noradrenalin
R ↓
Ach M2 muscarinic
β1 R
Increased Decreased
- Temp. ↑ (tachycardia in fever) - Drugs – Digitalis (ve inotrope)
- Drugs (Depresses nodal tissue &exerts vagal
effects)
Mainly to AV node
ANS
Physiological Pathological
Increase During muscular exercise Fever ( 10 beats / 1
Emotional excitement deg F )
Increased action of
High environmental temperature Haemorrhage
baroreceptors
During digestion (mild increase) Hyperthyroidism
Increased action of atrial
stretch receptors (Brain
bridge reflex)
Inspiration
Anger
Most painful stimuli
Hypoxia
Decrease Sleep (55 – 60) Hypothyroidism
Increased action of In trained athletes Increased ICP (Cushing
baroreceptors reflex)
Expiration
Fear
Grief
Stimulation of pain fibers of
trigeminal nerve
3 ©2017 A/L Repeat Campaign
Conducting system of the heart
SA node
Contractile tissue
Phase
Electrocardiogram (ECG)
Body fluids are good conductors – Changes in potential that measure the
algebraic sum of action potentials can be recorded.
Record of these changes are known as an electrocardiogram.
ECG leads
-ve
Record the electrical potential differences between electrodes placed on the body.
Anterior V3, V4
Septal V1, V2
(+) (+)
LIII LII
I + III = II
ECG Paper
ECG waves are recorded on special graph paper with 1mm2 grid-like boxes
Horizontal – duration
Vertical – wave amplitude
Horizontal
Paper speed usually 25 mm/s
Each 1mm (small square) = 0.04 s (40ms)
Each 5mm (large square) = 0.2 s (200ms)
Vertical
10mm (10 small squares) = 1mV
0.1 s
0.04
0.04 s
0.2 s
Tachycardia is seen during inspiration. Bradycardia is seen during expiration. Intra-thoracic pressure
decreases during inspiration. So venous return to the atria increases. Atrial stretch receptors are
stimulated which results in vasodilation and hypotension. These receptors in turn signal the medullary
control centers to increase the heart rate. This is called the Bainbridge reflex.
Cardiac Axis
The direction of the largest dipole in the frontal plane is called the Cardiac axis of the heart.
The Cardiac axis has a very wide, normal range, from −30° to +90 °.
The Cardiac axis depends partly on an individual’s anatomy; the heart.
Cardiac axis are more vertical in a tall, thin person than in a short, broad-chested individual.
The axis also becomes more vertical during each inspiration because the descending diaphragm tugs
on the pericardium and drags down the apex
The axis depends also on the relative thickness of the right and left ventricle walls
Hypertrophy of the left ventricle (e.g. due to exercise training, hypertension or hypertrophic
cardiomyopathy) shifts the electrical axis to the left (left axis deviation)
Hypertrophy of the right ventricle (often due to pulmonary disease) produces right axis deviation
1) late diastole
2) atrial systole VD VS
3) ventricular systole
AD AS AD
a. isovolumetric ventricular contraction
b. ventricular ejection (0.8 – 1s)
4) early diastole a) Protodiastole
b) Isovolumetric relaxation
c) Rapid ventricular filling
Late diastole
Atrial systole
Coincides with late ventricular diastole
About 30% of ventricular filling occurs
Atrial musculature contracts & propels additional blood to ventricles
Orifices of SVC, IVC & pulmonary veins narrow
But some regurgitation occurs
Early diastole
1) Protodiastole (0.04 s)
Ventricular muscle is fully contracted
Already falling ventricular pressure drops more rapidly
It ends when the momentum of ejected blood is overcome and
Aortic & pulmonary valves closed.
2) Isovolumetric relaxation
Both AV & semilunar valves are closed
Ventricular pressure continues to drop rapidly
Atria in diastole are filling and atrial pressure increases
Ends when ventricular pressure falls below atrial pressure & AV valves open; permitting ventricles to
fill
3) Rapid ventricular filling
Once AV valves open, blood accumulated in atria fill rapidly into ventricles
Rate ↓ as ventricles filled
End diastolic volume – Final volume in each ventricle at the end of diastole just before the systole. (130ml)
Stroke volume – Amount of blood ejected by each ventricle in each heartbeat. In a resting supine man of
average size, (it is 70 - 90ml)
End systolic volume – Amount of blood left in each ventricle at the end of ventricular systole. (around 50 ml)
𝑆𝑉
𝐸𝑗𝑒𝑐𝑡𝑖𝑜𝑛 𝐹𝑟𝑎𝑐𝑡𝑖𝑜𝑛 = = 65%
𝐸𝐷𝑉
Heart sounds
Name Character Reason Timing Specialities
S2 Shorter - high pitched Vibrations set up by End of ventricular Loud when diastole
(Dub) closure of aortic & systole P. is elevated in
pulmonary valves aorta
Systolic murmur seen in anaemia. (As a result of low viscosity of blood & associated rapid flow)
(NOTE- Systole and diastole of the cardiac cycle are named regarding to ventricles)
Characteristics of pulse
Rate
Rhythm
Character – feeling of pulse (e.g. :- thready in shock)
Volume – normal / high / low (e.g.:- strong pulse during exercise ↑SV)
Presence or absence of femoral pulse in relation to radial pulse (e.g. Post ductal coarctation)
Vessel wall [e.g. Adults – vessel wall is calcified, so pulse is strong
Children – vessel wall is elastic, so pulse is weak]
Arterial pulse
Blood forced into aorta during systole sets up a pressure wave that travels around arteries
This pressure wave expands arterial wall which is palpable as pulse
The pulse has no relationship with the flow of blood within the vessel.
The speed of the pulse increases with the decrease of elasticity. (e.g. – old age, in peripheral regions)
Due to the
closure of the
aortic valve
JVP
Measurement
1. Right internal jugular vein
2. Patient at 450 and head turned slightly to the left (at 450 so that jugular venous pressure is seen at
the neck. If kept supine, position where JVP is seen moves up)
3. Vertical distance between angle of Louise & highest level of jugular vein pulsation
4. Add 5cm (since R. atrium is 5cm below the angle)
Central Venous Pressure (CVP) – pressure in the SVC near the right atrium (= R. atrial P)
Important determinant of Preload
Normal CVP=8 cm H2O (6mmHg during expiration, 2mmHg during inspiration)
Venous pressure falls during inspiration as a result of the increased negative intrathoracic pressure &
rises again during expiration.
The changes in right atrial pulse pressure are transmitted to the great veins producing 3 characteristic waves
Stroke Volume
The degree to which Resistance against which The intrinsic ability of heart
myocardium is stretched blood is expelled muscle to generate force and to contract
before it contracts at a given degree of stretch
( TPR)
( EDV)
Venous Return Ventricular filling time Ventricular filling pressure Ventricular compliance
Describes the ability of the heart to change its force of contraction (& stroke volume) in response to changes
in venous return.
SV α EDV
Special.......
SV Chronotropy Heart rate
Inotropy Force of contraction
Dromotropy Transmission in cardiac conductive tissue
EDV
Changes in contractility
Sympathetic 1adrenergic stimulation + activation
SV Catecholamines of adenylyl cyclase cAMP
Inotropic agents (Dopamine)
Digitalis (Na+/K+ ATPase inhibitor)
Increased contractility
Xanthine – (Caffeine, theophylline) – Inhibit breakdown of cAMP
Force frequency relationship
Decreased contractility
Digitalis inhibits Na+/K+ ATPase and thus
activates Na+/Ca2+ ATPase which transports
Na+ out of myocyte and Ca2+ into myocyte.
Parasympathetic Thus, increases intracellular [Ca2+] in
Hypoxia , hypercapnia myocyte, increasing power of contraction.
Acidosis
Pharmacological agents (barbiturates, quinidine, procainamide)
EDV Loss of myocardium
(Intrinsic depression) Heart failure
Downregulation of 1receptor
Impaired Ca2+ release from SR
Ejection fraction = SV 60-65%
EDV
Cardiac index = CO
Surface area of the body
CO = O2consumption (ml/min)
Theoretical Amount of O2 in Amount of O2in
arterial blood (ml/L) venous blood (ml/L)
Factors affecting CO
Stroke work of LV is higher than RV (Because LV has to pump blood against a higher pressure in aorta)
in stroke work due to an in MAP causes a greater O2 consumption than in stroke volume.
Aortic Stenosis is considered to cause an increase in pressure work as a higher pressure must be given from
within the chamber.
Aortic regurgitation is considered to cause an increase in volume work as some amount of blood flows back,
needing a larger volume to be pumped.
An in afterload causes greater O2 consumption than an in preload.
Angina pectoris is more common in aortic stenosis than aortic regurgitation.
Elastic tissue % aorta > large arteries > small arteries > arterioles
Smooth muscle % aorta < large arteries < small arteries < arterioles
Muscle is innervated by noradrenergic fibres
(But in some instances, by cholinergic fibres. E.g. - Cutaneous blood vessels have muscarinic cholinergic )
Arterioles are the major site of resistance to blood flow
(As R 1/r4; small change in calibre causes large change in TPR)
Capillaries
Lymphatics
Following features differ a lymphatic from a capillary
1. No fenestrations in endothelium
2. Very little if any basal laminar under endothelium
3. Junctions between endothelial cells are open
4. No tight intracellular connections
5. Contain valves
Lymph flow occurs mainly due to contractions and not due to valvular action.
Flow
Q = MAP - MVP
Flow = Effective Perfusion Pressure (P) R
(Q) Resistance (R)
P = MAP MVP
Streamline Flow * When the vessel is obstructed flow
Parallel to long axis beyond that become turbulent.
Laminar Occurs in layers * Turbulent flow produces a noise
Flow Layer close to the wall doesn’t flow due to vibration.
Centremost layer has highest velocity * Results in bruits and murmurs
Flow is silent * This is being used as the principle of
Occurs in normal blood vessels auscultation method of BP measurement
10 © 2017 A/L Repeat Campaign
Re – Reynolds number * Higher the Re, higher the turbulence
Re = vD v – velocity
D – diameter
If Re<2000, flow is usually not
– density
turbulent
– viscosity
If Re> 3000, turbulence is almost
always present.
Turbulence increases at branching points
Resistance
Q=P R= 8l
Q= r4P
R r4
8l
Radius (R 1/r4)
Determined by
Viscosity (R )
Viscosity
Conditions Conditions
Polycythaemia Anaemia
Temperature Pregnancy
Flow rate THINK… why can murmurs be heard
Plasma volume in pregnant women even though they
Plasma proteins (mostly immunoglobulins) do not have any disease?
Hereditary spherocytosis
Increased viscosity of the blood, causing increased peripheral resistance leads to hypertension.
Shear stress
Shear stress force created on the endothelium parallel to the long axis of vessel
Systolic pressure: - Peak pressure in aorta and other large arteries during cardiac cycle
Depends on CO
120 mmHg
Diastolic pressure:- Minimum pressure in aorta and other arteries during cardiac cycle
Depends on TPR
70 mmHg
Recorded as SBP/DBP = 120 mmHg
70
Measurement of arterial blood pressure (Korotkoff sounds)
Snapping sound onset marks SYSTOLIC phase I
Becomes soft murmur (bruit) phase II
Sounds louder clearer phase III
Muffling of sounds phase IV
Sounds disappear phase V
1/3 PP is taken due to the time difference and the pressure difference between the two
Systolic pressure increases with age.
Diastolic pressure, 1st increases then decreases.
Therefore, pulse pressure increases.
Venous Pressure
Above
Peripheral veins
RA
Below
Thoracic pump
Venous Pressure is affected by Muscle pump
Variations in RA pressure
1) Auto Regulation
Constriction of arteriole
Decrease flow
Increase in decrease in
PCO2 PO2
T pH
K+
Lactate (Mainly in skeletal Muscles)
Histamine (Increases vascular Permeability)
Adenosine (only in cardiac muscle)
In generalized/ systemic hypercapnia vasodilation takes place only in Brain and Skin.
NOS 2 – macrophages
NOS 3 – endothelium
Nitroglycerin – treatment
in angina
Vasodilators
VIP (act via NO)
Kinins (via NO)
Natriuretic hormones
ANP, BNP found in blood
CNP not found in blood (MCQ)
ANP
Increases when atria are stretched and central venous P is increased.
Natriuresis (increased excretion of sodium and water in urine) (MCQ)
Vasodilation
BNP- secreted when ventricles are stretched
- Also from brain
CNP- c type natriuretic peptide
Paracrine action
From brain, kidneys, pituitary
Vasoconstrictors
Epinephrine, Norepinephrine, Vasopressin, Angiotensin II, Thromboxane A2
Receptor Baroreceptors
Centers IN Medulla
Effector
Buffer nerve – Both Vagus and glossopharyngeal nerves together known as buffer nerve. Vagus nerve carries
impulses from aortic sinus. Glossopharyngeal nerve carries impulses from carotid sinus.
Centers
Baroreceptors
Valsalva Manuever
Take a deep breath → exhale against closed glo s → blood pressure goes up (due to the
compression of aorta at onset) → Venous return decreases (due to compression of great
veins) → CO decreases → blood pressure decreases → baroreceptor discharge decreases →
parasympathetic inactivate, sympathetic activate → HR increases, Contractility increases, CO
increase, vasoconstriction → BP increase with tachycardia → exhale → venous return come
to normal → blood pressure increases → baroreceptor discharge increases → sympathetic
inactivates parasympathetic Activates→ HR decreases, contractility decreases → s ll vessels
compressed → Hypertension with bradycardia
CO TPR Sympathetic
(No parasympathetic)
Afterload BP
TPR (Total peripheral resistance)
Size of ventricle Sympathetic
Viscosity Catecholamines
Digitalis
Xanthines
SV Positive Inotropes-
Myocardial contractility Dopamine
Force frequency relation
Parasympathetic
Hypoxia
Hypercapnia
barbiturates, quinidine, procainamide
Frank Starling Law
Heart failure
EDV
Carotid body has the highest blood flow per 100g per minute
Depends on
1. CPP - MAP, ICP
2. Viscosity
Vessel diameter
Auto Regulation
Neural factors
Metabolic factors – CO2, Acidosis, Hypoxia
Important in Hypertension
Coronary circulation
250ml/min (5% of CO)
Supplies myocardium (no supply from blood within chambers)
Myocardium
–High O2 consumption and high O2 extraction (70-80%)
–Requires regular uninterrupted coronary blood flow to function
Left & right coronary arteries are end arteries.
If need to increase O2 supply - blood supply is increased. (Flow is coupled to O 2 demand)
Considerable auto regulation present
Coronary flow to
Left ventricle – mostly in diastole
Other chambers – throughout cardiac cycle
Most superficial part of LV is supplied throughout cardiac cycle
Subendocardium of LV is supplied exclusively in diastole
Coronary circulation
α β
Constriction Dilation
Increase activity of heart
Splanchnic circulation
Reactive hypermia
White reaction
Triple response
o Reddening
o Swelling
o Flare
Applied CVS
Hypertension
Causes;
Essential hypertension – multi factorial
Renal disease – increased secretion of renin
Hormonal overactivity – aldosterone, glucocorticoids,
catecholamine, GH
Coarctation of aorta
Drugs – oral contraceptives, cocaine
Pregnancy induced hypertension
Increased blood viscosity – polycythemia
Baroreceptor resetting at a higher BP in chronic HT
7 ©2017 A/L Repeat Campaign
Hypertension – principles of management
Vasodilators
Ca2+ channel blockers
Angiotensin Converting Enzyme Inhibitors (ACEI)
Angiotensin II Receptor Blockers (ARB)
α blockers
Drugs decreasing heart rate
β blockers
Diuretics (drugs reducing blood volume by increasing urine output)
Others….
Angina pectoris
Effects of IHD
Heart failure
Inability of the heart to maintain an enough cardiac output to meet tissue needs
Types
o acute or chronic
o LV (commonly), RV or both ventricles
o Systolic or diastolic
o High-output or low-output
LV failure RV failure
Pathophysiology Reduced LV output Reduced RV output
Tissue perfusion Reduced (apathy, faintness) Reduced (apathy, faintness)
Congested (Pulmonary
oedema, breathlessness on
exertion & lying down,
cough, blood stained
sputum)
Due to accumulation of
blood in the Left ventricle.
The back flow of blood to the
lungs causes to increase
pulmonary pressure. Causing
pulmonary oedema.
JVP Elevated
Lower Limb Oedema
Management –
↓preload and a erload
Note lowering preload is only for systolic failures
Lowering afterload is for both types
Decrease venous congestion-diuretics, venodilators, aldosterone antagonist
Decrease peripheral resistance-ACE inhibitors, Angiotensin receptor blockers
Improving contractility-Digitalis, ACEI
Improving symptoms
Reducing mortality- beta blockers
Shock
Definition;
Inadequate tissue perfusion with a relative or absolute inadequacy in cardiac output.
Classification
o Hypovolemic
o Haemorrhage, trauma, severe diarrhoea
o Cardiogenic
o Myocardial infarction, heart failure, arrhythmia
o Obstructive
o Tension pneumothorax, cardiac tamponade, pulmonary embolism
o Distributive
o Neurogenic shock (major brain or spinal injury)
o Anaphylaxis (triggered by allergens)
o Septic shock
Cardiac tamponade - fluid collects between myocardium and pericardium. pressure within
the pericardium prevents heart chambers from expanding fully. It reduces the preload.
Pulmonary embolism – blockage of a main artery of the lung or one of its branches
Haemorrhagic shock
• So, the venous return to the right atrium is reduced. It causes reduced preload and
stroke volume resulting in reduced cardiac output. It results in decrease in blood
pressure.
• Low blood volume causes reduction of discharge rate and stimulation of volume
receptors on atrial wall at the opening of the SVC, IVC and pulmonary vessels. low blood
pressure causes reduction of discharge rate and stimulation of carotid sinus and aortic
arch baroreceptors.
• This reduces the neural discharge of buffer nerves to the nucleus tractus solitarius
which in turn causes the stimulation of the vasomotor Centre and inhibition of the
cardiac inhibitory Centre resulting in an overall sympathetic stimulation and reduction
of parasympathetic activity.
• Increased heart rate causes rapid but thready pulse because the blood volume is
reduced.
• Angiotensin II causes the secretion of aldosterone and ADH which increase renal Na+
reabsorption from tubules and water reabsorption from collecting ducts respectively.
•Angiotensin II constricts renal afferent and efferent arterioles; efferent arterioles are
Constricted more and angiotensin II causes constriction of mesangial cells. In both these
ways it will reduce UFR resulting in oliguria and thus increasing blood volume in turn
increases the blood pressure to supply vital organs.
• In addition, Angiotensin II and ADH can act as a vasoconstrictor and cause an increase
in venous return.
• Haemorrhage causes decreased blood flow through aortic and carotid body chemo
receptors resulting stagnant hypoxia which stimulate the peripheral chemoreceptors.
• And due to the blood loss amount of RBC is reduced. Resulting anemia causes
Inadequate tissue perfusion.so the cells generate energy from anaerobic glycolysis.
Lactic Acid is produced. Lactic acid reduces blood pH and stimulate peripheral
chemoreceptors.
• The impulses from these via afferent nerves modulate the respiratory center to
increase discharge in the efferent nerves supplying respiratory muscles which would
increase respiratory rate and depth resulting in adequate O2 supply to vital organs.
●It is in the wake of these physiological adapta ons inside the body that you would see
a rapid thready pulse, increased respiratory rate, oliguria and cold clammy hands in a
person with shock.
CNS
Pumping
mechanism
Regulatory
Nerves = motor & sensory
(phrenic, vagus etc.)
The collective activity of all above results in the main function of gas exchange to supply O2 and remove CO2. This task of
delivering gases between atmosphere and cells is staged into the following processes.
1. 2. 3. 4.
VENTILATION GAS EXCHANGE GAS TRANSPORT REGULATION
Mechanism of Breathing
The movement of air between the lungs &
atmosphere depends on;
1. Total pressure gradient (mass movement)
2. Partial pressure gradient of individual gases
Pressures aiding ventilation;
Atmospheric pressure – The pressure of the outside air at sea level
Intra-alveolar pressure – The pressure inside the alveoli; Approx. to atmospheric pressure
at rest = 0mmHg
Inspiration
Active process
Contraction of inspiratory muscles increase thoracic
volume
Main muscle of inspiration – diaphragm
Other/ accessory muscles – external intercostals,
sternocleidomastoid, scaleni, serratus anterior
Chest wall expands, lungs begin to expand because
visceral pleura is in contact with parietal pleura,
expansion of lungs leads to increased elastic recoil
Intrapulmonary volume increases
Negative IPP transmitted to alveoli becomes -6 mmHg
Intrapulmonary pressure drops
Air flows into lungs
Expiration
Passive process during rest.
Inspiratory muscles stop contracting
Thorax & lung come back to their original positions because the lung & chest wall are elastic (passive
process)
Intrathoracic volume decreases.
Alveolar pressure becomes positive relative to the atmosphere
Air flows out until the pressure equalize
Negative intrapleural pressure returns to previous value (-2.5 mmHg) but does not become positive.
Trachea
RL main bronchi Lower
Lobar bronchi Airways
Segmental bronchi
Terminal bronchioles
A1V1 = A2V2
Total cross section area increases along the tract
∴Velocity decreases along the tract
Air flows by bulk flow up to the terminal bronchioles, thereafter the volume / total cross area
greatly increases causing velocity of air to rapidly decrease.
Therefore, there is a high chance of unfiltered inhaled dust particles depositing in the respiratory zone
Dilatation Constriction
Inspiration Expiration
Sympathetic Parasympathetic
1. Resistance - “Pressure difference required for a unit air flow (R = ΔP/Flow Rate)”
Depends on:
Pressure gradient between the mouth and alveoli (determines the volume of air coming in)
Caliber of the airways
o Tone of bronchial smooth muscle
Neural: Parasympathetic (Ach mediated) – constrict
Sympathetic (β2 adrenergic) – dilate
Chemical: NO, VIP – dilate
Histamine, substance P - constrict
o Patent bronchi
Density & viscosity of the inhaled gas (O2 mixed with He is given in hospitals)
Direction of flow
Nature of flow
Lung volume (this is why obstructive respiratory disease patients breathe at high lung volumes;
radial traction on bronchioles during inflation pulls them open.)
Large bronchi Medium size bronchioles Increase resistance
Medium size bronchi Small bronchioles Decrease resistance
Dilators
1. VIP – Relaxes smooth muscles
2. Salbutamol – β2 agonist
3. Atropine – Parasympathetic antagonist
Allergens of asthma
o infectious viruses, exercise, environmental and air pollution, occupational factors,
pharmacological agents.
Basis of treatment
3. Increase the pressure gradient – Mechanical ventilators & accessory muscles of inspiration
Compliance during,
Supine position Pulmonary congestion
Pneumothorax Removal of one lung
Pulmonary oedema Rigid chest wall
Old age Acute respiratory distress
Emphysema
As the walls of the airways are weaker and less supported they tend to collapse when the
pressure outside increases in expiration.
“Surface tension is the force acting perpendicular on an imaginary line 1cm long on the surface of a liquid”
This occurs due to the intrinsic property of a liquid to assume the minimum surface: volume ratio (the
attractive forces between liquid molecules is greater than their attraction to other surrounding molecules.
Work of Breathing
Dead Space
The volume of gas, which occupies that region of the respiratory system, which does not take part in gas
exchange.
Calculation of Ventilation
Tidal volume = Anatomic dead space + alveolar compartment
= 150 mL + 350 mL
= 500 mL
Obstructive Restrictive
Caused by airway obstruction Caused by stiff lungs
Difficulty in expiration Difficulty in inflating lungs
FEV1 decreases FEV1 decreases
VC unchanged VC decreases
FEV1/VC ratio less than 75% FEV1/VC ratio normal or higher than 75%
Ex: Asthma, COPD, Emphysema Ex: Lung Fibrosis, pneumothorax, pulmonary oedema
Peak flow is the volume of air that can be expired in a unit time in a maximum expiratory effort.
This ranges from 400 – 750 L/min
Peak flow meter is used
Measurement of PEF- select best of the 3 blows, not the average.
Peak flow is reduced in
o Restrictive diseases
Fibrotic diseases
Tuberculosis, Lung fibrosis, Silicosis
Abnormal chest walls
Kyphosis, Scoliosis
o Obstructive diseases
Asthma
Emphysema
Other Methods
i. Peak expiratory Flow
ii. Pulse oximetry – measure O2 saturation
iii. ABG testing
Partial Pressure
Oxygen Cascade
PIO2 = PB%
PAO2
PaO2
Gas exchange occurs at blood gas interface – Made of alveolar & capillary walls + fused basement
membrane/ Alveolar capillary membrane/ Respiratory membrane
Diffusion
Factors effecting the rate of diffusion across the membrane (V/t)
Thickness of the membrane (T)
Surface area of the membrane (A)
Pressure difference of the gas across the membrane (P1-P2)
Diffusion coefficient (D) – Depend on solubility (sol) & square root of the gas’s molecular weight (MW)
𝐕 𝐀
∝ × 𝐃 × (𝐏𝟏 − 𝐏𝟐)
𝐭 𝐓 In emphysema surface area
𝐬𝐨𝐥 decreases as alveoli coalesce
𝐃∝
√𝐌𝐖
“Volume of gas that will diffuse through the respiratory membrane each minute for a partial pressure
difference of 1 mmHg”
It is a measure of the ability of the lung to transfer gas across the respiratory membrane. (High surface
area, adequate perfusion with haemoglobin)
Procedure
1. Inhale a gas mixture with 0.3% CO. Condition DLCO
2. Hold breath for 10s. Exercise ↑
(CO diluted by gas already present and also Emphysema ↓
taken up by Hb.) Lung Fibrosis ↓
3. Exhale 1st to wash out the dead space Lung Lobe resection ↓
4. Next exhaled alveolar sample Anaemia ↓
collected. 5.CO concentration measured. Alveolar Hematoma ↑
6. Should make corrections for Hb concentration
and lung volume.
Diffusing capacity markedly increased in – exercise (because of capillary dilation and distension)
Diffusing capacity decreased in – emphysema, lung fibrosis, lung lobe resection, anaemia
Diffusing capacity CO2 >>O2 → CO2 retention is rarely a problem in patients with lung fibrosis
O2 diffusing capacity reduction severe
Pulmonary Circulation
2 main supplies
o Bronchial arteries – oxygenated blood from aorta, supply nutrients to the pulmonary tree.
o Pulmonary arteries – deoxygenated blood from r. ventricle for gas exchange.
After exchange, oxygenated blood is carried to the heart by pulmonary veins. There it is mixed with
deoxygenated blood draining the lungs. Thus, a physiological shunt is seen here.
Shunts Deoxygenated blood entering the arterial side of the circulation without undergoing gas exchange within
ventilated regions of the lung for oxygenation.
When enlarged to cause pathological Most added O2 is dissolved form, because blood that
conditions, ‘pathological shunts’ is perfusing, ventilated alveoli are hardly saturated.
17 ©2017 A/L Repeat Campaign
Pressures in the Pulmonary System
Mean pressure
15 mmHg
Inspiration PVR
Extra alveolar vessels are opened by radial traction from
surrounding lung tissue.
Upright
Lower regions ventilated better than upper
zones.
Supine
Apical ventilation = basal ventilation.
Lowermost (posterior) > Uppermost (anterior)
L/min
Q
V
Q
Bottom Top
Q>V V>Q
∴ V/Q is ∴ V/Q is
low high
Draw a graph showing the variation of V, Q & V/Q from the dependent part to non-
dependent part of a lung
V/Q abnormalities
o Do not commonly lead to CO2 retention, if ventilation can be increased.
o Hypoxemia cannot be eliminated by increasing ventilation
Different behavior of the 2 gases result from the different shapes of their dissociation curves.
V/Q mismatch is an important & common cause of hypoxemia. It can also cause hypercapnia BUT it
does not manifest! WHY? CO2 can be excreted by increasing ventilation but not O2 diffusion. CO2 is
highly water soluble than O2
V/Q ratio increase in emphysema, decrease in fibrosis.
21 ©2017 A/L Repeat Campaign
Autonomic supply – (sympathetic - ↓blood flow)
Active
- O2
Local factors (Hypoxic pulmonary vasoconstriction)
- CO2 (→ pH↓ → vasoconstriction)
- NO
Gravity
O2 Transport
O2 & Hb
2. O2 saturation
𝑂2 𝑐𝑜𝑚𝑏𝑖𝑛𝑒𝑑 𝑤𝑖𝑡ℎ 𝐻𝑏
× 100%
𝑂2 𝑐𝑎𝑝𝑎𝑐𝑖𝑡𝑦
Arterial blood = 97%
Venous blood = 75 %
≈30mmHg → 50%
50mmHg → 85%
2) ↓ temperature ↑ temperature
4) ↓Pco2 ↑Pco2
5) ↑CO
Fetal Hb
HbF affinity for O2 than HbA.
Mother to baby O2 movement is
facilitated.
Reason: chains in HbF have poor affinity for
2,3, BPG than in chains in HbA.
CO2 Transport
Solubility of CO2 in blood is about 20 times that of O2
Mainly 3 ways. - In
o RBC
o Plasma
1. Dissolved - 7 - 10%
2. Carbamino compounds - 23 - 30% -
(bound to amino groups of Hb, plasma proteins)
3. Hydration – HCO3- - 60 -70%
Haldane effect
Occurs at lung level
Deoxy Hb
o binds more H+ than HbO2 (Better buffer) Plasma
o forms carbamino compounds more readily RBC
than HbO2 CO2 CO2+ H2O
Binding of O2 to Hb affinity for CO2. Carbonic
anhydrase
H2CO3
Bohr effect
H+
Occur at tissue level Band 3 HCO3- HHb
Rise in Pco2 causes rise in H+ (AE1)
in O2 affinity of Hb when pH Cl- Hb
Deoxy Hb binds H+ more actively than HbO2 HbO2
Curve shift to the right.
O2 O2
P50 , thus affinity decreases
70% of HCO3- formed in RBC enters the plasma in exchange for Cl-.
By Anion Exchanger 1 (AE1/ Band 3)
Cl- of RBC in venous blood >>> arterial blood
For each CO2 molecule added to an RBC −−−→ ↑of 1 osmo cally ac ve par cle in the RBC
HCO3- or
Cl-
Lungs
RBC
CO2 CO2+ H2O
Carbonic
anhydrase
H2CO3
HCO3- H+ HHb
Band 3
(AE1)
Cl- Hb
HbO2
O2 O2
Neural
Effectors
Sensors Respiratory muscles
Chemoreceptors – Reciprocal innervation-
Central excite agonists, inhibit
Peripheral antagonists
PaCO2
PaO2
H+
Response
Change ventilation
Rate & depth
Central-medullary Peripheral
Carotid Bodies-IX Buffer nerves
Monitor [H+] in CSF and brain ECF Aortic bodies-X
Stimulated by –
↑ PaCO2, ↑ H+ in CSF and ECF Has a rich blood supply for a unit mass. – because the blood
flow per unit of tissue is so enormous, the O2 needs of cells
can be met largely by dissolved O2 alone. Therefore, the
H+ in blood cannot pass through BBB receptors are not stimulated in conditions such as Anemia or
CO2 diffuses CO poisoning
CO2 + H2O H2CO3 H+ +HCO3- respond to changes in dissolved O2, CO2 and pH
Not stimulated in
o Anemia (PaO2 is normal)
o CO poisoning
Receptors for H+ Receptors stimulated
o pH
Main stimulation PaCO2 o PCO2(above 40mmHg)
o PO2 (below 60mmHg) Discharge rate
When PaCO2 cerebral vasodilatation ↓
o Vascular stasis
More CO2 diffuses to CSF and brain ECF -
o CN poisoning Respiratory center
Stimulate respiration +
o K Infusion ↓
o Exercise Ventilation
o Nicotine & Lobeline
If peripheral chemoreceptors are denervated response to
hypoxia is abolished
Response to H+ is affected significantly
Morphine depresses respiration
Unmyelinated
Myelinated
fibers
Juxta Capillary
Slowly Adapting Rapidly Adapting
Receptors
Stretch Receptors
(Hering-Breurer Irritant Receptors
reflex)
Response to hypoxia
Hb less saturated
PaO2
More H+
Peripheral
Peripheral
Ventilation Chemoreceptor
Chemoreceptor
trigger
trigger HHb
Buffering of H+
Central PCO2
Chemoreceptor
[H+] in plasma
Triggered Respiration inhibited
RS Changes
PaO2 PaCO2 ,
Periodic breathing - apnoea →few shallow breaths → apnoea (During apnoea, the alveolar pO 2
falls and pCO2 rises. Breathing resumes because of hypoxic stimulation of carotid and aortic
chemoreceptors before the CO2 levels have returned to normal. Another few breaths eliminate
the hypoxic stimulus, then again apnoea occurs until the alveolar pO 2 falls again)
CO2+ H2O H2CO3H++ HCO3-
CNS Changes
HR - ↑
BP - ↑
Skin changes
High altitude
At 3000m above the sea level PAO2 is about 60mmHg. And there is enough hypoxic stimulation
of chemoreceptors under normal breathing to cause hyperventilation.
Cerebral oedema
Increased barometric P
P on the body rises
Pushes N2 into blood
N2 is very lipid soluble (nervous system, bone marrow, fat)
If ascent rapid, PN2 ↓ abruptly, N2 ‘boils’ out of tissuesair bubbles → bends and chokes
N2 narcosis is seen
Hypoxia
O2 deficiency at tissue level
Anaemic hypoxia
Hypoxia PaO2 normal
Hb ↓
O2 content of arterial blood is
low
Hypoxic Stagnant / Ischaemic Histotoxic hypoxia
hypoxia hypoxia O2 delivery normal Respiratory symptoms not
↓PaO2 O2 delivery inadequate Tissue O2 utilization severe at rest unless Hb is
Normal PaO2, Hb impaired very low
Impaired circulation (Dissolved O2 is normal →
Local E.g.- CN- poisoning Chemoreceptors not
Generalized Inhibit cytochrome stimulated)
oxidase
CO poisoning
Irreversible
Causes of hypoxemia −−−−−−−−→ COHb
Cherry red
1. Hypoventilation Cannot take up O2
Curve of remaining Hb → left
1.1. Restrictive diseases
Depression of the respiratory center by drugs (morphine & barbiturates)
Diseases of the medulla (encephalitis, hemorrhage)
Diseases of conduction pathways (spinal cord, nerves)
Diseases in neuromuscular junction (myasthenia gravis)
Diseases of respiratory muscles (Duchenne muscular dystrophy)
thoracic cage abnormalities (crushed ribs)
diseases of the pleura (pleural effusion, pneumothorax)
3. shunts
patent ductus arteriosus (PDA)
ventricular septal defects (VSD)
atrial septal defects (ASD)
4. V/Q imbalance
COPD
Pulmonary embolism
Cyanosis
Dusky, bluish discoloration of tissues due to increase of deoxygenated Hb concentration (above
5g/dL)
Depends on;
o Total Hb level in blood(polycythemia)
o Degree of saturation
o State of capillary circulation
Central peripheral
e.g.: - VSD e.g.: - impaired local circulation
Conjunctiva nail beds
tongue
In methhemoglobinemia (higher than normal level of methhemoglobin - metHb, [Fe 3+] rather than [Fe2+])
in the blood) discolouration is seen. Caused by nitrite, thiosulphate like drugs.
Management of hypoxia
Hypoxic hypoxia – O2 therapy very valuable except in R→L shunts & V/Q imbalance
Anaemic, stagnant, histotoxic hypoxia – O2 of limited value. Primary cause should be treated
CO2 narcosis
If CO2 concentration exceed 7%
o Depression of CNS
o Confusion
o diminished sensorium
o coma
o respiratory depression
o Severe acidosis
o death
Unit: L/min
Normal rate: 400L/min (varies with age, gender, height and ethnicity)
Method
1. Should hold the peak flow meter horizontally.
2. Do not block the indicator with your fingers.
3. Mouthpiece and lips should be sealed.
4. Inhale deeply then blow as fast as possible.
Do this three times and take the highest reading as the result.
Adenosine----PO4-----PO4----PO4
o As soon as we start exercising, we initially use the available ATP in the muscle (3s- one
half of a 50m dash), and then ATP energy stored as Phosphocreatine.
CVS in exercise
Types of contraction
A prompt
increase in HR
a result of psychic stimuli on medulla oblongata. [due to a decrease in vagal tone (mainly)
+ increase in sympathetic activity]
Increased total peripheral resistance due to Net fall in PR due to vasodilation in muscles
compression of vessels (increased intra- (initially neural, then local vasodilation due to
muscular pressure due to sustained accumulation of metabolites-CO2, K+,
contraction) vasoactive substances)
Decreased or zero muscle BF (>70% of max Increased muscle blood flow
muscle tension)
Low increase in venous return (lack of muscle Marked increase in venous return
pump)
Stroke volume relatively unchanged (due to very Marked increase in stroke volume
less increase of venous return)
CO increased (CO=HR*SV; HR has ) CO markedly increased (both ,SV )
Sharp increase in systolic & diastolic pressure Moderate increase in systolic
(increased CO and PR) pressure. (increased CO)
Diastolic pressure decreased/unchanged (due
to the fall in PR)
Max HR decreases
with age (Max
(Frank- Starling)
HR=220-age)
EDV SV (50%) Cardiac
Output
Increase due to,
×6
(5.5→20-35)
Muscle pump
Venous return Thoracic pump
(Not the main Mobilization from viscera
cause of CO) Noradrenergic
venoconstriction
(shunting blood from
reservoirs
:skin, GUT)
Increased pressure
transmitted from dilated
arterioles to veins.
Therefore they can achieve a given increase in Cardiac Output by further increases in Stroke
volume without increasing their HR as much as an untrained individual does.
RS in exercise
Changes occur in:
O2 consumption (cellular respiration)
Pulmonary ventilation
Diffusing capacity External and pulmonary respiration
O2 consumption:
O2 Consumption
VO2 max
Exercise intensity
Above the exercise intensity corresponding to VO2 max oxygen consumption levels off.
Stored 2L of O2 → Enough for 1min of heavy exercise.
Rate of utilization of E stores > Rate of aerobic resynthesis of E stores
Therefore, anaerobic metabolism begins Lactate is produced
O2 debt incurred
90 min
During moderate exercise Arterial pH, PCO2 & PO2 remain constant.
When exercise becomes more vigorous buffering of lactic acid liberates more CO2.
This further increases ventilation.
Increases ventilation (CO2 washout) & CO2 production remain proportionate. So,
alveolar and arterial CO2 change relatively little – isocapnic buffering
Further accumulation of lactic acid (stimulates Carotid body) causes increased ventilation
which outstrips CO2 production. Thus alveolar & arterial PCO2 fall.
The decline in arterial PCO2 provides respiratory compensation for the metabolic acidosis
caused by lactic acid.
Diffusing capacity:
Rate at which O2 diffuses from alveoli to blood
Changes in muscle
• ↑ Muscle blood flow (×30)
×100
• ↑ O2 extraction (×3)
O2 extraction
More O2 used by muscles muscle PO2 falls O2 gradient from blood
to muscle increased
High Temperature/ High 2,3BPG & acidosis (due to accumulation of CO2) shift the
O2-Hb dissociation curve to right. Reduces affinity of Hb for O2
Heat (75-80%)
I
N
C
R
E
A
Myofibrils S
Mitochondrial Ez E
Glycogen stores
Stored triglycerides
- Metabolic systems (aerobic + anaerobic)
Important haemoproteins
Haemoglobin, Myoglobin
Cytochromes (heam + protein)
cytochrome c – involves in ETC
cytochrome P450 – hydroxylation of xenobiotics
Chlorophyll (Mg containing porphyrin) – photosynthesis
Vitamin B12
Tryptophan pyrrolase – oxidation of tryptophan
Catalase
Peroxidases
Nitric oxide synthase
Heam
Protoporphyrin Fe2+
(Porphyrin)
Porphyrins
Porphyrinogens
E.g. uroporphyrinogen, coproporphyrinogen
Haem
ALA Synthase
This reaction is the committed and rate-controlling step in hepatic porphyrin (heam)
biosynthesis.
Co enzyme for ALA Synthase is pyridoxal phosphate (Vit. B6)
Done by ATP
dependent
chaperon I. ALAS I only unfolded form can cross
proteins II. N terminal signal sequence, cleaved by
III. To active refolding by oligomeric folding protein.
Metal Proteins
2) Glucose – repression
3) Substrate availability – Fe2+ (in Fe2+ deficiency, Zn can be incorporated into haem)
4) Drugs – derepression (Eg- barbiturate)
5) Certain steroids induce
Some drugs are detoxified/metabolized by Cyt. P450 in liver (Microsomal monooxygenase system)
consumption of haem
Derepression of ALAS 1
↑Synthesis of ALAS 1
Inhibits,
a) ALA dehydratase - Impairs PBG formation, Elevated porphyrin levels in RBC,
Elevated ALA & coproporphyrin in urine
b) Ferrochelatase - Decreases Haem formation, Causes sideroblastic anaemia
Porphyrias
Photosensitivity
(Skin itches, blisters)
1) Acute
Accumulation of ALA & PBG
Neurological, psychiatric & acute GI disturbances
2) Non-acute
Increased ALAS & defect in uroporphyrinogen
carboxylase
Specific uro & coproporphyrins accumulate
Urinary uroporphyrin excretion increase (Urine turns red on standing)
Congenital erythropoetic porphyria recessive.
Managing
Uptake by liver - Not rate limiting, facilitated transport, carrier mediated, saturable
Conjugation - Drug inducible (Phenobarbital)
Secretion by liver
Rate limiting
active transport
drug inducible (Phenobarbital)
Secretion of Bilirubin glucuronide into bile canaliculi is the rate limiting step.
Clinicals
1. Jaundice (Icterus)
Definition – Yellowish discoloration of skin, sclera and nail beds due to increased levels of
conjugated or unconjugated bilirubin or both in blood.
Clinically detectable when serum bilirubin > 2-2.5 mg/dl
Types of jaundice
Dark urine
Enterohepatic circulation of urobilinogen → more enter into blood → filtered into the urine
Plasma AST, ALT levels due to liver damage but no increase in ALP or slightly increased
GGT increased in severe conditions
Retention and regurgitation of bile due to bile duct obstruction (extrahepatic cholestasis ).
Due to,
Treated with
blue fluorescent light. Converts bilirubin to more polar compound (more water
soluble). Can be extracted with bile without conjugation.
Administration of phenobarbital
Exchange transfusion in severe cases
6. Congenital disorders
bilirubin in plasma.
Conjugated bilirubin level direct test (without methanol)
Unconjugated bilirubin level indirect test (by measuring total bilirubin level using
methanol)
2) Ehrlich’s test
bilirubin in urine
Ehrlich’s diazo reagent + bilirubin reddish purple
1) Major Minerals
Ca and P are the minerals present in the highest amount in the body.
All major minerals (Eg: -Na+, K+, Cl-) influence the fluid balance
Na+ K+
A major cation in ECF Major cation in ICF
Water balance Water and acid base balance
Regulate the acid base balance Muscle activity
Cell permeability CHO metabolism
Muscle action and nerve impulse Protein synthesis
transmission Control of blood pressure
“Trace Elements” - Inorganic metals which occur in biological fluids at a very low concentration
(less than 1μg/g of wet weight). Most essential, others may be required.
Deficiency of trace elements may occur due to: BUT, trace elements may be toxic,
Inadequate intake If taken excessively
Due to malnutrition (→ “food faddism”) If taken in the wrong chemical form
Due to malabsorption (Eg: Cr3+ is the normal active form while
Due to alcoholism Cr6+ is toxic)
Low bio-availability Depending on rate of excretion
Antagonistic interactions
Increased loss
As a consequence of disease
As a consequence of therapy (e.g.
dialysis, total parenteral nutrition/TPN)
Dietary sources: Meat, fish, poultry, dark green leafy vegetables, pulses
Iron is never found in free form (Fe2+) in cells because Fe2+ can generate oxygen free radicals.
Always converted to Fe3+ and bound to proteins:
During transport - bound to apotransferrin (to form transferrin)
During storage - bound to apoferritin (to form ferritin)
Iron Absorption
NOTE: There is no specialised route for excretion of iron. Iron absorption is controlled so that the
amount absorbed is just sufficient to replace losses.
Haem oxygenase
Biliverdin + Fe2+
2) Cellular iron status is regulated at cellular level through reciprocal regulation of transferrin
receptors and ferritin expression
Translation of mRNA coding for ferritin and transferrin receptors (TfRs) is reciprocally
regulated.
When intracellular iron level is high, ↑ ferritin ↓ TfR
When intracellular iron level is low, ↓ ferritin ↑ TfR
Discussed in detail under “Regulation of Gene Expression” lesson
Iron is one-way element and very little of it is excreted. Any type of bleeding will cause loss
of iron.
Almost no iron is excreted through urine.
Considerable faecal loss.
Some amount from skin.
Iron overload
1. Excessive absorption → Hereditary haemochromatosis
2. Excessive intake
3. Transfusional haemosiderosis - multiple blood transfusions
4. Inappropriate administration of iron
Absorption
Intestine most rapid in duodenum (pH <7)
2 mechanisms,
a) Active transcellular absorption
Duodenum and proximal jejunum, at low luminal Ca concentration, controlled by
Vit. D through the protein calbindin.
b) Passive para cellular absorption (between cells)
At high luminal Ca2+ conc. and is bidirectional.
Effects of Hormones
Ca transport in plasma
Total Ca
Free ionic Ca physiolo. Active (50%)
Diffusible (60%)
Complexed [with citrate, Phosphate] (10%)
Associated disorders
Hypocalcaemia Hypercalcaemia
With low PTH Hyperparathyroidism
Hypoparathyroidism high serum Ca2+
With high PTH ↑ Ca excretion & renal calculi can occur
Deficient intake/absorption of Vit. D or Ca 2+ Malignant diseases
Inadequate exposure to sunlight Excessive Vit. D and Ca intake
Disordered Vit. D metabolism
CRF failure to form 1,25 dihydroxyD3
Thiocyanate & perchlorate: Inhibit the Na+/I- symporter in thyroid follicle cells
Propyl thiouracil, carbimazole, methimazole: Inhibit iodination & coupling
Iodine deficiency will produce hypothyroidism and then it will lead to goitre. Goitre is not
always iodine deficiency. (Selenium deficiency)
PHOSPHORUS
85% bones
Total body P 600g
15% soft tissues and blood
Absorption of phosphorus
Absorbed very effectively from the small intestine
Functions of phosphorus
Part of a major buffer system in body cells (as phosphoric acid and its salts)
Component of DNA and RNA. Hence essential for growth and function of cells.
Assist in energy metabolism: - many enzymes and substrates activated by phosphorylation
ATP as energy currency.
Phospholipids: - membranes and phosphoproteins in milk.
Covalent modification
increased FA synthesis
a) Allosteric regulation
b) Covalent modification
protein phosphatase
cAMP dependent
ADP protein kinase ATP
+
+ Metformin
Used in the treatment of type
Glucagon + AMPK 2 diabetes
Epinephrine Kinases Lowers plasma TAG through
(covalent) (covalent) activation of AMPK
Resulting in inhibition of ACC
AMP
+ activity, inhibition of ACC & FA
(allosteric)
synthase expression
LCFA
Net reaction
Reused for Acetyl CoA carboxylase
Acetyl CoA + 7 Malonyl CoA + 14 NADPH + 14 H+ C16:0 fatty acid + 8 CoA + 7CO2 + 14 NADP+
O
||
O- —C—CH2 —CH2–CH2 - - - - - - - - CH2–CH2
Multi-functional
7 enzyme functions
Cytosolic
Contains Vit.B5 ----> Acyl carrier protein
Contains ‘Phospho-pantatheine’ residue derived from B5, which contains -SH group at the
active site and cysteine residue
Primary end product is palmitate
Sources of NADPH
HMP Pathway
Cytosolic conversion of malate to pyruvate
Major7 steps for one cycle. 4 carbons, saturated fatty acyl –ACP)
Repetition of cycle of reactions producing palmitate (16carbon) as the primary end product.
For the initial step Acetyl CoA is utilized but for further elongation 2C donor is Malonyl CoA.
Shorter length fatty acids are produced in the lactating mammary gland.
Elongation
Further elongation
Primary end product (Palmitate) In SER and mitochondria
Separate enzymic processes
Desaturation
+
Acetyl CoA [ dimer] Acetyl CoA [ polymer]
-
PDH
Glucose mobilization
Insulin +
Glut 4 [Adipose muscle]
cAMP
+ +
Glucagon Insulin
ROLE OF INSULIN
TAG synthesis
Liver
Can synthesize glycerol 3 phosphate from glycolysis and by glycerol kinase activity.
Adipose tissue
HS-Lipase →
Hormone sensitive
Glycolysis
lipase
Glucose
FA CoA
synthatase
Cholesterol Biosynthesis
CoA
Acetoacetic CoA
HMG CoA reductase is an integral membrane protein of the SER, with its catalytic domain
projecting into cytosol.
SCAP- SREBP
cleavage activating ↑ transcription
protein SREBP2-SCAP-inactive
(integral proteins
[-] of SER membrane)
↑ translation Cholesterol
DHAP DHAP
Glycerol 3 Glycerol 3
phosphate phosphate
dehydrogenase dehydrogenase
Plant sterols appear to block absorption of dietary cholesterol – useful in the treatment of
hypercholesterolemia.
Hormone
Receptor (β- adrenergic)
Phosphorylation of
Adenyl cyclase Perilipin that coats
lipid droplets
ATP cAMP
Translocation
of Perilipin
Protein kinase A Protein kinase A
(Inactive) (Active) Facilitates binding
of HSL to TAG
P
TAG
High level of
insulin and glucose Free FA
+
DAG
Protein
Pi phosphatase H2O
Introduction,
Source – from diet & adipose tissue (because enzymes are here)
Occurs in the mitochondrial matrix
Products – Acetyl CoA, NADH, FADH2
The products of oxidation will further be oxidized through the electron transport chain in
the mitochondria, to form ATP
Easily reversible, however phosphatase based hydrolysis shifts equilibrium to right & makes
it irreversible.
ATP dependent (only energy dependent step)
Short and Medium Chain (12C) Fatty Acids (SCFA & MCFA)- can cross the inner
mitochondrial membrane directly (Without transporters) - activation occurs inside
mitochondria
Long Chain(>14C) Fatty Acids – cannot cross inner membrane – activation occurs at outer
mitochondrial membrane (ER/peroxisome)
Acetyl CoA/CoA regulates FA oxidation.
Long Chain Fatty Acyl CoA are transported into the mitochondria through
Carnitine Acyl-Transferase System. (Because inner membrane impermeable to CoA)
Carnitine Shuttle
[ 𝐴𝑐𝑒𝑡𝑦𝑙 𝐶𝑜𝐴
𝐶𝑜𝐴 ] Ratio ------ Leads to inhibition
Carnitine deficiency
Sources of Carnitine
Primarily in meat
Synthesized from AAs → Lysine & methionine → Liver & Kidney
Most of the carnitine in the body present in skeletal muscles (97%)
Each Cycle produces one acetyl CoA and a Fatty Acyl CoA with 2
carbons reduced.
Also each cycle produces 1 NADH and 1 FADH2 → they enter ETC to
yield ATP
The Acyl CoA dehydrogenases vary according to the no. of carbons in
the Acyl CoA (very long chain/medium chain/short chain Acyl CoA
Dehydrogenase). As three isoenzymes are favo proteins.
Acetyl CoA can,
- Enter TCA and form ATP
- Be used as a substrate for Amino Acid biosynthesis. But CANNOT
be used as a substrate for gluconeogenesis.
β – oxidation only produces the reducing equivalents NADH and FADH2. But ATP is made in
the e-transport chain.
Oxygen is necessary for the electron transport chain
When oxygen is deficient e-transport chain inhibited Accumulation of NADH and
FADH2 inhibit β – oxidation
Increased β – oxidation
KETOGENESIS
NAD+
3-hydroxybutyrate
dehydrogenase
Thiolase HMG CoA synthase HMG CoA lyase NADH
2AcetytlCoA Acetoacytyl CoA HMG CoA Acetoacetate
Mitochondrial + Acetyl CoA
CoA Acetyl matrix
CoA blood
CoA
CO2
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Acetone
Utilization of Ketone bodies
- hydroxybutyrate
- hydroxybutyrate dehydrogenase Acetoacetate
Succinyl CoA
NAD+ NADH + H+
Acetoacetate – Succinyl CoA
transferase
Succinate
Acetoacetyl CoA
2 Acetyl CoA
TCA
Liver lacks the “Thiophorase” enzyme which is need for metabolize Acetoacetate, hence liver
doesn’t utilize KBs, but export them into other tissues.
Plasma lipids
Lipid transport
Majority
Lipoproteins
Macromolecules
Have week covalent bonds
Spherical particles
Contents : TAG, CE, PL, Cholesterol, Proteins
Lipids Proteins
Classes of LP
Density CM
Origin
CM
VLDL LDL (β lipoprotein)
LDL protein content & density VLDL (pre β
HDL Mobility
lipoprotein)
HDL
(α lipoprotein)
Apo LP LP Function
AI HDL Structural protein. Activates LCAT (PCAT). Interacts
with ABC AI transporter.
AII HDL Structural protein
B48 CM Structural protein required for synthesis and
CM remnants secretion of CM.
B100 VLDL , LDL, IDL Structural protein required for synthesis and
secretion of VLDL
Recognition and binding of LDL to LDL receptors.
( reduced due to autosomal dominant disease)
CII CM, VLDL, HDL Activates LPL.
Apo E CM, VLDL & Triggers clearance of remnants of VLDL (IDL) & CM
remnants remnants. Is recognized by remnant receptors.
Nonsense modification
Apo B gene m-RNA m-RNA R-RNA RER Apo B48 SER
(For Apo B100) (For Apo B48)
Lipids
CM Golgi Microsomal TAG
transfer protein (MTP)
CM Metabolism
VLDLs are secreted directly in to the blood by the liver as nascent VLDL.
Nascent VLDL contain Apo B100.
They obtain Apo C2 & E from HDL in the blood plasma.
Apo C2 activates LPL
LPL hydrolyzes TAG into FFA & glycerol.
Remnants of VLDLs, (IDL) now take part in the formation of LDLs.
VLDL remnants return the Apo C & E to HDL but retain Apo B100.
Lipoprotein lipase
Insulin induces synthesis and transfer of LPL to the luminal surface of capillaries
And on the surface of capillaries (outside the tissues) or on the surface of the hepatocyte
(liver cells)
Hydrolyzing TG to release fatty acids near the tissue. High local concentration of fatty acids
leads to their uptake by tissues.
Apo CII activates LPL and Apo CIII inactivates LPL.
LPL has different Km values depending on the tissue.
Ex: Km in heart muscle cells < Km in adipose tissue
So adipose tissue only takes up TAG when there is excessive amount.
LDL metabolism
Uptake of LDLs
Uptake of LDL by tissue is mediated through specific cellular LDL receptors. It’s a negatively
charged glycoprotein.
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LDL binding domain of the receptor is in the N terminal end. (rich in Glu, Asp) (-)
Cytosolic domain controls interaction with clathrin coated pits & participates in endocytosis.
Uptake is controlled by intra cellular free cholesterol concentration.
Adrenals, gonads, etc. has more LDL receptors.
Produced in liver & intestine. Apo C& E synthesized in liver- transferred to intestinal form in
plasma
Acts as a repository of Apo C & E required for CM & VLDL metabolism
Uptake of unesterified cholesterol
Esterifies Chol & transfer to other LPs
Reverse transport of Chol (from tissues to liver)
HDL metabolism
1. Nascent HDL are disc shaped particles that contain PL and Apoproteins A, C and E.
2. They rapidly accumulate cholesterol via ATP binding cassette transporter-1
(ABC-A1).
3. Cholesterol is esterified within HDL by LCAT/PCAT (lecithin cholesterol acyl transferase)
4. LCAT is activated by Apo AI.
5. As the nascent HDL accumulates CE, it 1st becomes a relatively CE-poor HDL3 and eventually
CE-rich HDL2.
6. CEs are transferred to VLDLs via cholesterol ester transfer protein (CETP).
A. Free fatty acid amounts that taken up by liver can be raised due to
1. Mobilization of fat from adipose tissue
2. Hydrolysis of LP TAG by LPL in extra hepatic tissue
Increase amounts of free fatty acids are taken by liver and esterified. The production of
VLDL does not keep pace with the influx of the FFA, allowing TAG to accumulate causing
fatty liver.
During starvation, quantity of TAG in the liver is increased, and ability to secret VLDL is
impaired. Tis may be due to low level of insulin.
B. Due to metabolic block in the production of plasma lipoproteins, thus allowing TAG to
accumulate. lesion could be due to:
1. A block in apolipoprotein synthesis
2. A block in synthesis of lipoprotein from lipid and apolipoprotein.
3. A failure in the secretary mechanism itself.
Ethanol Acetaldehyde
Alcohol
Dehydrogenase/microsomal
ethanol oxidizing system
Liver (Points)
1. Tip of right 10th rib in midaxillary line
2. Left 5th intercostal space in midclavicular line
3. Right 5th intercostal space in mid axillary line
*Not palpable in normal subjects
Midclavicular line
Transpyloric plane
Transtubercular plane
Scarpa’s fascia
Goes to corona of penis Over scrotum Over perineum Goes over the inguinal
(junction between neck and ligament and blends with
shaft of the penis fascia lata (Holden’s line)
Dartos fascia Colles’ fascia
Buck’s fascia
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Line of attachment of membranous layer
o Holden’s line-a horizontal line extending laterally
from the pubic tubercle where the membranous
layer is firmly attached to the deep fascia of the
thigh
**Importance of this line- when the urethra is injured in
the perineum, it prevents extravasated urine from
descending into the thigh beyond this line
o Pubic tubercle
o Body of pubis & margins of the pubic arch
o The posterior border of the perineal membrane
RECTUS SHEATH
▪ Definition–Aponeurotic sheath covering the rectus abdominis muscle
▪ 2 walls-Anterior wall- continues throughout
Adherent to the rectus muscle at tendinous intersections
- Posterior wall - free
Above costal margin – ant wall: external oblique
Post wall: deficient (muscle rests on 5, 6, 7 costal cartilages)
Between costal margin- ant wall: ext. oblique, ant. Layer of int. oblique
& arcuate line
post wall: transverses abdominis, post. Layer of int. oblique
(arcuate line=halfway between umbilicus and pubic symphysis)
Below arcuate line – ant wall: aponeurosis of all 3 muscles
Post wall: deficient, muscle rests on fascia transversalis
Few para-umbilical veins accompany ligamentum teres. In portal vein obs: dilated veins cause
caput medusae at the umbilicus
▬ Lymph drainage
Above umbilicus – Axillary nodes
Below umbilicus – Superficial inguinal nodes
Water-shed line – lymph and venous blood flow upwards above the plane of umbilicus &
downwards below the plane
- Innervation -lower 5 intercostal and subcostal (between internal oblique & transverse
abdominis) T7- xiphoid process, T10- umbilicus level
- Iliohypogastric L1
- Ilioingunal L1
- Subcostal and iliohypogastric supply the gluteal region as well
-between the anterior superior iliac spine & the pubic tubercle the external oblique
aponeurosis folds on itself to form the inguinal ligament
-internal oblique muscle arises from its lateral 2/3 -transversus abdominis arises from its lateral 1/3
-Conjoint tendon: fused lowest aponeurotic fibers of the internal oblique & transversus abd.
muscles. Is attached to the pubic crest
INGUINAL CANAL
▪Definition–Oblique musculo-aponeurotic passage in lower anterior abdominal wall just above the medial
half of inguinal ligament, extending from deep ring to superficial ring(4cm)
▪Rings -Superficial inguinal ring
*Is a V shaped gap in the external oblique aponeurosis, above the pubic crest
- Deep inguinal ring
*Is an opening in the fascia transversalis, situated ½ inch above the midpoint of the inguinal
ligament and immediately lateral to the stem of the inferior epigastric artery
▪Walls–
Anterior wall
Whole extent – skin, superficial fascia, external oblique aponeurosis
Lateral 1/3 – Internal oblique muscle fibers
Posterior wall
Whole extent – Fascia transversalis, extraperitoneal tissue, parietal peritoneum
Medial 2/3 – Conjoint tendon, at the medial end by the reflected part of the inguinal ligament
Lateral 1/3 -interfoveolar ligament
Roof
Arching fibers of internal oblique & transversus abdominis (arching in front of the cord laterally to
behind the cord medially)
Floor
Grooved upper surface of Inguinal ligament
Medial end by Lacunar ligament
▪Contents–Male
1. Spermatic cord (male reproductive system)
• three layers of fascia – the external spermatic, from the external oblique aponeurosis; the cremasteric,
from the internal oblique aponeurosis (containing muscle fibres termed the cremaster muscle); the
internal spermatic, from the transversalis fascia;
• three arteries – the testicular (from the aorta); the cremasteric (from the inferior epigastric artery); the
artery of the vas (from the inferior vesical artery);
• three veins – the pampiniform plexus of veins (draining the right testis into the inferior vena cava and the
left into the left renal vein), and the cremasteric vein and vein of the vas, which accompany their
corresponding arteries;
Female
1. Round ligament of uterus 2. Ilioinguinal nerve
▫Hasselbach’s triangle
Boundaries
A-inguinal ligament
B B-inferior epigastric artery
C C-lateral border of rectus abdominis
medial lateral
A
Surface marking of inferior epigastric artery
0.5in just above the femoral pulse (midinguinal point=halfway between pubic symphysis and anterior
superior iliac spine)
Abdominal incisions
McBurney’s incision – for appendicectomy
(Iliohypogastric and ilioinguinal nerves should be
preserved)
Kocher’s incision
Midline incision
Paramedian incision
2 Layers – Parietal
Visceral
Various folds or reflections of the peritoneum connect viscera to abdominal wall or to one
another.
Some are properly called folds, others are called mesentery, omentum or ligament.
Peritoneal folds of anterior abdominal wall
Falciform ligament - connects liver to anterior abdominal wall & diaphragm, sickle shaped
Ligamentum teres - from umbilicus to the inferior margin of Falciform lig. (remnant of
left umbilical vein)(left is left)
Median umbilical fold - containing median umbilical lig. (remnant of urachus), from apex
of bladder to umbilicus
Medial umbilical fold - containing medial umbilical lig. (remnant of umbilical artery)
Lateral umbilical fold - containing inferior epigastric vessels (only up to arcuate line)
Superior layer of coronary lig. – formed from the right leaf of the Falciform lig.
Right triangular lig. – formed where the superior & inferior layers of the Coronary lig. meet.
7. Gastrophrenic ligament
Omentum
Contents Attachment
1. Greater omentum
R & L gastro epiploic vessels
Double layer of peritoneum folded on itself to form four
Fat layers
Lymph nodes & lymphatics
Anterior two layers descend from greater curvature
Curves back on itself & ascends
Blend with – peritoneum on anterior surface of transverse
colon & transverse mesocolon
Bile duct
Hepatic artery
Portal vein
2. Lesser omentum Right gastric vessels Superior - liver (inverted L shaped attachment to porta
Hepatogastric lig. Left gastric vessels hepatis & Ligamentum venosum)
Hepatoduodenal lig. Lymph nodes Inferior - lesser curvature of stomach, 1st part of duodenum
(Extends from abdominal oesophagus → lesser
Gastric nerves curvature → duodenum )
2. Greater sac - Rest of the space among the serous coated organs
Epiploic foramen - a slit at the right border of lesser sac through which it communicates with greater sac
Boundaries Anterior – Right free margin of lesser omentum
Containing – Common bile duct (R)
Hepatic artery proper (L)
Portal vein (P)
Posterior – IVC, T12 vertebra, right suprarenal gland.
Inferior – 1st part of duodenum
Superior – Caudate process of liver
Peritoneal compartments
1. Right sub-phrenic space (closed above by – superior layer of coronary lig.)
2. Left sub-phrenic space (closed above by – left triangular lig.)
3. Right sub-hepatic space(closed above by – inferior layer of coronary lig. & right triangular lig.)
4. Right para colic gutter (lateral to ascending colon)
5. Left para colic gutter (lateral to descending colon)
Fluid Collects in the Hepatorenal pouch of Douglas =>Subphrenic abscess (Commonest site)
Most dependent part in the supine position
By spread of infection from GB, Appendix
▪Treatment =>
Paracentesis – Removal of fluid in abdomen by puncturing the abdominal wall
Posterior Colpotomy – Drain pus from the Hepatorenal pouch of Douglas through
Rectum or Posterior fornix of the vagina
Pneumoperitoneum
– Air in peritoneal cavity
Haemoperitoneum – Blood in peritoneum
4. Internal Hernia –
o Through epiploic foramen into the lesser sac (Strangulated)
Surgically approached through the greater omentum =>
Epiploic foramen cannot be enlarged because there are important structures
o Paraduodenal fossa => between the duodenojejunal flexure and the Inf. Mesenteric V.
o Intersigmoid fossa => formed by the inverted V attachment of the meso sigmoid
Cystic artery
Splenic artery
Coeliac Trunk
Tortuous
Runs behind upper pancreatic border
Gives off posterior gastric artery
Runs towards the hilum of left kidney
Runs in splenorenal ligament
Common Hepatic
Gastroduodenal artery
Pass behind the 1st part of the
duodenum
Anterior Posterior
Clinicals
Foregut - Posterior gastric ulcer or cancer may erode the pancreas giving pain referred to back.
Ulceration into splenic artery (direct posterior relation to stomach) may cause torrential hemorrhage.
posterior duodenal ulcer can erode gastroduodenal artery resulting a severe hemorrhage.
Midgut - Acute infection in appendix may result in thrombosis of appendicular artery, which is an end
artery thus leading to gangrene of appendix.
Ileocolic artery
Superior branch
Inferior branch Anastomose with right colic
artery
Appendicular artery
Anterior caecal artery Posterior caecal artery
End artery
1st runs in the free margin of
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the mesoappendix, then
close to appendicular wall
Ascending branch
Cross left psoas, gonadal
Inferior mesenteric artery (L3) vessels, ureter, genitofemoral
nerve, quadratus lumborum
Crossed anteriorly by inferior
Left colic artery mesenteric vein
Descending branch
Anastomoses with highest
Sigmoid arteries (2-4) sigmoid artery
Runs in the sigmoid
mesocolon
Left branch
Right branch
Clinicals
Anastomotic branches near inner margin colon forms marginal artery of Drummond.
Avascular window lies between middle colic and left colic arteries around the splenic flexure where
surgeons use to enter the lesser sac.
Ligamentum Teres
Portal Vein
Runs in the free
Right Gastric Vein margin of the lesser Left Gastric vein
omentum short Gastric
Vein
Superior
Pancreaticoduodenal vein Passes behind the lower border of the body
of the pancreas in front of left renal vein and
joins splenic vein
Crosses the third
part of the
duodenum and
uncinate process Left colic vein Sigmoid veins
of pancreas.
▪Relations –
-Peritoneal,
Ventral mesogastrium (dorsal part) - lesser omentum
Dorsal mesogastrium 1.along the greater curvature- greater omentum
2. near the fundus- gastrosplenic ligament
3. near the cardiac end- gastrophrenic ligament
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-Visceral,
Anterior – Anterior abdominal wall
Left costal margin
Diaphragm
Left lobe of liver
Posterior (Stomach bed) –
Pancreas
Transverse colon
Left kidney
Left suprarenal gland
Spleen
Splenic artery
▫Are separated from stomach by the lesser sac
Superior – left dome of diaphragm
Inferior – coils of intestine
Functions
Storage of food
Mechanical grinding and digestion
Prevent reflux
Prevent digestion and damage of its wall
Controlled release of food at pylorus
Absorption (H2O, Ethanol)
Intrinsic factor
Nerve supply
Sympathetic greater splanchnic nerves
Parasympathetic ant & post vagal trunks
Hepatic branch
Not to sphincter
1. Regarding stomach
a. Prepyloric vein marks the pyloric sphincter
b. Cardiac orifice lies deep to the left seventh costal cartilage
c. Part of lesser sac lies within gastrocolic ligament
d. Left supraclavicular nodes enlarges in gastric carcinoma
e. Lymph from upper part of greater curvature drains into pancreaticosplenic nodes
2. The stomach
a) Is supplied in part by arteries arising from the splenic artery
b) Is supplied by arteries which each arise from branches of the coeliac trunk
c) Has a venous drainage passing equally to the portal and systemic venous systems
d) Is lined by columnar and squamous epithelium
e) Is totally covered by serosa (peritoneum)
2) DUODENUM
C shaped loop around head of pancreas
Secondarily retroperitoneal except duodenal cap.
Forms lower most boundary of epiploic foramen of Winslow.
Two papillae: Major – hepatopancreatic ampulla (ampulla of Vater). 8-10cm distal to pylorus
Minor – accessory pancreatic duct opens 2cm above the major papilla
Duodenal cap: Seen after a barium meal. 1st part of duodenum is seen as a shadow.
o Reason: absence of plicae circularis.
Suspensory ligament of Treitz
between DJ junction and right crus of diaphragm
marks DJ junction
Inferior mesenteric artery lies immediately to the left of the DJ junction.
Clinical
o peptic ulcer – common site – 1st part
o obstruction
o Annular pancreas
o Pressure by the superior mesenteric artery
o Contraction of suspensory ligament of duodenum
o Ulceration of gall stones into duodenum & obstruct the lower ileum-gall stone ileus
o Posterior duodenal ulcer
o Damages the gastroduodenal artery & pancreas
1. Duodenum
a) Is almost completely covered by peritoneum
b) Lies behind the portal vein
c) Lies anterior to the hilum of the right kidney
d) Is crossed anteriorly by the superior mesenteric vessels
Jejunum Ileum
1.Wall Thicker & more vascular Thinner & less vascular
2.Lumen Wider & often empty Narrow & often loaded
3.mesentery • Less fat • More fat
• Windows present • No windows
• 1/2 arcades(few) • 3/5 arcades(numerous)
• Vasa recta long & few • Vasa recta short & numerous
4.Plicae Large & closely placed throughout Small & sparse, only in proximal part
circularis
5.Villi Large, thick & more Short, thin & few
6.Payers Present
patches Absent
7. solitary
Fewer More
lymph follicles
1. The caecum
a) Is completely invested in peritoneum
b) Possesses a longitudinal muscle coat but no taeniae coli
c) Lies on the right psoas muscle
d) Has an ileocecal orifice opening inferiorly
e) Lies adjacent to the right femoral nerve
●Appendix
o Vermiform blind ended tube ,situated in right iliac fossa, larger in children & base is fixed
o Opens into posteromedial wall of caecum
o Tip of the appendix has no anatomy, it can be anywhere within abdominal cavity
o Position - Retrocaecal – 65%
Pelvic – 30% Retroileal
o Base - McBurney’s point (gridiron incision)
Junction between lateral 1/3 & medial 2/3rd of line joining the
umbilicus & the right anterior superior iliac spine
o Taeniae coli meet at the base
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o Blood supply – Lower division of ileocolic artery
Runs first in free margin of mesoappendix and then along the appendicular wall.
Clinical
Inflammation: Appendicitis
Pain initially referred to umbilicus (T10)
Later when parietal peritoneum irritates – pain in right iliac fossa
Thrombosis of appendicular artery causes gangrene as it is the
sole blood supply to the appendix.
McBurney’s point- site of maximum tenderness in appendicitis
Appendix of
Children – larger
Adults – obliterated
So appendicitis occurs more in teenagers.
1. The appendix
a) Arises from the inferior aspect of the caecum
b) Has a mesentery
c) Is commonly absent
d) Usually lies retrocaecally.
e) Is clothed in peritoneum
Descending colon is also supplied by pelvic splanchnic nerves which arise from anterior
primary rami of S2, S3, S4 sacral nerves. These supply parasympathetic function including
transmitting the sensation of pain.
Tuber Omentale
Papillary Process
Caudate Process
Peritoneal Attachments –
o Liver is enclosed in peritoneum (Ventral mesogastrium), except at the bare area
Ventral part
i. Falciform lig. – Attached to liver & anterior abdominal wall
o Inferior margin – Ligamentum teres hepatis (Remnant of L. Umbilical V.)
ii. Right & left triangular ligaments
iii. Coronary ligament – Superior & Inferior layers
Dorsal part
Lesser omentum – arise from inverted ‘L’ attachment
o Vertical limb – Ligamentum venosum (Remnant of Ductus Venosus)
o Horizontal limb - margins of porta hepatis
Lobes – Right & Left
Anatomical Division
Functional Division
According to distribution of Bile duct, Hepatic artery, Portal vein. Oblique plane through the GB
Fossa & IVC groove divides it into left and right halves.
8 lobes
Caudate lobe is supplied by both hepatic arteries, both portal veins, both hepatic
ducts, but it has an independent venous drainage
Stability – Ligaments, Hepatic veins, Abdominal muscle tone
Relations-5 Surfaces
Anterior Surface
●Diaphragm
●Pleura
●Anterior Abdominal Wall
●Xiphoid Process
Right
2. Portal vein
Left
Clinical
1. Liver biopsy – Needle passes through right 8th intercostal space
2. Cirrhosis – Liver Fibrosis, causes Caput medusae
3. Malignant growths – Tumors
Can send an embolus to destroy tumors (contain end-arteries)
Secondary tumors – from colon cancers
4. Hepatomegaly – Liver enlargement
5. Pringle’s Maneuver – Liver bleeding stopped by = compressing right free margin of lesser omentum
6. Liver resection & transplantation
Important Facts
O Can regrow
O Occupies R.Hypochondrium, Epigastrium, L.Hypochondrium,Under the Costal margin
Normally not palpated in the infrasternal angle
Due to - tone of the recti muscles & the softness of the liver
Apparatus consists of –
i. Right & left hepatic ducts
ii. Common hepatic duct
iii. Gall bladder
iv. Cystic duct
v. Bile duct
Calot’s triangle –
i. Cystic duct
ii. common hepatic duct
iii. inferior surface of liver
Cystic artery and cystic lymph nodes can be located here.
i. Gall bladder
Pear shaped fibromuscular sac for storage and concentration of bile.
Lying in gall bladder fossa
Plastered onto the visceral surface of right lobe of liver, adjacent to quadrate lobe.
Capacity:- 30-50 ml
Relations
Neck – Superior - Attached to liver, by areolar tissue
Inferior - 1st part of duodenum
Fundus – Anterior – Anterior abdominal wall = 9th costal cartilage tip (transpyloric plane)
Posterior – Transverse colon
Blood Supply
It has a Dual blood supply from:
-Cystic artery (cystic veins do not accompany the cystic artery. Venous drainage is via multiple
veins in gall bladder bed to Liver
-From liver bed, So gangrene is rare.
Clinical
Gall Stones
In gall bladder-Cholelithiasis
Spasmodic pain occurs
Murphy’s sign – Pain felt when pressing at 9 th costal cartilage tip in
Hartmann’s pouch. -Posteromedial wall of the neck is dilated (Gall stones lodge here)
Inflammation of gall bladder
Referred pain -in the lower border of the scapula via sympathetics
- Stomach via vagal fibers
-Shoulder tip via phrenic nerve
4. Courvoisier’s Law
Extrinsic obstruction (Carcinoma of head of the pancreas) – Dilation of GB
Intrinsic obstruction (Stones) – Fibrosis, no dilation of GB
▫Infraduodenal part
-Anterior-head of pancreas (neoplasm of duct may obstruct here)
-Posterior-IVC, Left renal
vein
Join main pancreatic duct of Wirsung at angle of 600 degrees, to form Ampulla of Vater guarded by sphincter
of Oddi.
Surface marking
The transpyloric plane defines the level of the neck of the pancreas which overlies the vertebral Column. From
this land mark head passes downward & to the right, the body & tail pass upward
& to the left
Blood supply
Lymph drainage
Coeliac
Head Neck Pancreaticosplenic nodes Pre aortic nodes
Superior mesenteric
Tail and Body Nodes along splenic artery
Referred pain to
Epigastrium => T6 to T10
Posterior paravertebral region =>inflamed soft tissues of retro-peritoneum
Histology
Encapsulated and lobulated gland
Exocrine pancreas –
compound branched acinar gland
Individual acini consists of pyramidal cells which secrete digestive enzymes
Acinar cells have abundant RER, secretory zymogen granules
Ducts systems eventually drain to large interlobular ducts lined by tall cuboidal/columnar epithelium
Endocrine pancreas –
Pancreatic islets / islets of Langerhans
Most numerous in the tail
Highly vascularized
Contain Alpha(secrete Glucagon), Beta, and Delta cells(secrete somatostatin)
Beta cells secreting insulin is most abundant
Spleen
Surface anatomy
In Left hypochondrium
(Points) – Left side
1. Axis – 10th rib directed downwards forwards and laterally
2. Upper pole – upper border of 9th rib
3. Lower pole – lower border of 11th rib
4. Medial end – 2 inches from midline
5. Lateral end – Mid axillary line
*Must be enlarged 3 times than normal to be palpated
Important Facts
1) Tetrahedral in shape
2) Lies deep to the left 9th to 11th ribs
obliquely along the long axis of 10th rib
3) 2 surfaces – diaphragmatic (smooth,
convex) and visceral.
4) Borders –
Anterior/Superior – notched
Posterior/Inferior
Intermediate – separating gastric
and renal impressions
5) Wedged between fundus of stomach
and diaphragm
Referred Pain
Referred pain is a term used to describe the phenomenon of pain perceived at a site adjacent to or at a distance
from the site of an injury's origin.
3. Appendix - appendicitis
•Umbilical region – 1st felt => T10
•Right iliac fossa - increased inflammation =>Inflamed appendix touches the parietal peritoneum
4. Pancreas - Pancreatitis
•Epigastrium => T6 to T10
•Posterior paravertebral region =>inflamed soft tissues of retro-peritoneum
5. Kidney
• Lumbar region of back
• External genitalia of Anterior abdominal wall
=>T12 to L1 via sympathetic fibers
6. Ureter
• Renal colic – severe pain due to a ureteric stone
• Pain starts in the loin & radiates down the groin, the scrotum or labium majus & the
inner thigh [Pain is referred to the cutaneous areas innervated by segments,
mainly T11 & L2 which also supply the ureter]
7. Uterus.
• corresponding dermatomes =>T10-L1 via sympathetic fibers
8. Ovary.
• Loin & groin =>T10-T11 via Aortic plexus
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POSTERIOR ABDOMINAL WALL
Made up of 3 bony & 4 muscular structures
Bones- Bodies of lumbar vertebrae
Sacrum
Wings of ilium
(11th & 12th ribs)
Muscles - Diaphragm
Quadratus lumborum
Psoas major & minor
Iliacus
Psoas major
Origin - transverse process of all lumbar vertebrae
Side of the bodies (T12-L5 )
Intervening discs (T12-L5 )
Insertion - lesser trochanter of femur
Action – flexion of the hip joint
Roots of lumbar plexus lie within the substance of the muscle.
Genitofemoral nerve - front of psoas
Femoral, Iliohypogastric, ilioinguinal, lateral femoral cutaneous
nerves, femoral nerve - lateral border
Obturator & lumbosacral trunk - medial border
Nerve supply - first 3 lumbar nerves
Quadratus lumborum
Origin - transverse process of vertebra LV, the iliolumbar ligament, and the adjoining
part of the iliac crest
Insertion - attach superiorly to the transverse processes of the first four lumbar
vertebrae and the medial half of the inferior border of rib XII.
The surface marking of the abdominal aorta is from a point 2.5 cm above the
transpyloric plane in the midline to a point 1 to 2 cm below and to the left of a
normally situated umbilicus, level with the highest points of the iliac crest.
Enters the abdomen behind the median arcuate ligament behind peritoneum
slightly inclining to left.
The main branches of the abdominal aorta fall into 3 main categories.
A small posterior branch, the median sacral artery leaves the aorta a little above its
bifurcation.
Lumbar arteries 4
(Leave the aorta opposite the
bodies of L1-L4)
Portal vein
Formed by draining of the splenic vein into the superior mesenteric vein
Behind the neck of the pancreas
At the L2 vertebral level
Relations
Infraduodenal part
Anteriorly – neck of pancreas
Posteriorly – IVC
Retroduodenal part
Ant. - 1st part of duodenum
Common bile duct
Pancreas
Gastroduodenal artery
Post. – IVC
Supraduodenal part - between the 2 layers of the free edge of lesser omentum
Ant. – Hepatic artery
Bile duct
Post. - Epiploic foramen
Tributaries
Splenic vein
Superior mesenteric vein
Left gastric vein
Right gastric vein
Superior pancreaticoduodenal vein
Paraumbilical vein (running with the ligamentum teres)
Cystic vein (if present)
Branches
Right – shorter & wider
Receive cystic vein & enters the right lobe of the liver
Left - longer & narrower
Receive paraumbilical vein
Ligamentum teres
Ligamentum venosum
Iliolumbar vein
Median sacral vein
Lateral sacral vein
3rd & 4th lumbar veins The 3rd and 4th lumbar veins
(1st & 2nd lumbar veins join ascending drain directly into the IVC
lumbar vein while the 1st and 2nd veins
do not.
2 Right gonadal veins 2 venae
commitantes unite on psoas
Right gonadal vein
Fibers pass downwards into pelvis from superior hypogastric plexus as the
hypogastric nerves to form the inferior hypogastric plexus with pelvic splanchnic
nerves.
Somatic nerves
Lumbar plexus
Formed by anterior rami of upper 4 lumbar nerves.
L1 - Iliohypogastric & ilioinguinal
Skin over the inguinal region & front of the scrotum
Motor supply for the internal oblique & transversus abdominis (conjoint
tendon)
L1,L2 - genitofemoral
Genital branch - Sensory to tunica vaginalis & spermatic fascia
Motor to cremaster muscle
Femoral branch – supplies an area of skin below the middle of the inguinal ligament
L2,L3 (posterior division) - lateral femoral cutaneous
Wholly sensory to the iliac fascia & peritoneum of the iliac fossa &
To the lateral side of the thigh down to the knee.
L2,L3,L4 (posterior division) - femoral
L2,L3,L4 (anterior division) - obturator
Left hilum
Transpyloric plane
Right hilum
Side differences –
o R. kidney little lower => Liver superiorly located
o R. kidney little away from the mid-line => IVC medially located
o R. kidney lies anterior to 12th rib, while L. kidney lies anterior to 11th& 12th ribs
Relations
-Posterior – similar to both kidneys
Diaphragm & quadratus lumborum muscles
Behind the diaphragm – costodiaphragmatic recess
Medially overlaps (hilum) – Psoas major
Laterally overlaps – Transversus abdominis
Upper pole – Medial & lateral arcuate ligaments
Emerging beneath the lateral arcuate ligament – Subcostal vein, artery and
nerve
Emerging from the lateral border of psoas major – Iliohypogastric & ilioinguinal nerves
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Right Left
- Anterior
Superior R. Suprarenal gland L. Suprarenal gland
Liver Stomach & Spleen
Peritoneum of hepatorenal Peritoneum of lesser sac medially
pouch (greater sac) Peritoneum of greater sac laterally
Middle 2nd part of Duodenum Body of the pancreas
Splenic A. & V.
Lateral Hepatic flexure Splenic flexure of colon
Inferior Beginning of Descending colon
Medial Small intestine Jejunum
Medial
Above the hilum - Suprarenal glands
Below the hilum - Ureter
Lateral
Right kidney Left kidney
Right lobe of the Liver Spleen
Hepatic flexure of the colon Descending colon
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Coverings (inside to outside)
1. Fibrous/true capsule- easily stripped off in normal, but becomes adherent in disease conditions
4. Paranephric fat
Variable amount of fat lying outside the renal fascia
Fills up the paravertebral gutter, forming a cushion for the kidney
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▪Structure
Renal pyramids – Conical masses in the medulla
Apices of the pyramids form the renal Papillae which indent into minor calyces
Cortical Arches– Form the caps over the pyramids
Renal columns – Dip in between the pyramids
A lobe of the kidney– Each pyramid along with the overlying cortical arch
Renal sinus – Space extending into kidney from the Hilum, containing
Renal artery – branches
Renal vein – tributaries
Renal pelvis ( Major calyces Minor calyces Papillae)
Hilum – A deep vertical slip on the medial aspect of the kidneys extending to the renal sinus
Level – L1 lower border [Transpyloric plane]
Renal V, A, P and Lymphatics and Nerves travel through this
Blood supply
Supply each vascular segment
Venous drainage Arterial supply [END ARTERIES]
But their corresponding veins
IVC Aorta communicate with each other
RENAL
INTERLOBAR
Arches over pyramid bases
ARCUATE At right angles to interlobar A
At corticomedullary junction
INTERLOBULAR
EFFERENT ARTERIOLES
PERITUBULAR CAPILLARIES
Renal artery
Apical segment
Upper segment
Anterior division
Middle segment
4 Lower segments
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Lymphatic Drainage
Into para aortic nodes- L2 level
Nerve Supply
Sympathetic – from T12 to L1
Pain may be referred to back and lumbar region which may radiate to anterior abdominal wall and down to
the external genitalia
▪Clinical
2. Renal angle – Angle between 12th rib-lower border & erector spinae-outer border
▪Enlarged kidney – Lower pole bimanually palpated, on deep inspiration
4. In Renal Failure –
o Kidney Transplantation – In recipient’s pelvis
o Peritoneal dialysis or hemodialysis
6. Nephroptosis
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Ureter
Extraperitoneal throughout
25cm
Whitish non pulsatile cord which shows peristaltic
activity when gently pinched with forceps.
Constrictions
1. Pelvi-ureteric junction
2. Pelvic brim
3. Point of crossing of the ureters by the
ductus deferens/ ligamentum teres.
4. Passage through the bladder wall
5. At its opening at the latera angle of
the trigone.
▪ Course
1) Abdominal part
Begins within renal sinus=renal pelvis
Renal pelvis lies along medial border of kidney behind it
At lower pole it becomes ureter proper
Lies on psoas major, underneath the peritoneum
Crosses in front of the genitofemoral nerve
It descends in front of tips of transverse processes of L2-L5
Crossed By [Anteriorly]
Right Both Sides Left
rd
3 part of Duodenum Gonadal vessels Left colic
Right colic Genitofemoral N. [Posteriorly]
Ileocolic
Root of the mesentery of small intestine
2) Pelvic part
Passes anterior to the bifurcation of the common Iliac A.
o At pelvic brim + In front of Sacroiliac jnt. + Level of lumbosacral disk
o Left side – In the Intersigmoid recess [Under the apex of sigmoid mesocolon]
Goes along the curvature of greater sciatic notch & anterior to internal Iliac A.
Reaches ischial spine & turns forwards & medially
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MALE FEMALE
Crossed By - [Superiorly from lateral to medial]
Ductus deferens Uterine artery
Lies - [Superior to]
Seminal vesicles Lateral fornix of vagina
o Posterior –
Sacroiliac joint
Lumbosacral trunk
Internal iliac vessels
o Lateral –
Obturator internus and fascia
Obturator nerves and vessels
Superior vesical arteries
Inferior vesical veins
Posterior border of ovarian fossa
3) Intravesical part
Enters the bladder at an acute angle
Obliquity of the course produces a sphincteric function
4) Nerve supply
- Sympathetic => T10 to L1 Parasympathetic => S2 to S4 (pelvic splanchnic)
5) Blood Supply
Segmental blood supply
Upper end – ureteric branch of renal artery
Middle – abdominal aorta, gonadal, common iliac, internal iliac
Lower end – superior and inferior vesical, uterine artery
Clinical
1. Ureteric Stones [Calculus]
- Lodge in constricted sites of ureter
- Renal [Ureteric] Colic => Due to spasm of the ureter
Severe pain – radiates from loin to groin, referred to testis
- In X-rays =>
Postero-Anterior View - Ureteric stones – At the tip of transverse processes of lumbar vertebra
Lateral view - Ureteric + Kidney stones – On the body of vertebra
GB stones – Anterior to the body of vertebra
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Supra renal gland
Two parts
- Cortex -- mesodermal origin
- Medulla (1/10 of gland)-- neural crest origin
Right supra renal gland apex related to bare area of liver. It is overlapped medially by the inferior vena cava.
Blood supply
o Arterial supply
Superior suprarenal artery– from inferior phrenic artery
Middle suprarenal artery – abdominal aorta
Inferior suprarenal artery- renal artery
o Venous drainage
Right suprarenal vein– to IVC
Left suprarenal vein – left renal vein
Lymph Drainage
To para aortic lymph nodes
Nerve Supply
Preganglionic sympathetic fibers from splanchnic nerves via coeliac plexus
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PELVIS
1. Bony Pelvis formed by 4 bones united by 4 joints
2 hip bones anteriorly by pubic symphysis (2ry cartilaginous joint)
Sacrum & coccyx by sacrococcygeal joint
Sacrum & 2 hip bones each side by 2 sacroiliac joints
2. Bony pelvis is divided into true pelvis & false pelvis by,
Pelvic brim (pubic crest, pectinate line of pubis, arcuate line of ilium, ala & promontory of sacrum)
3. The plane of the pelvic brim is oblique, lying at 600 with the horizontal plane (the vagina lies in the same plane)
4. Pelvic floor slopes downwards and faces forwards (so that the anterior superior iliac spine (ASIS) and the upper
border of the pubic symphysis lies in the same coronal plane)
True pelvis
Superior ASIS
aperture
Pelvis False pelvis Head of Ischial spine
the femur
Inferior Perineum
aperture
Upper border of
pubic symphysis Apex of Tip of the
greater coccyx
Boundaries of true pelvis trochanter
1. Upper border of pubic symphysis
2. Pubic crest
3. Pubic tubercle
Pelvic
4. Pectineal line
inlet
5. Arcuate line
6. Sacroiliac joint
7. Sacral promontory
Sex differences
Due to easier passage of fetal head in labor
female bones are more slender than male bones
1. Transverse diameter of the outlet- distance between the ischial tuberosities along a plane of the anus
2. Anteroposterior outlet diameter-distance from the pubis to the sacrococcygeal joint.
3. Diagonal conjugate—from the lower border of the pubic symphysis to the promontory of the sacrum.
4. Finger of the examiner should not reach sacral promontory in vaginal examination
Clinical
Caudal anesthesia
The sacral hiatus, between the last piece of sacrum and coccyx - entered by a needle which pierces skin, fascia
and the tough posterior sacrococcygeal ligament to enter the sacral canal.
Pelvic fascia
Pelvic muscles
Piriformis
Origin – front of the middle 3 pieces of its own half of the sacrum
Sacral plexus and sacral nerves lie on the muscle
Pelvic surface of the muscle and sacral plexus are covered by pelvic fascia.
Obturator Internus
Origin – from the whole Obturator membrane and from the bony margins of the foramen
Leaves the pelvis through the lesser sciatic foramen; makes a 90° bend around the ischium between the
ischial spine and ischial tuberosity.
Levator ani
Nerve supply from the S4 sacral nerve & inferior rectal nerve
Arises from the posterior aspect of the body of the pubic bone, the fascia of the side wall of the pelvis
(thickening of obturator internus fascia/white line) and the spine of the ischium.
Contain 2 parts
1. Pubococcygeus
Levator prostate/Sphincter vaginae
o Anterior fibers
o form a sling around the prostate/vagina
o In both sexes, fibers also attach to the perineal body
Puborectalis
o Middle fibers
o form a sling around the rectum and also insert into deep part of the longitudinal muscle
coat of the anal sphincter at the anorectal ring
Pubococcygeus proper
o Posterior fibers
o Attached to the sides of the coccyx and to the median fibrous raphe, which stretches
between the apex of the coccyx and the anorectal junction.
2. Iliococcygeus
o posterior half of the white line & ischial spine
Actions
1. Acts as the principal support of the pelvic floor
2. Has a sphincter action on the rectum and vagina.
3. Assists in increasing intra-abdominal pressure during defecation, micturition and parturition.
Obturator artery
Periosteum of back of pelvis
Accessory/abnormal obturator artery can arise from the
inferior epigastric artery*
Crossed by ureter (in the ovarian fossa in females)
Uterine artery
Uterus, cervix, uterine tube
Anterior Crossed by ureter 1cm lateral to supra vaginal fornix
Uterine
division
Vaginal
Upper part of vagina
Inferior vesical
Trigone, lower bladder, vas deferens
Internal pudendal
Leaves the pelvis through the greater sciatic foramen below the piriformis
Anal region, external genitalia
Inferior gluteal
Leaves the pelvis first through S1 & S2 ventral rami & then
through the greater sciatic foramen below the piriformis
Anterior (lateral)
Psoas, Quadratus lumborum
Lumber branch (5th
lumbar segmental
artery) Posterior
Erector spinae
Iliac branch
Iliac fossa, iliacus, iliac
bone
Posterior Anastomosis
Lateral sacral around ASIS
division
Piriformis
Spinal branches
Superior gluteal
5 Leaves the pelvis first through lumbosacral trunk ©2017 A/L Repeat Campaign
& S1 ventral rami & then through the greater
sciatic foramen above the piriformis
Bladder
Pelvic organ; as the bladder fills, it
domes into the abdominal cavity.
Trigone of the bladder
o Least mobile part of the bladder
o Mucous layer tightly adhered
Relations
Empty bladder is tetrahedral (three
sided pyramid) in shape.
Has an apex, base, neck, superior
surface and 2 inferolateral surfaces.
o Neck
In the male; lies against the upper surface or the base of the prostate
In the female; lies above the urethra in the connective tissue of the anterior abdominal wall
1. Anteriorly - the pubic symphysis, puboprostatic & pubovesical ligaments in the retropubic space
2. Superiorly - the bladder is covered by peritoneum with coils of small intestine and sigmoid colon In the
rectovesical pouch in male. In the female; the body of the uterus flops against its posterosuperior aspect forming
the vesicouterine pouch.
3. Posteriorly - in the male; the rectum, the termination of the vas deferens and the seminal vesicles; separated
from the rectum by denonvilliers’ fascia
in the female; the vagina and the supravaginal part of the cervix (with no peritoneum
intervening)
4. Laterally - the levator ani and obturator internus
Blood supply; mainly by superior and inferior vesical arteries. Veins do not follow the arteries; instead forms
the vesicoprostatic plexus in the groove between the bladder and prostate, which drain into internal iliac
vein.
Lymph drainage is mainly into external iliac nodes.
Nerve supply;
o Sympathetic (vasomotor & inhibitory to Detrusor muscle) – superior and inferior hypogastric plexus
(L1,L2)
o Parasympathetic (motor and sensory) – Pelvic splanchnic nerves
o Trigone is supplied exclusively by sympathetic nerves
Ischiopubic ramus
Ischial tuberosity
Anal aperture
Sacrotuberous ligament,
covered by inferior border
Anal triangle of gluteus maximus
wedge shaped space filled with fat either side of anal canal Below the pelvic diaphragm.
Clinical
1. Abscesses can be ruptured internally or externally into the anal canal or to the surface of perineum –
anorectal fistula.
2. Ischiorectal fossa acts as a cushion giving support to rectum & anal canal.
3. Anteriorly infection of one space can't communicate across the midline, but posteriorly communicates
through horseshoe shaped path
Pudendal canal
connective tissue tunnel on the lower lateral wall of the ischioanal fossa
Attachments: -
external anal sphincter – unpaired
pubovaginalis / puboprostaticus of levator Ani.
Bulbospongiosus Paired
Superficial transverse perineal muscle
deep transverse perineal muscle
action: -
stabilizing influence for pelvic and perineal structures
Weakness causes prolapse of the vagina and uterus.
Urogenital Region
Perineal Membrane
bulbous scrotal expansion (dartos fascia) cylindrical penile expansion (buck’s fascia)
Clinical
Pudendal nerve block Inferior rectal nerve
Needle passes through
vaginal wall to ischial
spine guided by finger
OR
Just medial to ischial
tuberosities
Anterior Anastomose at
Transverse Posterior
margin of
scrotal artery Glans penis
perineal artery perineal
membrane
Helicine arteries
Skin, fascia of penis
Supply cavernous
1. Uterus
▪ Peritoneal attachments
1. Anterior ligament or uterovesical fold
2. Posterior ligament or rectovaginal fold
3. Two broad ligaments
Mesovarium-ovary to posterior layer
Mesosalpinx - part between ovarian ligament & uterine tube
Mesometrium- part below ovarian ligament
4. Suspensory ligament of ovary
1. Broad ligament
Primary Secondary 2. Uterovesical fold
3. Rectovaginal fold
Fibromuscular Muscular
Structure
Muscular organ responsible for the protection & nourishment of fertilized ovum so
that it can develop into a full-term fetus.
Pear shaped
Possess 3 parts
FUNDUS
Posterior surface
Directed upwards
Related to coils of terminal ileum & sigmoid colon
Covered with peritoneum & forms rectouterine pouch posterior to it
Lateral borders
Provide attachment of uterus to the side walls of the pelvis
Uterine tubes open into the uterus at the upper end of this border
Anteroinferior to the opening of uterine tubes is the round ligaments
Posteroinferior to the opening is the ligament of the ovary
Uterine cavity occupies the body & is triangular shaped
Apex is directed downwards & is continuous with the cervical canal via the internal
os.
CERVIX
Lower cylindrical part of the uterus
Projects into the vault of the vagina
Contains two parts
1. Supravaginal part
Related anterior to bladder
Posteriorly to rectouterine pouch
Lateral to it are the ureters
Uterine artery between layers of the broad ligament
2. Vaginal part
Projects into vagina
A deep sulcus is formed around (fornices of the vagina)
Cervical canal opens to the vagina through the external os
Ureter runs forwards slightly above the lateral fornix of vagina and is 2cm lateral to
supravaginal part of cervix
Uterine artery crosses ureter superiorly at right angles from lateral to medial
▪ Clinical
- In hysterectomy ureter can be divided in the process of clamping uterine artery
- The only site where a ureteric stone can be palpated is where the ureter relates to
supravaginal cervix
2. Ovaries
Situated in ovarian fossa of lateral pelvic wall
Has 2 poles; upper and lower.
Has 2 borders; anterior or mesovarian border and posterior border.
Has 2 surfaces; medial and lateral.
3. Uterine tubes
- form a connection between abdominal & uterine cavities
Infundibulum – mouth is fimbriated
Ampulla (lateral 2/3rd) – widest
Isthmus (medial 1/3rd)
Intrauterine/ Interstitial part – narrowest
Only the lower pole and the lateral surface of the ovary are not related to the
uterine tube. The remaining 2 borders, upper pole and medial surface are related
to the tube.
- Clinical
Blockage of uterine tubes – commonest cause for female sterility
Rubin’s test
Hysterosalpingography
4. Vagina
Fibromuscular tube
Extends from vaginal orifice within vestibule
Upward & backwards towards uterus
Passes through pubovaginalis, deep perineal pouch & the perineal membrane
Expanded upper end has uterine cervix projected into it
Circular groove in the vagina around uterine cervix is fornices
4 fornices
Anterior –shallowest, posterior-deepest & 2 lateral
Below the cervix anterior & posterior walls of vagina lie within contact with each
other to form a H shaped slit
Lower end of vagina is covered by a thin fold called hymen in virgins, in married
women replaced by tags called hymen caruncles
▪Relations
Ant 1. Base of bladder (upper half)
2. Urethra embedded in anterior wall (lower half)
Post (above downwards)
▪ant wall of vagina >1.Pouch
pos wallof Douglas (in upper 1/4th)
th
▪ ant wall of vagina >2.pos
Rectum
wal (in middle 2/4 )th
3. Anal canal (in lower 1/4 ) [separated by perineal body]
Lat 1. Transverse cervical ligament (upper 1/3rd)
2. pubovaginalis muscle (middle 1/3rd)
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3. Bulb of vestibule, bulbospongiosus & ducts of greater vestibular
gland (lower 1/3rd – after piercing perineal membrane)
▪ per vaginal examination
1. Anterior & posterior relations are palpable
2. Ureteric stones
3. Ovary, uterine tubes, side of pelvis is felt laterally
4. Collection of fluid, prolapsed uterine tubes, ovaries & distended bowel in pouch of Douglas
Arterial Supply
1. Ovarian Artery
Arises from the abdominal aorta, just below the renal artery.
Descends over the posterior abdominal wall & enters the suspensory
ligament of the ovary.
Supplies the ovary through the mesovarium & continues medially through
the broad ligament to anastomose with the ovarian artery.
Also supplies the lateral 1/3rd of the uterine tube, the side of the uterus &
ureter.
2. Uterine artery
Branch of the anterior division of the internal iliac artery.
First passes medially across the pelvic floor in the base of the broad
ligament to reach the cervix.
Crosses the ureter above the lateral fornix of the vagina, 2cm lateral to the
fornix.
Ascends along the side of the uterus, with a tortuous course.
Runs laterally towards the ovary & ends by anastomosing with the ovarian
artery.
Also supplies the medial 2/3rd of the uterine tube, vagina, ovary, ureter &
structures in the broad ligament.
The vagina is supplied mainly by the vaginal branch of the internal iliac artery. In
addition,
Upper part - Uterine artery
Lower part - Middle rectal & uterine artery
Nerve Supply
Lower 1/3rd of the vagina is pain sensitive & supplied by the pudendal nerve
through the inferior rectal & posterior labial branches of the perineal nerve.
The rest has a sympathetic & parasympathetic supply
Parasympathetic supply for the ovaries, medial half of the uterine tubes, uterine
tubes and vagina is by the nerve rots S2 – S4
Lateral halves of the uterine tubes are supplied by the vagus nerve.
1. Ovary
Supplied by the ovarian plexus
Sympathetic supply is by T10/ T11
2. Uterine tubes
Supplied by the hypogastric plexuses
Sympathetic supply is by T10 – L2
3. Uterus
Supplied by the inferior hypogastric plexus & the ovarian plexus.
Sympathetic supply is by T12 – L1
Lymph Drainage
The lateral 2/3rd of the uterine tubes drain into the lateral & preaortic nodes.
The medial 1/3rd of the uterine tubes drain into the superficial inguinal nodes
following the course of the round ligament.
Vagina
Upper 1/3rd - External iliac nodes
Middle 1/3rd - Internal iliac nodes
Lower 1/3rd - Superficial inguinal nodes
Clinical
Scrotum is supplied by widely separated dermatomes (L1 & S3)
So whole scrotum is difficult to anesthetize
The glandular part of the testis consists of lobules which contains seminiferous tubules.
Seminiferous tubules Rete testis Efferent ductules Epididymis
Arterial supply - testicular artery
venous drainage - pampiniform plexus of veins
Clinical
1. Referred pain: - loin
2. Varicocele: - dilation of veins in pampiniform plexus
mostly left side. Why??
Left testicular vein drains in to left renal vein at right angle
Tumour of the left kidney can invade left renal vein & block the drainage of left testicular vein
Left renal vein put into spasm by adrenalin rich blood by suprarenal vein
Pressure of the superior mesenteric artery
3. Penis
Made up of
A root (attached portion)
Body (free portion)
▪ Root
Made up of 3 masses of erectile tissue:
two crura – covered by ischiocavernosus muscle
bulb - covered by bulbospongiosus muscle. The deep surface is pierced by the urethra.
▪ Body
Composed of three elongated masses of erectile tissue;
Right and left corpora cavernosa- Forward continuation of the crura. They terminate
under the cover of the glans penis.
Corpus spongiosum- This is the forward continuation of the bulb of the penis. Its terminal part
enlarges to form the glans penis. Traversed by the urethra throughout the whole length.
Arterial Supply
Clinical
1. Catheterization – catheter should be introduced into the urethra beak downwards???
Roof of navicular fossa bears a mucosal fold called lacuna magna. It is directed forwards and can
catch the tip of catheter.
2. Urethral rupture- In damage to spongy part of urethra, urine does not extravasate into;
a) Thigh
b) Ischiorectal fossa
Urine passes into;
a) Scrotum
b) Penis
c) Lower part of abdomen
Because the attachment of membranous layer of superficial fascia.
Holden’s line (just below the inguinal ligament, Scarpa’s fascia joins the inguinal ligament,
preventing urine leakage into the thigh)
Pubic tubercle
Body of pubis
Pubic arch
Posterior border of perineal membrane
Internal genitalia
1. Epididymis
Organ made of a highly coiled tube
Three parts
o Head
o Body
o Tail (inferiorly)
Lies on the lateral part of posterior border of testis
Supplied by branches of the testicular artery
2. Ductus deferens
45cm long thick-walled muscular tube
Originates from the tail of epididymis
Ascends along posterior border of testis medial to epididymis
Enters the spermatic cord.
Traverses the inguinal canal within spermatic cord
At deep inguinal ring winds around inferior epigastric artery
Along its course in the pelvic wall it is crossed by the obturator vein, artery, nerve and
obliterated umbilical artery and the ureter
Crosses the ureter and approaches its opposite from the other side
Turns medially to base of bladder
Medial to seminal vesicles and dilate to form ampulla
Ampulla is joined by duct of seminal vesicle to form the ejaculatory duct and
Open in to the prostatic urethra at the verumontanum on either side of utricle
4. Prostate gland
Pyramidal shape fibromuscular gland
Apex lies inferiorly
Five lobed
The prostatic urethra emerges just in front of the apex. Base directed upwards and fused
with the neck of the bladder.
Relations
Superiorly- neck of bladder
Inferior – apex rests on urogenital diaphragm
Anterior – pubic symphysis separated by retropubic fat
Prostatic venous plexus
Puboprostatic ligament
Posterior – Rectum (Separated by Denonvillier’s fascia)
Lateral – Levator ani
Capsules
TRUE capsule :- condensation of peripheral part of gland
FALSE capsule :- endopelvic fascia
o Prostatic venous plexus lies between two capsules
Zones
- Peripheral zone - 70% of glandular tissue. Located behind the central zone.
- Central Zone – 20% glandular tissue. Forms the base of the gland. Surrounds the ejaculatory
ducts.
- Transistional zone - 5% of glandular tissue. Lies around the distal part of the pre- prostatic
urethra.
Blood supply:
Supplied by the artery to the ductus deferens.
Venous drainage is to the venous plexus situated between the false and the true capsules.
Clinical
1. Pathological capsule
Benign prostatic hypertrophy
Normal peripheral part of the gland become compressed into the capsule.
2. Prostatic venous plexus has valve-less communications with vertebral venous plexus
Carcinoma of prostate may spread to pelvic bones, vertebrae & to skull
● deep dorsal vein of penis also drains in to the prostatic venous plexus
3. Denonvillier’s fascia
In excising rectum, the plane passes through this without damaging prostate &
urethra and acts as a barrier to prevent spread of carcinoma of prostate into
the rectum.
4. Prostatectomy
Both true & false capsules are left with venous plexus
Scrotum
Prostate
Relations
Peritoneal relations
upper 1/3rd front and side
middle 1/3rd only the front
lower 1/3rd below the level of peritoneum
visceral relations
Posterior - [female, male similar]
Waldeyer’s fascia
Sacrum, coccyx
Median sacral, superior rectal vessels
Sympathetic trunk
Anterior - [Male]
Denonvilliers’ fascia
Upper 2/3 - recto vesical pouch
Lower 1/3 - base of bladder
Ductus deferens
Seminal vesicles
1
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Anterior - [Female]
Denonvilliers’ fascia
Upper 2/3 - rectouterine pouch
Lower 1/3 - lower part of vagina
Supports
1) Pelvic floor by levator ani
2) Waldeyer’s fascia
Condensation of pelvic fascia behind the rectum.
Attaches the lower part of the rectal ampulla to the sacrum.
Encloses superior rectal vessels and lymphatics.
3) Lateral ligaments of rectum
4) Rectovaginal fascia of Denonvilliers’
5) Perineal body
Anal Canal
Relations
Anteriorly
In both sexes → Perineal body
In males → Membranous urethra & bulb of the penis
In females → Lower end of vagina
Posteriorly
Anococcygeal ligament
Tip of the coccyx
Laterally
Ischio-anal fossae
All around
Sphincter muscles
2
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Musculature of the Anal canal
Anorectal ring
Muscular ring formed by puborectalis, deep external sphincter & internal sphincter
Main support of rectum.
3
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Blood supply of the rectum and anal canal
Arterial supply
Venous drainage
Clinical
Hemorrhoids
4
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Per rectal examination
Finger directed towards umbilicus
Normal
both sexes - the anorectal ring, coccyx and sacrum, ischiorectal fossae, ischial spines
male - prostate, rarely the healthy seminal vesicles
female - perineal body, cervix, the ovaries.
Anal fissure
Caused by the rupture of one of the anal
valves by passage of dry hard stool.
Anal fistula
Fistula is an abnormal epithelialized track
connecting two cavities or one cavity with
the exterior.
Anorectal abscess tends to track in
various directions and may open
medially into the anal sinus
laterally into the ischio-anal fossa
inferiorly at the surface
superiorly into the rectum
5
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Physiology – Term 3
2017 A/L Repeat Campaign
GIT
Mouth
Saliva - Composition
A. Water
Lingual lipase # FA + 1,2 DAG #glands of the tongue
B. Enzyme # Active in stomach
# can digest up to 30% of dietary TAG
Salivary α amylase (optimal pH 6.7) #salivary glands
Function stops in the stomach
Nausea Conditional
Sight, smell & thought of food.
Reflex Food in mouth/ chewing
Secretion
Vagal afferents from gastric end of
esophagus
Neural control
Fear +
Sleep Sympathetic Parasympathetic
(VII, IX cranial nerves)
Fatigue
vasoconstriction Vasodilatation
Dehydration ↓ amount ↑ amount
↑ organic ↓ organic
Fear
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Problems related to impaired salivary secretion
(1) Dry mouth
(2) Difficulty in swallowing
(3) Bad smell (Halitosis)
(4) Dental caries
(5) Speech difficulty
Oesophagus
Two sphincters
1. upper - Functionally less important (normally closed by continuous contraction of
cricopharyngeus) 1.Oesophageal smooth muscles
2. lower – tonically active, Relaxes upon swallowing, made of 2.Crural fibers of the diaphragm
Prevent regurgitation (heart burn, strictures) 3.Oblique muscle fibres of stomach
Tone -↑ Ach, ↓ NO, VIP
Resting pressure is approximately 15mmHg; higher than the intragastric pressure
Clinicals,
GERD
o Permits reflux of gastric contents into esophagus, making symptoms such as heartburn and
esophagitis.
NG tube insertion
Achalasia – LES is always tight – Results in food accumulation and oesodilation
Swallowing
Is a reflex
Centre NTS/ NA
Effect Swallowing
Anti-reflux mechanism
Tonic constriction of LES
Lower end of oesophagus has a higher pressure than stomach
Flap valve is formed by oblique angle of LES
Fold of the mucus barrier
Voluntary collection of food on the tongue and pushing them back into the pharynx
Relaxation of UES
9. Contraction of smooth
muscles behind the bolus
5. Activate neurons to .
release NO, VIP
Secondary peristalsis
Peristalsis wave stimulated by distention of oesophagus by retained food
Continues in waves till the oesophagus is cleared
Gastric secretion
Gastric secretions – 2.5 L/day
Gastric lipase
TAG FA + Glycerol
Ileal receptors
Absorbed by endocytosis
Alkaline urine
1. Cephalic Gastrin
Food in mouth, sight/ smell/ thought of food Receptors CCK-B
Stimulation of hypothalamus/ frontal cortex
Emotional responses – anger/hostility increase
Fear/ depression decrease
1/3 – ½ of acid secretion in response to a normal meal in this phase
Due to vagal outflow →causes ↑ of Ach and GRP
Activation of one receptor type potentiates the response of another for stimulation synergistic
action
Ach is direct effector while GRP (Gastrin Releasing Peptide) acts through Gastrin release
Atropin (anti-muscarinic) doesn’t affect Gastrin secretion as GRP is involved (not Ach)
2.Gastric
a local reflex arcs
Stimulus: -
- Stretch
Gastrin↑ - Products of digestion Receptors in stomach wall
- Amino acids & ↑pH
Acid secretion
Neural effects
Hormonal effects (somatostatin, GIP,
Gastric acid and pepsin
Fats, carbohydrates and
secretion
acids in duodenum
Gastric motility
Others - Stimulants
Hypoglycemia – acts via brain and vagal afferents
Alcohol – acts directly on the mucosa
Caffeine – Stimulate CCK / gastrin
Mucus
Forms a flexible gel coating the mucosa Secretion stimulated by prostaglandins
Made up of glycoproteins(mucins) Function – “Gastric mucosal barrier”
Secreted by neck and surface mucosal
cells
Disrupted by,
-ethanol NSAIDS Inhibits cyclooxygenase
-Vinegar
-Bile salts Prostaglandin secretion is inhibited
-NSAIDS e.g.-Aspirin
-Helicobacter pylori infections Mucus secretion Acid secretion ↑
Liver
Functions
1. Nutrient metabolism
2. Inactivation of substances (toxins, ammonia, steroids and other hormones)
3. Storage (blood, vitamins A, D, B12, iron)
4. Synthesis of Plasma proteins (clotting factors, binding proteins, albumin,) But liver does not
5. Immunity (Kupffer cells) synthesize
6. Formation and secretion of Bile Immunoglobulins
Bile
Haem Globin
Porphyrin Fe2+
Prehepatic
Biliverdin
Circulation Bilirubin reductase
Bilirubin + Albumin Bilirubin
uptake
Bilirubin + 2UDPGA
Conjugation Glucuronyl Transferase Hepatocellular
Bilirubin Diglucuronide [BDG]
Excretion
Excrete
In Rate limiting step
Bile EHC Post
BDG Urobilinogen Hepatic
Fecal excretion
Unconjugated bilirubin (Indirect) Conjugated bilirubin (Direct)
Poor water solubility More water soluble
Not excreted in urine Excreted in Urine
High lipid affinity Low lipid affinity
High albumin binding Low albumin binding
JAUNDICE(Icterus)
When total plasma bilirubin (free and conjugated bilirubin) level is greater than 2mg/dL or 34µmol/L it is
known as Jaundice.
Yellowish tint to the body tissues (skin, sclera, deep tissues)
Classification of Jaundice
Prehepatic Hepatocellular Post-hepatic
excess production of bilirubin decreased uptake of bilirubin extrahepatic bile duct obstruction
into hepatic cells
disturbed intracellular protein
binding or conjugation
disturbed secretion of
conjugated bilirubin into bile
canaliculi.
intrahepatic bile duct
obstruction
unconjugated bilirubin conjugated or unconjugated conjugated bilirubin
bilirubin
hemolytic anemia Cirrhosis bile duct obstruction (cholestasis)
Inflammation of hepatocytes, Ex: Carcinoma in bile duct
tumors, drugs, hepatocytes (bilirubin enters circulation
(Functions of the hepatocytes are through hepatic vein)
impaired)
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Bile Salts
Synthesis and Circulation
Cholesterol HEPATOCYTE
↓
I bile acids (0.2 g/d)
ry
Secondary bile salts are produced by action of bacteria on Iry bile salts in the colon.
Gall stones
Calcium bilirubinate stones
1. 2 types Cholesterol stones
2. Causes: -
Due to increased hemolysis increased bile pigments
Disturbance of cholesterol: Bile salt: lecithin (1 :10: 3)
Inflammation of epithelium.
In acute pancreatitis, intra pancreatic activation of pancreatic enzymes like trypsin and auto digestion of
pancreatic issue.
Vagus Ach
Neural
Small Intestine
Adaptations for absorption
Carbohydrate absorption
Luminal Enterocyte Basolateral
3Na+
+
2Na
SGLT 1 & 2
2K+
Glucose(&Galactose)
GLUT 2
GLUT 5
Glucose
Fructose
[Independent of Na+
facilitated diffusion] Some fructose is converted to glucose in
the mucosal cell.
Pentose
Simple Diffusion
Lactose Intolerance
Deficiency of intestinal lactase causes abdominal cramps & diarrhoea after consumption of
food that contains lactose.
Na+/AA Co transporter
AA
Na+ independent transport
H+/di or tri peptide co transport (hydrolysis release AA in muscle cells)
Clinical implications
Congenital transport system Hartnup’s disease: - neutral AA Absorption
defects Cystinuria: - Basic AA impaired
Infants IgA in colostrum
Food allergy absorb small quantities of proteins / small peptides
Finally emulsified in SI
(Detergent action of bile salts, lecithin, monoglycerides)
Take up lipids
Enter Enterocyte
FA > 10 - 12 C & Re-esterified Tri Glycerides Chylomicrons
Cholesterol
Fat & cholesterol
Lacteals
SCFA (FA < 10 - 12 C)
In infants, fat absorption mechanisms are not well developed by birth and malabsorption of fat soluble
vitamins may occur.
Steatorrhoea Fatty
Bulky
Clay coloured
Stools Pale
Foul smelling
Greasy
Hard to flush
Pancreatic Lipase
deficiency Chronic liver ↓ Alkaline secre on from
disease pancreas
Acidity
Fat ↑ Gastric Acid
Bile duct
Malabsorption
obstruction
Vitamin B12
Binds to Intrinsic Factor in the small intestine
The complex is absorbed predominantly in the Ileum
PT Fat malabsorption
Ca2+
Large Intestine
Functions K+, HCO31-
1. Absorption of water (1 – 2 L) and electrolytes
K+ - component of mucus, Na+, Cl-, H2O
along an electrochemical gradient
HCO3- - to neutralize the acidic substances
Produced by microbial activation.
Na+ - active transport (ENaC) Desquamated mucosal
Cl- in exchange for HCO3- cells/mucus
Inorganic material
mostly Ca2+, PO43-, fat
and fat derivatives.
Non-dietary in origin (unaffected by diet & starvation
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4. Microbial activity LI colonized in early life.
Effects of intestinal bacteria Very few in jejunum
But sterile at birth
High in colon
4. Conversion of AA NH3
Harmful in liver disease
Associated with hepatic
encephalopathy
Vit ADEK ↓
Overgrowth of bacteria
Steatorrhoea Ca2+↓
E.g. blind 100p Unconjugated
syndrome PT ↑
bile salts
Irritates
Colon Diarrhoea
Gastroileal reflex
Food leaving stomach Relaxation of caecum Passage of chyme through ileocecal valve
Ileocecal valve
Usually closed. Opens when ileal pressure ↑ & closes when colonic pressure ↑
Movements of colon
Peristalsis
Segmentation contraction
Mass action contraction
o Only in colon. Simultaneous contraction of smooth muscle over a large confluent area.
Urge to defecate
Inappropriate Appropriate
Defecation
Reverse peristalsis
Ejecting gastric content
Stimulation of vomiting
Patterns of GI motility
Associate with increase in gut secretions and helps to clean the left overs (Housekeeping Waves)
In the stomach and SI up to distal ileum.
During periods of fasting and abolished by eating.
Each cycle
Phase I - Quiescent period (resting/ inactive)
Phase II – irregular electrical and mechanical activity.
Phase III – burst of regular activity.
Mediated by motilin which increases in blood of intervals of 90- 120 min between meals.
Causes gastric secretion, bile flow, pancreatic secretion.
Clear the stomach & small intestine to avoid bacterial growth.
Segmentation
A segment of bowel contracts at both ends and forces chyme backwards and forwards.
Slows down movement of intestinal contents along intestine allowing time for digestion &
absorption.
Carried out by enteric nervous system.
Neural regulation
Intrinsic innervation
Hormonal regulation
Excretory
Urea,
creatinine
Regulatory Metabolic
Functions of Kidney
Fluid, electrolyte, pH Gluconeogenesis
Endocrine
renin, erythropoietin,
25(OH)D3
Urine Formation
Site – Nephron (functional unit)
3 steps
1. glomerular filtration
2. tubular reabsorption
3. tubular secretion
1) Glomerular Filtration
I. Filtration Membrane (contains negatively charged heparin sulphate. Therefore, repels albumin
preventing filtration)
These are stellate cells located
Afferent between the basal lamina and the
arteriole endothelium
Efferent arteriole
Capillary
endothelium
Mesangial
cells
Basal lamina
Epithelium
of capsule Podocytes
Filtration slit
II. Filtrate
Isotonic to plasma
Contain plasma except – plasma proteins (albumin)/ fat/ blood cells/protein bound
calcium ion
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III. GFR Determinant-Effect on GFR
The amount of plasma ultrafiltrate formed by
Net filtration pressure
two kidneys per minute - 125 ml/min in a
healthy adult male - Hydrostatic pressures
Depends on - Osmotic pressures
Age – with age ↓ Glomerular ultrafiltration coefficient -Kf
Gender – (F) < (M)
- Surface area of filtration
Body surface area – with body surface area ↓
Mesangial cells regulate this by
contraction (reduces surface area)
Glomerular filtration - Permeability of membrane
Permeability of the
𝐺𝐹𝑅 = 𝐾 [𝑃 − 𝑃 − (𝜋 − 𝜋 )] membrane depends on the
charge & size of the
molecules.
Neutral molecules of up to
4nm can pass
Filtration Almost no particles greater
Glomerular Glomerular colloid than 8 nm are able to pass
hydrostatic pressure - osmotic pressure –
PGC (45) πGC (20)
(no proteins)
Capillary length
GFR may vary due to changes in the above quantities
Changes in PGC
Changes in mean arterial pressure (eg - shock)
Constriction of afferent/efferent arterioles
Changes in PB
Obstruction of the ureter, bladder, urethra
Oedema of the kidney within the capsule
Changes in πGC
Changes in plasma protein levels
Changes in πB
Changes in the permeability of Glomerular capillaries
Glomerular capillaries have high concentrated plasma proteins as plasma filters through the membrane.
𝐺𝐹𝑅
𝐹𝑖𝑙𝑡𝑟𝑎𝑡𝑖𝑜𝑛 𝐹𝑟𝑎𝑐𝑡𝑖𝑜𝑛 = = 0.16 − 0.20
𝑅𝑒𝑛𝑎𝑙 𝑃𝑙𝑎𝑠𝑚𝑎 𝐹𝑙𝑜𝑤
(Note: When blood pressure drops GFR and Renal Plasma Flow both reduced. But Renal Plasma Flow reduced
more than GFR. So filtration fraction increases.)
(mL/min)
Arterial pressure
(mmHg)
90 220
The volume of plasma that is completely cleared or removed of substance by the kidneys in unit time.
Renal Clearance
Complete
Zero Partial
Eg:- PAH (para amino hippuric
Eg:- glucose acid) Eg:- creatinine
All substances filtered is Almost completely removed By filtration & tubular secretion
completely absorbed (90%)in a single circulation, by Inuline
filtration and tubular secretion
Only by filtration.
Inulin is the standard substance used to measure GFR but in clinical practice creatinine is used.
Advantages Disadvantages
Plasma[y] mg/ml × Plasma volume filtered ml/min = Urine[y] mg/ml × Urine volume excreted ml/min
GFR = Volume of plasma cleared of substance ‘y’ by the kidneys per minute
V – Urine volume
CCr (mL/min)
0 60
Serum Urea
influenced by many factors. not constant.
95% of urea excretion is by the kidneys.
Physiological control of
GFR & RBF
Mesangial cells
Increased flow through the ascending limb of LOH cause decreased GFR in the
same nephron.
Maintain the consistency of load delivered to DCT.
Mechanism
Increased Na+ reabsorption via Na+/K+/2Cl- co-transporter
Na+ and Cl- in DCT sensed by macula densa
Increased Na+/K+ ATPase activity
More adenosine formed by ATP hydrolysis
Act on receptors of macula densa cells
Release of Ca2+
Endothelin flow
Collecting Tubule
PCT
Collecting Duct
The fluid which filter from glomerular membrane remain isotonic when passing through PCT.
02.Thin Limb of LOH
Water is reabsorbed mainly along the osmotic gradient which is produced by medullary
hyperosmolality.
03.Thick Ascending Limb of LOH
Intercalated Cells
Principal cells
In late part of DCT, Principal cells involve in water reabsorption by the actions of ADH &
Aldosterone. Intercalated cells involve in Acid Base Balance.
Collecting tubules act same as late part of DCT.
Urea Reabsorption
02.Na+
7% cotransporter
99% reabsorbed
Na+/ Cl-
3%
65% mainly at PCT
1. Na+ /H+
Aldosterone
exchanger (Main) + + -
Na / K /2Cl
2. Na+/glu Bind with receptors of
Cotransporter Cotranspor Principle cells →
3. Na+/AA ter Increase ENaC synthesis
and insertion
→Increased Na+/K+
Not permeable to solutes
The ability to eliminate unwanted K+ is less dependent on GFR than urea and creatinine
04.H2O
PCT – passively along osmotic gradient 65%-70% reabsorbed.
Aquaporin 1(not sensitive to ADH), simple diffusion
LOH-thin descending limb of LOH → 15% reabsorbed
Thick ascending limb of LOH → not permeable
DCT-5% (with solutes) (early part)
CD- predominantly Na+ independent.
Depends on ADH (vasopressin) → Bind with V2 receptors of P cells → insert aquaporin 2
channels→ ↑ Permeability of CD to H2O
Humans have the concentrating ability of urine according to the needs of the body. Osmolality of urine
varies in a vast range according to the body water need. (30-1400 mOsm/kg)
Depends on
Produced by Maintained by
Solutes recirculate in medulla while water get absorbed to the vasa recta.
This maintain the medullary hyperosmolality
↓ Gradient of
Osmolality
Isotonic
Hypotonic
Isotonic Cortex
Isotonic
Medulla
Hypertonic
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Regulation of renal functions
Renin-Angiotensin-Aldosterone mechanism
Renin is a glycoprotein
Secreted by juxtaglomerular cells in the juxtaglomerular apparatus
Converts angiotensin to angiotensin I
Lead to formation of Angiotensin II from angiotensin I by ACE
ACE found in vascular endothelium
Specially lungs
Cirrhosis
Intra renal baroreceptor mechanism – Renin is secreted when the blood pressure falls.
Angiotensin II
Stimulate aldosterone
secretion(indirect effect
*Angiotensin II stimulate aldosterone secretion but main stimulus for Aldosterone secretion is
increasing the Plasma K+ concentration
Natriuretic peptides
Vasopressin secretion
Receptors
Osmoreceptors – In hypothalamus
Baroreceptors – In blood vessels
Vasopressin
Cause vasoconstriction.
Increase water reabsorption. How??
NTS
Vasopressin
Increased plasma
osmolality
Low pressure baroreceptors
V2 Receptors in Principle
cells Decreased blood
volume
Baroreceptors
Osmoreceptors in
hypothalamus Angiotensin II
Hypothalamus
Dryness in
pharyngeal mucosa Thirst
Drinking
vasopressin hypothalamus
GFR is increased
Converted by Renin
Angiotensin I Angiotensinogen
Regulation of K+ concentration
In diabetes mellitus
Water Diuresis –
Begins 15 mins. After drinking water (40 mins maximum)
Small decrease in vasopressin secretion even before water is absorbed from the gut.
Ethanol → inhibit vasopressin secretion
Antagonists of V2 receptors → inhibit action of vasopressin on CD
Osmotic Diuresis –
Increase in urine volume due to presence of large quantities of unabsorbed solutes in the renal tubules
In diabetes mellitus filtered glucose is not completely reabsorbed. Remaining glucose cause
osmotic diuresis leading to polyuria and polydipsia
Process-
1.↑concentra on of osmo cally ac ve par cles in PCT lumen hold water in the tubules, not
allowing reabsorption
Limiting pH of urine-4.5
Intracellular pH 6.8
If pH is more than normal - alkalemia.
If pH is lower than normal - acidemia ECF survival range 6.8-7.7
Defense mechanisms
1. Buffer systems in body fluid (Act immediately)
2. Respiratory system (within minutes)
3. Renal system (hours, days) – Most effective
H+ in ECF H+ in ECF
<7.4 >7.4
↓ ↓
Acidemia Alkalemia
Mechanisms of H+ secretion
1. Na+/H+ exchange – PCT, Thick ascending limb of LOH and early DCT
2. ATP-driven proton pump – Intercalated cells in late DCT
and CD (Increased by aldosterone)
3. H+/K+ ATPase – In DCT and CD
HCO3- buffer
Rapidly removes H+ from urine. But no excretion of H+ in urine.
Prevents decrease in pH of filtrate
For each HCO3- absorbed from filtrate one HCO3- is added to blood – “Reclaiming HCO3- “
Phosphate buffer
Generates new HCO3-.
Buffer about 50% of the acid excreted. For each NH4+ or phosphate excreted, one
Mostly in DCT and CD as the concentration increases. HCO3- added to the blood
Excreted as titratable acidity.
Metabolism of proteins
↓
Non-volatile acids
-
H+ secretion HCO3
H+ secretion
Independent of Na+ reabsorption
Secreted by ATPase driven proton pump – I cells of CD
Iry active transport
Aldosterone increases its activity.
In acidosis many tubulo-vesicular structures are inserted to the apical membrane to
increase H+ secretion.
Limiting pH is achieved. (4.5pH)
For each H+ secreted, HCO3- enters the interstitial fluid
Secreted H+ buffered by
o Phosphate buffer in the filtrate
o NH3 made in the cells
Mainly in I cell
Amino acid metabolism Glutamine ( in liver )
Glutamine glutamate + NH4+
Glutaminase
-KG + 2 H+ 2HCO3-
NH3 lipid soluble diffuses across cell membranes
Most of the acid is excreted in PCT. In the PCT pH drops slowly as secreted H+
binds with HCO3- and form H2CO3 and then
- But only little as × 4 increase in urine [H+]
CO2 and H2O. The apical membrane is
- Lower limit pH 6.7 permeable to CO2 and it is removed from
Only 5% of the acid secreted in DCT the tubular cells by Carbonic Anhydrase.
- But as × 900 increase in [H+] But,
In DCT, secreted H+ is buffered by many
- Lower pH limit 4.5
HPO4- or NH3
Increase Decrease
PCO2 ↑
H+ ↑ , HCO3- ↓
ECF volume ↓ Opposite
angiotensin II ↑
aldosterone ↑
Hypokalemia
Male Female
SEXUAL DIFFERENTIATION
Embryonic
ovary does
not produce
or excrete any
hormone in
considerable
amounts
AND
X
(From 8th -
13th week)
X - 5α Reductase type 2
• Hormonal treatment of the mother has no effect on gonadal differentiation. But affects internal and
external genitalia development
At the 13th week development of genitalia is complete. So exposure to hormones after this period will not
affect development of any genitalia.
Both DHT and testosterone bind with the same receptors. But DHT has higher affinity to the receptor.
MIS Levels
In females, MIS is secreted in very low (undetectable) amounts by granulosa cells in the fetal and pre
pubertal stage.
Levels increase at puberty and acquire a constant value.
After puberty plasma MIS level is equal in both male and female. (2ng/mL)
Chromosomal Hormonal
Results in Pseudohermaphroditism
Cholesterol
3 HSD
21 HSD
11 HSD
Puberty is the period when endocrine and gametogenic functions of the gonads have first developed to
the point where reproduction is possible.
Age of onset
o Girls: 8 – 13 years
o Boys: 9 – 14 years
BOTH SEXES
1. Increased physical growth
t
Pubertal growth spurt
ga 15.2
in
(c Pubertal growth spurt
10.2 occurs earlier in females
Girls
Boys
5.1
2 4 6 8 10 12 14 16 18 18
Age in years
Though both DHT and Testosterone play huge roles in the changes which occur in males at puberty, these 2
hormones also have functions which are exclusive to each of them
1. Dihydrotestosterone (DHT)
Enlargement of the prostate
Enlargement of the penis
Temporal recession
Facial hair
Acne
2. Testosterone
Increase in muscle mass
Increase in male sex drive and libido
Boys Girls
Axillary and Pubic hair Axillary and Pubic hair
Growth and enlargement of internal Growth and enlargement of internal
and external genitalia and external genitalia
Increased facial + body hair Breast development
Decreased scalp hair (hair line goes Subcutaneous fat deposition
above) Menarche
Increased muscle mass
Low pitched voice
4. Adrenarche
Increase in adrenal androgenswithout a simultaneous increase in ACTH.
Due to increased activity of enzymes in androgen producing pathway
Principal adrenal androgen – DHEA (Dehydroepiandrosterone)
Promotes;
physical growth,
axillary and pubic hair growth,
sebaceous gland development,
body odour and acne.
Note; Growth of pubic and axillary hair in both sexes is due to androgens,rather than oestrogen
GIRLS-Order-
Breast budding (Thelarche)
1. Thelarche
Pubic hair begins (Pubarche)
Development of breast followed by development of pubic and axillary hair
Ovarian oestrogen stimulates growth of lactiferous ducts Peak height spurt
Progesterone – Alveolar lobule development
Menarche
Onset of PUBERTY
Precocious puberty
True-precocious Pseudo-precocious
- Maturation of H-P-G axis - H-P-G axis is immature
- GnRH, FSH, LH increased - GnRH, FSH, LH levels are low
- True gametogenesis - No gametogenesis
- Early, but normal pubertal pattern of - Excess oestrogen in girls and Androgens
pituitary gonadotrophin secretion. in boys
Delayed puberty
Boys Girls
- No genital growth by 20 years - No menarche by 17 years (primary
amenorrhoea)
Causes Causes
- Klinefelter Syndrome - Turner’s Syndrome
- Anorexia Nervosa
Transport of Hormones
1 Note; Increase muscle mass, sex drive, libido depends on testosterone. NOT on DHT
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Spermatogenesis
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Acquire progressive motility (the ability to move forward) by activating CatSper proteins in principal piece
of the sperm within epididymis.
The CatSper protein forms an alkaline sensitive Ca2+ channel that becomes more active when the sperm
travels from the acidic vagina to the more basic cervical mucus.
At rete testes, fluid is absorbed, and spermatozoa are concentrated.
This is carried out by the activity of oestrogen on receptors in this region.
Failure of this process leads to infertility.
Spermatozoa contain olfactory receptors required for chemotaxis
Capacitation–
Functional changes which make sperms able to fertilize.
Occurs in isthmus of uterine tubes
Increase motility
Preparation for acrosome reaction
Capacitation is facilitatory, not obligatory, because fertilization can be produced in vitro without it.
Acrosome Reaction
Breakdown of acrosome and release of enzymes- proteases
Proteolytic enzymes help in penetrating zona pellucida
Acrosomal reaction can occur in many sperms. But only one acrosome reacted sperm fuses with the oocyte.
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Seminal Fluid
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Hypothalamus
GnRH
Stimulation
Negative feedback
Anterior pituitary
LH FSH Male gonadotrophin secretion is
noncyclical
Testosterone Inhibin B
Estrogen Estrogen
Administered testosterone decreases sperm count due to negative feed back of FSH and LH.
Testosterone doesn’t inhibit FSH at physiological concentrations but may do so in large doses.
Inhibin is used as a male contraceptive. (Testosterone can also be used)
Inhibins are produced in Sertoli cells in males and granulose cells in females.
Testosterone mainly bound to GBG/SHBG.
Androstenedione, estradiol and progesterone bound to albumin.
Late spermatids & spermatozoa contain a germinal Angiotensin-converting enzyme.
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Female Reproductive System
Menstruation
Periodic vaginal bleeding with shedding of uterine mucosa, from menarche to menopause which is absent during
pregnancy & sometimes during lactation. Most common cause for secondary amenorrhoea is pregnancy.
Menorrhagia is excess bleeding during menstruation.
Dysmenorrhoea is painful menstruation.
Note; Oogenesis begins during fetal life. No new ova formed after birth.
Formation of an antrum around the oocyte causes the development of several antral
follicles
Development of
Recruitment of dominant follicle Formation & maintenance
follicles (1-5 d) Rest – become atretic. of corpus luteum
1 6 14 24 28
Dominant follicle; has the highest Ovulation Corpus luteum
capacity to secrete estragon regression begins
Ovarian Changes
FSH levels high in early follicular phase to stimulate granulosa cells to produce estragon. Decrease in
follicular phase and luteal phase due to negative feedback.
LH levels initially low due to negative feedback. Peak happens at mid-cycle due to positive feedback from
high levels of oestrogen.
LH surge occurs 9 hours before ovulation.
Corpus luteum secretes oestrogen and progesterone in luteal phase and maintains FSH and LH at low
levels.
Inhibin levels reach the peak at mid luteal phase. Then decrease allowing FSH levels to rise.
Progesterone and oestrogen levels then decrease in late luteal phase due to formation of corpus albicans.
Endometrium is shed because high levels of oestrogen and progesterone are needed to maintain it in
secretory phase.
Ovum lives for 72 hours after ovulation but fertilizable for 24 hours.
Oestrogen levels show 2 peaks. Just before ovulation mid luteal phase.
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Pattern of secretion of reproductive hormones during the normal menstrual cycle
•primary oocyte
•granulosa cells
Secondary
(Pre-Antral) •theca cells (interna + externa)
follicles •Theca interna- Andogen producing Theca externa-Protective capsule
Menstruation
•due to regression of Corpus Proliferative phase
luteum (5th - 14th day)
•endometrium - becomes thinner •rapid increase in
•spasm & degeneration of walls of thickness. (proliferation)
arteries due to locally produced •Straight uterine glands
prostaglandins --> ischemia and lengthen
necrosis of superficial layers -->
spotty haemorrhages --> •Maintained by estrogen
confluence --> menstrual flow
Secretory phase
•highly vascularised
•stroma oedematous
•coiled glands
•spiraling of the arteries
increased
Length of the secretory •secretes clear fluid
phase is more constant than •changes in cell adhesion
the length of the proliferative molecules etc Note Menstrual blood is
•later --> Prolactin mainly arterial and does
phase. production
not clot due to the
•Maintained by estrogen
& progesterone presence of fibrinolysin
Cervical mucus
Effects on breast
Estrogen & progesterone act on the breast during the luteal phase.
Swelling, tenderness, and pain during the 10 days preceding menstruation due to distension
of ducts and hyperaemia.
Anovular menstruation
Can occur during the,
a. 1st 12 – 18 months after menarche
b. Before the onset of menopause
Duration of the cycle is variable, but is always less than 28 days.
Estrogen synthesized
Endometrium develops absence of progesterone
Follicular atresia
Estrogen endometrium breaks
Oestrogen Synthesis
C LH FSH
Cholesterol
i
r Cholesterol Androstenedione
c A
u n
Androstenedione aromatase
l t
a r
Estrone Estrone Estradiol
t u
i Estradiol Granulosa m
Theca interna
o cells/theca lutein
cells/theca lutein
n in corpus luteum
in corpus luteum
Note;
Both LH and FSH act by increasing cAMP levels
Granulosa cells produce inhibin too
LH also stimulate mature granulosa cells
Hypothalamus Stimulate
GnRH Negative
Follicular
feedback
Ant. pituitary
LH FSH
Ovarian follicles
Oestrogen Inhibin
Hypothalamus Positive
Mid Cycle GnRH feedback
GnRH
Luteal phase
Ant pituitary
LH stimulate progesterone LH and FSH
production. FSH and LH both
stimulate estrogen
production.
Corpus Luteum
Oestrogen Inhibin
Progesterone
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Detection of ovulation
Menstrual history – regularity, Dysmenorrhoea (pain in menstruation),
Mid cycle pain (indicate the ovulation)
During second half of cycle – Serum hormones (progesterone day 21 to 24)
Changes in cervical mucus (watery change to viscid)
Rise in basal body temperature (1-2 days after ovulation)
Secretory endometrium
Visualization by ultrasound and laparoscopy (corpus luteum or Graafian follicle)
Oestrogen Progesterone
3 forms, Thermogenic
Regulation of hypothalamus and
17β estradiol-Normal menstrual cycle
Estrone-After menopause pituitary
Estriol-Pregnancy Breast-lobular, alveolar growth
Menopause
Q. Why FSH, LH found in the urine of women after menopause in considerable amounts?
Decrease of oestrogen & progesterone levels will reduce their negative feedback on FSH &
LH.
No significant change in the progesterone levels as
it is produced by the corpus luteum.
Transitional period (4th decade) -
↓Reduc on in gonadotrophin- ↓Estradiol ↑FSH (Progesterone and LH no
responsive follicles Inhibin significant change)
After menopause -
↓Absent gonadotrophin- ↓Estradiol ↑ FSH, LH (Excreted in urine)
responsive follicles Inhibin Progesterone
Estrogen deficiency
Hot flushes
Atrophy of breast & reproductive tract
Reduced vaginal acidity (reduced glycogen in cells – prone to infections)
Dyspareunia (pain during sexual intercourse)
Prone to IHD. Why?
Behavioural & emotional changes
Osteoporosis
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Wave of heat passing over the chest & spreading to neck, face, upper arms followed by
sweating
Marked vasodilatation followed by vasoconstriction
Oestrogen therapy brings relief
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Fertilization & Implantation
One sperm fuse with ovum, mediated by fertilin in sperm head, nucleus released, and fusion of
nuclei
Sperms move up due to their own motility and due to propulsion of uterus and oviducts,
produced by oxytocin.
Sperms fertile up to 72 hours in female genital tract
Ovum fertilizable up to 24 hours after ovulation
Most fertile period is 48 hours before ovulation
Blastocysts
Forms placenta
Placenta
Oestrogen synthesis during pregnancy 37th week of gestation is called the Term
Source - Corpus luteum of pregnancy-2/3months
Feto placental unit
Main type-estriol
Functions- Enlargement of uterus, genitalia
Enlargement & ductal proliferation of breast
Relaxation of pelvic ligaments
Cholesterol
Estriol 16OHDHEAS
(Principal)
hCS
hCG: - (glycoprotein)
Secreted by the syncytiotrophoblast(also; Fetal liver ,kidney or even by GIT tumours)
Primarily luteinizing effect. (prevent degeneration of CL)
Acts on the same receptors as LH.
Present in blood 6 days after conception/fertilization Basis of
present in urine 14 days after conception/fertilization pregnancy test
Peak-10th week
Detectable even before missing menstruation.→Sensitive method to detect pregnancy
Relaxin
Polypeptide
Found in prostate gland in men (involved in sperm motility & penetration)
Found in the secretory phase, not proliferative phase
Secreted by
Corpus luteum Uterus
Placenta
Actions
Relaxes pubic symphysis & other pelvic joints
Softens and dilates uterine cervix
Inhibits uterine contraction
o hCG and relaxin – peak in first trimester
o oestrogen,progesterone,hCS – peak at term
Amniotic fluid
o 300-800 ml term
o Similar to ECF. Contains waste products, foetal cells
o Allows free movement, diffusion of external trauma, provides constant environment
o Amniocentesis for pre-natal diagnosis
Diagnosis of pregnancy
Clinical: Amenorrhoea Foetal heart sounds
Uterine enlargement Breast, skin changes
Nausea, vomiting Frequency of micturition
Investigations: Biological,immunological assays Ultrasound scanning
Period of gestation-280days from the 1st day of the last regular period
37thweek→term
conception
12 28 40 weeks
General -
o Weight gain
o Increased BMR (5-25%)
Cervix,Vagina, Vulva
o Cervix softens, ↑vascularity and secretions
Skin
o Linear nigra
o Striae gravidarum
Breast
Metabolic changes
o ↑Fat mobilization and tendency of ↑ketoacidosis
Endometrium
Oxytocin release
In early labour, maternal plasma concentration of oxytocin, is not elevated from the pre-
labour value. There is only a marked rise in receptors.
It is considered that the signal for birth to occur is given by the fetus.
Increase of ACTH
Increase of Cortisol
Maturation of
Respiratory system
Painful uterine contractions aided by voluntary contractions of, maternal abdominal muscles for
expulsion of uterine contents
Beginning of painful uterine contractions
Birth of baby
Delivery of placenta
Puerperium
Changes in pregnancy revert approximately to the non-pregnant state during the 6 weeks from
child birth
Lactation is established.
Systems come to non-pregnant levels
Lactation
During puberty
Oestrogen Progesterone
During pregnancy
[Oestrogen]&[ progesterone] are high
Prolactin levels increase steadily in term Full lobulo-alveolar development of breast
Milk secretion is inhibited by oestrogens.
Ejection of milk
Expulsion of placenta initiates lactation.
Hypothalamus
Oxytocin ↓Dopamine
Contraction of myoepithelial cells ↑ Prolactin
Milk ejection/ let down ↑Milk production
(↑mRNA of milk proteins-
Lactalbumin, casein
↑mRNA of UDP-galactosyltransferase
Oestrogen – prevents lactation
Binding of PRL to receptors
Milk volume
Progesterone – prevents initiation
No effect once established
Prolactin
From anterior pituitary
Secretion inhibited/regulated by dopamine (prolactin inhibiting hormone)
A peptide, structurally similar to GH &hCS.
Receptors resemble GH receptors
1) InhibitsGnRH secretion and action of it on pituitary
2) Antagonizes the gonadotrophins' actions in ovary
So, women who nurse regularly have amenorrhea for 25 – 30 weeks (who do not - up to 6 weeks)
Hypothalamus
GnRH
-
Prevent
↑ Breast ↑ Prolactin - Anterior
pituitary
menstruation
feeding & ovulation
- FSH/LH
Contraceptive
Ovary effect
Oestrogen& Progesterone
Contraceptive methods
Contraceptive methods
Barrier
Ryhthm/calander method Condoms
Methods Hormonal IUCD Vasectomy LRT
Subdermal
Cervical Mucus method Condoms OCP DMPA
Implants
Spermicidal
POP
Creams
Emergency CP
*calendar method
Record the length of at least six menstrual cycles
Subtract 18 from the shortest cycle (Gives the probable 1st day of fertile
period)
Subtract 10 from the shortest cycle (Gives the probable last day of fertile
period)
Avoid sexual intercourse during fertile period
Barrier methods
Contraceptive Mechanism Advantages Disadvantages
of action
Male condom Prevent entry Prevent sexually Some may find it difficult to
of sperms to transmitted use correctly (correct
vagina diseases technique)
Safe to use less effective if not used
No systemic correctly
effects Require partner corporation
Easy to initiate May interrupt sexual
and discontinue activity
Do not require Cultural barriers may
Female clinic visits prevent use
condom/Diaphragm Immediate return Need proper storage and a
to fertility after continuous supply
discontinuation
* IUCDs are Small flexible device usually made of plastic. They are three types
Inert
Copper bearing – Most efficient emergency contraceptive method available
Hormone releasing-Release progesterone
Emergency contraceptives
Note; Though 4 low dose COC pill within first 72 hours and then another 4 COC pills
after 12 hours can be taken Instead of Prostinor , they are intolerance due to severe
side effects
Cu-IUCDs Copper prevents Should be inserted If a woman is
fertilization by within 5 days (120 pregnant should not
causing a hours) of be used
chemical change unprotected Most effective form of
that damages intercourse emergency
ovum & sperm Most efficient contraception
emergency available
contraceptive Safe method-Risk of
method available infections, expulsion,
& perforations are
less
Unit change in pH changes [H+] by ten-fold (e.g. when pH increases by 1, [H+] decreases
by 10 times)
Biological systems (e.g. enzymes) are extremely sensitive to changes in pH.
Conjugate Acid-Base pair: A proton donor and its corresponding proton acceptor
HA ⇌H+ + A−
Acid dissociation constant = Ka
𝐾𝑎 =[𝐻+][𝐴−]
[𝐻𝐴]
(Higher the Ka, better the dissociation of the acid)
[𝐻+ ]=𝐾𝑎[𝐻𝐴]
[𝐴−]
−log10[𝐻+] = −log10𝐾𝑎−log10[𝐻𝐴]
[𝐴−]
𝐩𝐇=𝐩𝐊𝐚+𝐥𝐨𝐠𝟏𝟎[𝐀−]
[𝐇𝐀]
Weak acids (e.g. aspirin, pKa ≈ 3.5) are in the unionized form in the stomach
(due to its highly acidic pH)
Unionized form of a drug (i.e. HA) is more soluble in phospholipid bilayer
Therefore, will cross the cell membranes more rapidly and move into blood
Buffers
Substances that resist pH changes
Combinations of H+ donors and H+ acceptors (weak acids or weak bases)
Mixture of weak acid/base and its conjugate base/acid
Buffers work by accepting H+ when they are in excess and donating H+ to the solution
when they are depleted
Buffering capacity depends on the type of buffer and the molarity of the solution
Optimum activity of buffer occurs when pH = pKa (i.e. when [A-] = [HA])
Maximum buffering capacity in the pH range (pKa ± 1)
Conjugate acid-base pairs act as buffer when pH = pKa
Buffering systems in the body: (controlled by lungs/kidney)
Diagnosis of any disease is first done by considering the medical history and physical examination &
can be confirmed by lab diagnostic tests. Also, they are important in determination of,
severity of the disease
Assess patient response to specific treatments
Body fluids - blood, serum, plasma, urine, cerebrospinal fluid (CSF), feces.
Body tissues (Biopsy) - tumors.
Blood collection or Phlebotomy - drawing blood from a vessel for laboratory analysis. Different
specimens may be used,
Whole blood
Serum
Plasma
Serum is same as plasma except that it does not contain clotting factors, but plasma
contains all clotting factors.
Eg - Fibrinogen.
Anyway, serum and plasma contain the same contents of electrolytes, enzymes,
proteins & hormones.
1) Constituent enzymes
2) Non-constituent enzymes
Heamolysis
↓ Temperature ↑ Stability
Denaturing of enzymes & Sun-light damage to cell membranes, can leads to heamolysis.
Diabetes Mellitus
Fasting plasma glucose - ≥ 7.0 mmol/l [126 mg/dl] or
2h plasma glucose - ≥ 11.1 mmol/l [200 mg/dl]
ADA (American Diabetes association) Criteria for the diagnosis of Diabetes Mellitus.
GOD
Glucose + O2 + H2O ------------------> Gluconolactone + H2O2
Peroxidase
2H2O2 + 4 NH3-phenazone + Phenol----------------------> 4 Phenazone (Quinonimine) + 4H20
Hexokinase method
Glucose Dehydrogenase method
Orthotoluidine method
not commonly utilized nowadays, because Orthotoluidine is carcinogenic
Factors causing misleading results in HbA1c test (A1c values are influenced by red cell survival)
Cardiac biomarkers
(MI - Myocardial Infarction)
Cardiac biomarkers should be measured in all patients who present with chest
discomfort consistent with Acute Coronary Syndrome (ACS).
Troponin
Troponin is a protein released from myocytes, when irreversible myocardial damage occurs.
It is highly specific to cardiac tissue
Accurately diagnoses myocardial infarction with a history of ischemic pain or ECG changes
reflecting ischemia.
Considered as the “gold standard” for the diagnosis of acute myocardial infarction (AMI).
Specific cardiac isoforms of TnT & Tnl are possible to detect, & they are located in the thin
filaments of myofibrils. They are consisting of 3 isoforms.
cTnT, cTnl (specific to heart) released early, peak at 12-24 hours and remain
elevated for 7-10 days.
TnT is also released in small amounts by skeletal muscles. But clinical assays
do not detect skeletal TnT.
TnC is similar in cardiac and skeletal muscle. So it is not cardiac specific.
Fewer false positive results in the presence of skeletal muscle injury.
Discriminates myocardial injury even when CK-MB is minimally increased.
CK - 1 (CK - BB)
Brain fraction
CK - 2 (CK - MB)
specific to myocardium (greater concentrations in cardiac muscle)
10 - 20 % of total CK activity
Following AMI, it rises within 3 - 8 hrs & peaks in 10-24 hrs
Plasma t1/2, is about 12 hrs
Returns to normal in 48-72 hrs, in contrast to troponins
CK - 3 (CK - MM)
in skeletal & heart muscle
Myoglobin
Precautions
Direct measurement of LDL is time consuming, expensive & requires specialized equipment.
So, LDL is most commonly estimated from quantitative measurements of Total Cholesterol (TC),
HDL & plasma Triglycerides (TG) using the Friedwald Formula.
If concentrations measured by,
mg/dl, [LDL-c] = [TC] - [HDL-c] - [TG/5]
mmoI/L, [LDL-c] = [TC] - [HDL-c] - [TG/2.2]
The quotient - TG/5 is used as an estimate of VLDL concentration. It assumes, that all the
plasma TG is carried on VLDL & the TG: VLDL ratio is constant at about 5: 1
Urine Testing
Microalbuminuria
It’s a clinical condition, which moderate increase in the level of urine Albumin.
It's a marker of vascular endothelial dysfunction & important marker for kidney diseases
in Diabetes Mellitus, Hypertension.
During this phase
It's associated with retinopathy, peripheral vascular disease and neuropathy.
Blood pressure increases and lipid abnormalities develop in this phase, so, strongly predictive
of death from a cardiovascular disease.
Also, Glomerular filtration rate (GFR) starts to decline during the phase of Microalbuminuria.
Diagnosis;
Excretion of 30 - 300 mg of Albumin / 24 h urine collection.
ACR (Albumin / Creatinine Ratio) 30 - 300 mg/g.
External occipital protuberance – junction of head & neck, most prominent point – INION
Superior nuchal line – junction of head & neck – pass from the protuberance
Highest nuchal line – begin from upper part of the protuberance
Occipital point – above inion farthest from glabella
Occasionally interparietal bone present
Lateral view
(temporal view)
Zygomatic arch – temporal process of zygomatic bone + zygomatic process of temporal bone
Jugular point – anterior end of zygomatic arch
PTERION: point where frontal, parietal, temporal, sphenoid bones meet
- Deeply lies middle meningeal vein, anterior of middle meningeal artery & stem of the lateral sulcus of the
brain (7.17 C) grants
- 4cm above zygoma, 2.5cm behind frontozygomatic suture
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3. Norma basalis
*attachments
Pharyngeal tubercle: raphe of superior constrictor
Medial pterygoid: pharyngobasilar fascia, superior constrictor, pterygomandibular raphe
Lateral pterygoid plate: lateral pterygoid and medial pterygoid
Foramen magnum: anterior, posterior Atlanto-occipital membrane, alar ligament
External occipital protuberance: ligamentum nuchae
Lateral view
Zygomaticofacial foramen – Zygomaticofacial nerve
Superior view
Parietal foramen – emissary veins
Inferior view
Incisive foramen – nasopalatine nerve, greater palatine vessels
Greater palatine foramen – greater palatine nerve
Lesser palatine foramen – lesser palatine nerve
Pterygoid canal – pterygoid nerve and vessels
Foramen ovale – Mandibular nerve
Accessory meningeal artery
Lesser petrosal nerve
Emissary vein
Foramen spinosum – middle meningeal artery, meningeal branch of mandibular nerve
Foramen lacerum – filled with cartilage
Foramen magnum – continuation of brain and spinal cord, vertebral arteries and nerve plexus
Anterior spinal artery
Posterior spinal arteries
Roots of accessory nerve
Meninges
Carotid canal – internal carotid artery and nerve plexus
Condylar canal – emissary veins
Hypoglossal canal – hypoglossal nerve (XII) and vessels
Jugular foramen – Internal jugular vein
Glossopharyngeal nerve (IX)
Inferior petrosal sinus
Vagus nerve (XII)
Accessory nerve (XI)
Stylomastoid foramen – Facial nerve (VII)
INTERNAL FORAMINA
Clinicals
Anterior cranial fossa fracture:
bleeding or CSF leakage through nose-CSF rhinorrhoea
Black eye
Middle cranial fossa fracture: -
commonly fractured
Bleeding & leakage of CSF through ear
Bleeding through nose & mouth
Vertigo
Damage to the VII & VIII nerves
Posterior fossa fracture: Bruise extends over mastoid region to sternocleidomastoid
3. Straight sinus
Commence continuation of inferior sagittal sinus with receiving the great cerebral vein of Galen
Ends turning into the transverse sinus generally to the left at the internal occipital protuberance
Course slopes down steeply in the attachment of the falx cerebri into the tentorium cerebelli
Drains from inferior sagittal sinus, great cerebral vein, adjacent occipital lobes, upper surface of cerebellum
Drains from Right sup sagittal sinus Left inf sagittal sinus
Nearby surfaces of cerebral and cerebellar hemispheres
One sinus is larger – which receives the sup sagittal sinus (right)
Communicate with each other at confluence of sinuses
5. Sigmoid Sinus
Communicates with the internal vertebral plexus (veins outside the spinal dura) at the foramen magnum
7. Basilar plexus
On the clivus
Connects the two inferior petrosal sinuses
Drains from the lower part of medulla and pons
No veins accompany the vertebral and basilar arteries
Vertebral vein itself commences outside the skull below the occipital bone.
8. Cavernous sinus
Commence medial end of the superior orbital fissure (apex of the orbit)
Ends apex of the petrous bone
Course alongside the body of the sphenoid bone in the middle cranial fossa
Structures in the center and lateral wall of sinus are separated from blood by the endothelial lining.
Communications (valve-less)
Extradural hemorrhage
Fractures of the side of the skull may rupture the middle meningeal artery (especially the frontal
branch)
Hematoma between the bone of the skull and the dura
In x-rays, it has a lens shaped whitish area as it is attached to the sutures.
Subdural hemorrhage
Venous blood escapes into the (potential) space between the dura and arachnoid
Venous blood is involved (so it is slower to develop and less severe)
In x-rays, they are shown in a crescent shape (falx cerebri)
Subarachnoid hemorrhage
Rupture of arteries that lie within the space, such as aneurysms of arterial circle at the base of
brain.
Causes blood to contaminate CSF
Appear in whitish (accumulation of blood in fissure)
Blood accumulates along fissures
Scalp
Extent
Anteriorly - supraorbital margin
On each sides - superior temporal line
Posteriorly - superior nuchal line, external occipital protuberance
5 layers
S - Skin
C - Connective tissue
A – Aponeurosis
(Epicranial/deep fascial galea)
L - Loose connective tissue
P - Pericranium
The 1st 3 layers are called the
surgical layers of the scalp /
scalp proper.
Skin
Thick (thickest in occipital region)
High concentration of sebaceous glands
Aponeurosis
Epicranial aponeurosis is movable on
Pericranium
on each side attached to superior temporal
line – blends with temporoparietal fascia
Occipitofrontalis
Occipitalis arises from the lateral 2/3rd
of superior nuchal line
Occipital muscle bellies are separated
across the midline by the aponeurosis
Occipitalis is innervated by posterior
auricular branch of facial nerve
Frontalis arises from the front of the aponeurosis/skin of forehead and is inserted to the upper part of
orbicularis oculi and overlying skin of the eyebrow. (Frontalis part has no attachment to the skull).
The subaponeurotic space extends down beneath the orbicularis oculi into the eyelids.
Bleeding anywhere beneath the aponeurosis may appear as a ‘black eye’ due to the blood tracking through
the space.
Frontalis muscle bellies are partially united in the midline and innervated by the temporal branch of the
facial nerve
Function of the frontalis muscle is to raise eyebrows & cause horizontal wrinkles in the forehead.
Pericranium
Loosely attached to surface of the bones but adherent to the sutures
Therefore, a collection of fluid deep to the pericranium (cephalohematoma) takes the shape of the bone
concerned.
Blood Supply
External carotid – occipital, posterior auricular, superficial temporal
Internal carotid – supraorbital and supratrochlear (via ophthalmic artery)
There is an external and internal carotid anastomosis around the vertex.
Veins receive diploic veins from vault bones and emissary veins from intra cranial sinuses.
Superficial temporal vein retromandibular vein
Posterior auricular vein external jugular vein
Occipital vein vertebral vein
Supratrochlear & supraorbital veins angular vein facial vein
Lymph drainage
Anterior – pre auricular
Posterior – mastoid
Ultimately drain into deep cervical chain
No lymph nodes within the scalp.
Nerve supply
Occipital region – greater occipital & 3rd occipital nerves
Skin behind the ear – lesser occipital
Temple – auriculotemporal & zygomaticotemporal
Forehead & front of head – supratrochlear & supraorbital
Scalping – evulsion of the layers of the scalp above the loose areolar tissue that doesn't cause necrosis of
underlying bones
Face
Extends from adolescence position of hairline (superiorly) base of mandible (inferiorly) & auricles (on either side)
Forehead common both to face & scalp
Skin – very vascular (wounds heal rapidly)
rich in sebaceous & sweat glands
Lax
Boils in nose & ear causes pain because of fixity of skin to cartilage
Superficial fascia
facial muscle inserted into skin – injuries tend to gape
Fat absent in eyelids but well developed in cheeks
Deep fascia – absent except over parotid gland & buccinator muscle
Orbicularis oculi
2 parts
palpebral part (close eye lids gently)
Orbital part (both parts – close eye lids forcibly)
Nerve supply – temporal & zygomatic branches of facial nerve
Orbicularis oris
Bulk is formed by buccinator
Nerve supply – buccal and marginal mandibular branches of facial nerve
Buccinator
Origin – alveolar processes of maxilla & mandible, pterygomaxillary ligament, pterygomandibular raphe
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Insertion – orbicularis oris (fibers from the raphe decussate; maxillary & mandibular fibers do not
decussate)
Nerve supply – buccal branch of facial nerve
Action – prevent distention of cheeks when intraoral pressure rises
Pierced by the parotid duct opposite the 3rd upper molar teeth.
Arterial Supply
1. Facial artery External carotid
2. Transverse facial artery – superior temporal
3. Supraorbital and supratrochlear – from ophthalmic artery – Internal carotid
Venous drainage
Entirely superficial
Forehead – supraorbital & supratrochlear veins unite at medial canthus to form the angular vein
CLINICALS
Common External
facial vein jugular vein
Internal
jugular vein
Parotid capsule
deep cervical fascia splits to form the capsule (between angle of mandible and mastoid process)
superficial lamina thick & adherent to gland
attached to zygomatic arch superiorly
deep lamina thin & attached to styloid process & angle of mandible
part of the deep lamina forms stylomandibular ligament which separates the gland from the submandibular
gland
thickened anteroinferiorly
Surface marking
1. upper border of the head of the mandible
2. center of the masseter muscle
3. posteroinferior to the angle of the mandible
4. upper part of the anterior border of the mastoid process
Relations
pyramid shaped: base, superficial surface, anteromedial & posteromedial surfaces
Apex
a) Overlaps posterior belly of digastric
b) Cervical branch of facial nerve & 2 divisions of retromandibular vein
Base
a) Cartilaginous part of external acoustic meatus
b) Posterior part of TM joint
c) Superficial temporal vessels
d) Auriculotemporal nerve
Superficial surface
a) Skin
b) Parotid fascia
c) Lymph nodes
d) Anterior branch of great auricular nerve
Anteromedial surface
a) Grooved by ramus of mandible
b) Masseter
c) Lateral part of TM joint
d) Medial pterygoid
e) Emerging branches of facial nerve
f) Maxillary artery emerges
Posteromedial surface
a) External carotid artery enters through
this surface
b) Mastoid process
c) Styloid process & structures related to it
Blood supply
Arterial supply - external carotid artery
Venous drainage – Retromandibular vein
Nerve supply:
Lymphatic drainage
Parotid nodes upper deep cervical nodes
Facial Nerve
Extra-cranial course
Crosses the lateral side of the styloid process after emerging through stylomastoid foramen
Enters the posteromedial surface of the parotid gland
Crosses the retromandibular & external carotid artery
Behind the neck of mandible divides into terminal branches
c) Chorda tympani
Vertical part of facial nerve, arises 6mm above the Stylomastoid Foramen
Closely related to tympanic membrane
Leaves middle ear through petrotympanic fissure
Medial to the spine of sphenoid
Joins the lingual nerve
Carries,
1. Preganglionic secretomotor fibers to submandibular & sublingual glands
2. Taste fibers from tongue
b) Digastric
c) Stylohyoid
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Enters the parotid gland & divides into a temporofacial and a cervicofacial branch. These divide into
branches which rejoin to form the pes anserines
C. Terminal branches
The branches leave the gland through its anteromedial surface & appear on the surface at the
anterior border.
a) Temporal
1. auricularis anterior & superior
2. Intrinsic muscles on lateral side of ear
3. Frontalis
4. Orbicularis oculi
5. Corrugator supercili
b) Zygomatic
1. orbicularis oculi
c) Buccal
1. Orbicularis oris
2. Buccinator
3. Muscles of nostrils & upper lip
d) Marginal mandibular
1. Platysma
2. Muscles of lower lip & chin
e) Cervical
1. platysma
Contents
1. temporalis muscle
2. Deep temporal arteries
3. Deep temporal branches of mandibular nerve
4. Middle temporal artery – a branch of superficial temporal artery
Masseter Lower border of Angle and Lateral Masseteric branch Elevation and
Zygomatic Arch surface of Ramus of Anterior division protrusion
3 layers of the Mandible of mandibular
nerve
Contents
1. Pterygoids – medial and lateral
2. Mandibular nerve
3. Maxillary artery
4. Pterygoid venous plexus
5. Otic ganglion and lesser petrosal nerve
6. Maxillary nerve
7. Chorda Tympani nerve
Deep- Deep head of medial pterygoid, sphenomandibular ligament, middle meningeal artery, mandibular nerve
Maxillary artery
Larger terminal branch of
external carotid.
Enters infratemporal fossa
by passing forwards between
the neck of mandible and
sphenomandibular ligament.
Above – auriculotemporal
Nerve N
Below – maxillary Vein A
Runs forwards deep to the V
lower head of lateral
pterygoid and then between
the 2 heads.
Enters pterygopalatine fossa
through pterygomaxillary
fissure .
Then enters infraorbital canal through inferior orbital fissure and continues as the infraorbital artery.
3 parts- Sphenomandibular ligament
1st part – before lateral pterygoid muscle Derived from Meckel’s cartilage
5 branches
2nd part – on the lateral pterygoid muscle
each arises from the spine of
3rd part – beyond the lateral pterygoid
sphenoid and inserts into the
muscle
lingula and inferior margin of
mandibular foramen.
1st part It runs deep to
auriculotemporal nerve,
maxillary artery & vein
It is pierced by
2nd part mylohyoid nerve, which is
Deep auricular artery accompanied by mylohyoid
vessels.
Anterior tympanic artery
3rd part
pterygoid
Middle meningeal artery Infraorbital artery
Masseteric
Accessory meningeal artery Sphenopalatine
2 Deep temporal main supply to nasal cavity
Inferior alveolar artery
Buccal Posterior superior alveolar
Greater palatine
Pterygoid plexus
Lie around and within the lateral pterygoid muscle Pharyngeal
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Artery of Pterygoid Canal
Plexus is valved, and acts as a peripheral heart
Receives inferior ophthalmic vein, deep facial vein
Drains into Short Maxillary Vein
Connect with cavernous sinus via emissary veins through Foramen Ovale and Foramen Lacerum
Meningeal branch
(nervus spinosus) Via otic ganglion Nerve to Medial Pterygoid
supplies dura
Motor
Nerve to mylohyoid
Lingual nerve Pierces Sphenomandibular
Ligament
Mental nerve supplies mylohyoid and
anterior belly of digastric.
Pterygopalatine fossa
Narrow space communicating with infratemporal fossa through
pterygomaxillary fissure.
Boundaries
Anterior wall – posterior surface of maxilla
Posterior wall – sphenoid bone
Medial wall – perpendicular plate of palatine bone
Roof – body of sphenoid
Floor – articulation of pyramidal process of palatine bone with
lateral pterygoid plate.
Contents
maxillary vessels (3rd part – 5 branches)
Maxillary nerve
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Pterygopalatine ganglion & fat
Maxillary nerve
enters fossa through Foramen Rotundum and runs through inferior orbital fissure into Infraorbital Canal as
Infraorbital Nerve.
Completely sensory
Branches
From main trunk –
meningeal, zygomatic,
superior alveolar nerves
(anterior, middle and
posterior), infraorbital nerve
Joint capsule
Stability
Most stable when teeth in occlusion.
Forward displacement is more common.
Relations
Superiorly – glenoid fossa, middle cranial fossa
Medially- maxillary artery & proximal branches (middle meningeal), auriculotemporal nerve
Laterally- parotid capsule, facial nerve
Anteriorly – lateral pterygoid, articular eminence
Posteriorly – tympanic plate, tegmen tympani, superficial temporal artery (Lat)
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Movements
1. Depression and elevation
a. Lower compartment – hinge movement
b. Upper compartment – gliding movement
c. Axis – horizontal
2. Side to side movements – Medial and lateral pterygoids of the same side contract together.
3. Protraction – All 4 pterygoids contract.
Retraction – Elastic recoil (Temporalis, Masseter)
Depression – digastric, mylohyoid, geniohyoid
Elevation – masseter, medial pterygoid,
temporalis
Nerve Supply
Auriculotemporal Nerve
Nerve to Masseter
In middle cranial fossa – Middle meningeal veins are closer to the bone than artery
Clinical
Lesion of:
Anterior branch – Contralateral hemiplegia
Posterior branch – Contralateral deafness
• Is bounded by the
1. T1 vertebra
2. 1st pair of ribs & costal cartilages
3. Manubrium of the sternum
Scalenus Anterior
Origin – Anterior tubercles of the transverse processes of typical vertebrae (C3-C6)
Insertion – Scalene tubercle & adjacent ridge on 1st rib
Nerve supply – Anterior rami of C4-C6
Anterior relations
1) The Phrenic Nerve,
passes vertically down across the obliquity of the muscle. (plastered to the prevertebral fascia).
The nerve leaves the medial border of the muscle low down.
Crosses in front of the Subclavian Artery and its internal thoracic branch, behind the Subclavian Vein.
Lying on the supra pleural membrane it passes medial to the apex of the lung, in front of the Vagus Nerve,
to enter the superior mediastinum.
1) The common carotid artery, medial to the internal jugular vein, lies deep to sternocleidomastoid
immediately in front of the pyramidal space.
2) The space contains the stellate ganglion & vertebral artery and vein(s).
3) The inferior thyroid artery arches medially in a bold curve whose upper convexity lies in from of the apex of
the pyramidal space (C6 level).
4) At a lower level, and further forward, the Thoracic Duct (or right lymphatic duct) makes a similar convexity
as it arches over the lung apex and subclavian artery enter the confluence of the subclavian and internal
jugular veins.
Posterior relations
2nd part of the Subclavian artery.
Scalenus Medius
Lateral relations
3rd part of the Subclavian artery.
Cervical pleura:
Covers the apex of the lung.
It rises into the root of the neck.
The pleural dome is strengthened on its outer surface by the supra pleural membrane (Sibson’s Fascia) so that
the root of the neck is not puffed up and down during respiration.
1) Glands
Thyroid Gland
Introduction
• Butterfly shaped/ shield like endocrine gland.
• The gland has 2 conical lobes each joined by an isthmus in its lower part.
• An inconstant pyramidal lobe may project upwards form the isthmus.
Arterial supply
1. Superior Thyroid Artery
The 1st anterior branch of external carotid artery
Close relation to external laryngeal nerve away from gland.
At the upper pole divides into anterior and posterior branches.
Divides into branches after piercing false capsule
External laryngeal nerve deviates at the apex of a lobe of the gland. Therefore, during thyroidectomy superior
thyroid artery is ligated near the gland
Venous drainage
• Superior thyroid vein emerges from the upper pole of the gland drains into internal jugular vein.
• Middle thyroid vein also drains into internal jugular vein.
• Inferior thyroid vein emerges from the lower border of the isthmus, to be eventually drained into the left
brachiocephalic vein.
• Dense capillary plexus present deep to the true capsule.
Lymphatic drainage
Lymph from the upper part of the gland drains into upper deep cervical lymph nodes.
Nerve supply
Sympathetic fibres are mainly derived from the middle cervical ganglia / cervical sympathetic trunk.
Relations
• Superficially/Anterolateral
skin, superficial fascia and investing deep fascia
strap muscle of the neck (sternohyoid, sternothyroid, superior belly of omohyoid) overlapped by
sternocleidomastoid.
Anterior jugular vein courses over the isthmus.
• Medially
On the deep aspect lie the larynx (Cricothyroid) and trachea, pharynx (Inferior constrictor) and
oesophagus
Recurrent laryngeal nerve coursing on the tracheoesophageal groove is closely related to the inferior
thyroid artery.
External laryngeal nerve is closely related to the superior thyroid artery.
• Behind/Posterolaterally
the carotid sheath (common carotid artery) lies on either side.
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Clinical Anatomy
1. Swellings (goitre) move with deglutition (gland is adhered to the trachea)
2. Flex head when palpating
3. Cancer recurrent laryngeal nerve damage hoarseness of voice.
4. In thyroidectomy Superior thyroid ligated near gland to save the external laryngeal nerve. Inferior thyroid
ligated away from gland to spare the recurrent laryngeal nerve
Parathyroid gland
• 2 pairs Superior and inferior. (1 pair on each lateral lobe).
• Lies on the posterior surface of the thyroid gland, within the false capsule
• Size of split pea
• Brownish yellow colour
• Lie close to anastomosis between superior & inferior thyroid arteries.
• Superior parathyroid more constant in position
• Inferior parathyroid inconsistent position
Within capsule
Outside capsule
Within substance of lobe
Within thymus (due to the same embryological origin )
Behind trachea
Behind great vessels
• Blood supply – mainly from Inferior Thyroid Artery (both inferior & superior glands)
• Easily subject to subscapular haematoma formation on handling
Relations
3rd PART
Costocervical trunk Axillary artery
• Passes back across the suprapleural membrane
towards the neck of the 1st rib & divides into. Dorsal scapular
1. Superior/Supreme intercostal (runs downwards) – • Runs laterally through the brachial
into the thorax. plexus in front of scalenus medius &
2. Deep cervical (runs upwards) – Passes backwards then deep to the levator scapulae to
between the transverse process of C7 & the neck take part in the scapular
of the 1st rib and then ascends. anastomosis.
Relations
3) Veins
1. Subclavian Vein
Continuation of the axillary vein at
the outer border of 1st rib. Joins
internal jugular vein to form
brachiocephalic vein.
Receives External jugular vein.
Receives the thoracic duct (left) or
right lymphatic duct (right) at its
confluence with the internal jugular
vein.
Relations
Anterior - Clavicle
Posterior - Subclavian artery,
Scalenus anterior & Phrenic nerve
Inferior - Upper surface of 1st rib
Tributaries are:
External Jugular vein
Dorsal scapular vein
3. Brachiocephalic vein
The left is longer than the right.
Formed behind the Sternoclavicular
Joint
Right – Vertical
Left – Oblique
The two unite at lower border of right 1st coastal cartilage to form SVC
Tributaries
Branches of 1st part of subclavian artery
1st posterior intercostal vein
Clinical Anatomy
1. Cardiac failure - Internal jugular vein dilated.
2. Closely associated lymph nodes mean that the vein should also be resected in removing malignancy.
4) Nerves
1. Phrenic nerve
Origin - C3, C4 (main), C5
Mixed nerve
The sole motor supply of diaphragm.
Sensory to Central Tendon of Diaphragm, Pleura, Pericardium & part of Peritoneum.
Formed at lateral border of scalenus anterior at the level of upper border of Thyroid Cartilage.
Runs vertically downwards on Scalenus Anterior from lateral to medial.
Leaves scalenus anterior & runs downwards on cervical pleura & enters thorax behind 1st costal cartilage.
Descends anterior to the lung root & then on the surface of the pericardium.
In the left side, the nerve leaves the medial margin of the Scalenus Anterior at a higher level and crosses in
front of the first part of the Subclavian Artery.
Also, at the lower border of the cricoid cartilage (C6) lies the,
1. junction of larynx with trachea
2. junction of pharynx with oesophagus
3. inferior thyroid artery enters & middle thyroid vein leaves the thyroid gland
4. vertebral artery enters foramen transversarium of C6 vertebra
5. superior belly of omohyoid crosses carotid sheath
6. middle cervical sympathetic ganglion
7. carotid artery can be compressed against anterior tubercle of the transverse process (carotid tubercle) of 6 th
cervical vertebra
Cutaneous innervation
C2, C3, C4
anterolateral part – anterior primary rami through
lesser occipital
great auricular
Transverse cervical
supraclavicular
posterior part – posterior primary rami
*C1 – no cutaneous innervation
C4 – through supraclavicular nerves supply pectoral region
SUPERFICIAL FASCIA
platysma
cervical branch of facial nerve
lymph nodes & vessels.
external jugular vein
deep to platysma
posterior auricular + posterior division of
retromandibular vein
Clinical:
Division of the external Jugular vein in the supraclavicular space may cause air embolism and death because the cut
ends of the vein are prevented from retraction and closure by the fascia, attached firmly to the vein.
Anterior Jugular vein
begins in submental region
Descends in the superficial fascia
Above the sternum it pierces the
investing layer of deep fascia
Enters suprasternal space
Connected to opposite vein by
jugular venous arch
Turns laterally and runs deep to
sternocleidomastoid just above the
clavicle
Ends in the external jugular vein.
1. investing layer
surrounds the neck like a collar
Forms the roof of anterior & posterior
triangle.
attachments
A) superiorly – external occipital
protuberance,
Superior nuchal line,
Mastoid,
Lower border of mandible
between angle of mandible &
mastoid process, the fascia
splits to enclose the parotid gland
superficial lamina is thick – attached to zygomatic arch
deep lamina is thin – attached to styloid process, mandible,
tympanic plate
o deep lamina forms stylomandibular ligament – separates parotid & submandibular glands
o pierced by external carotid artery
Suprasternal
space of Burns
jugular venous arch and
the anastomotic arch
between them
sternal heads of
sternocleidomastoid
lymph node
interclavicular ligament
supraclavicular space
external jugular vein
supraclavicular nerves
lymphatics
2. Pretracheal layer
forms the false capsule
of thyroid gland
The posterior layer of
the Thyroid capsule is thick. On either side it makes the suspensory ligament of Berry which is attached to the cricoid.
attachments
superiorly – hyoid bone
Oblique line of thyroid cartilage Cricoid cartilage
inferiorly – encloses inferior thyroid veins
Passes behind brachiocephalic veins & blend with arch of aorta
laterally – fuses with carotid sheath
Clinical:
Thyroid gland and all thyroid swellings move with deglutition because the thyroid is attached to
cartilage of the larynx by the suspensory ligament of Berry.
Swellings due to lymph node enlargement do not move with deglutition.
3. Prevertebral layer
in front of prevertebral muscles
forms floor of posterior triangle
attachments
superiorly – base of skull
inferiorly – anterior longitudinal ligament & body of T4
anteriorly – separated from pharynx & buccopharyngeal fascia by retropharyngeal space (areolar tissue)
anterior surfaces of transverse processes and bodies of vertebrae C1 – C3
Laterally – thins out deep to trapezius
cervical & brachial plexuses lie behind the fascia
forms the axillary sheath – does not contain axillary vein
Posteriorly – ligamentum nuchae
6. Pharyngobasilar layer
Thick between upper border of superior constrictor & base of skull
Clinicals
parotid swellings are painful due to the unyielding nature of parotid fascia
while excising submandibular gland external carotid artery should be secured
thyroid gland & all swellings move with deglutition due to fascial attachments
pus due to tuberculosis of vertebrae may pass forward forming a chronic retropharyngeal abscess in
the median plane
o it may extend laterally through axillary sheath; it may descend as far as superior
mediastinum
pus collected from neck infections
In front of prevertebral fascia extend in a paramedian position as far as the posterior
mediastinum
neck infections
STERNOCLEIDOMASTOID MUSCLE
origin
- sternal head – (tendinous) manubrium sterni
- clavicular head – (musculotendinous) medial 1/3rd of superior surface of clavicle *deep to the interval between the 2
heads lie the internal jugular vein
insertion
- mastoid process
- lateral half of superior nuchal line
nerve supply
motor – spinal accessory nerve proprioceptive – ventral rami of C2
blood supply
occipital artery (2 branches), superior thyroid & suprascapular arteries
actions
contraction of 1 muscle – 1. Turns chin to opposite side
2. Tilts head towards shoulder
contraction of both muscles – 1. Draw head forwards
2. Flex neck against resistance
3. Forced inspiration
deep
bones & joints – mastoid process, sternoclavicular joint
carotid sheath
muscles – sternohyoid, sternothyroid, omohyoid, 3 scaleni. Levator scapulae, longissimus capitis,
posterior belly of digastric
arteries – common, internal & external carotids, arteries to muscles, occipital, subclavian,
suprascapular, transverse cervical
veins – internal jugular, anterior jugular, facial & lingual
nerves – X, XI, cervical plexus, upper part of brachial plexus, phrenic, ansa cervicalis
lymph nodes deep cervical.
CLINICALS
most common cause for swelling in the posterior triangle is due to – enlargement of supraclavicular lymph nodes
left supraclavicular nodes – signal nodes (malignancies in stomach & testis)
wry neck – head bends to 1 side & chin points to other side: spasm of muscles supplied by spinal accessory nerve
It’s a space on the side of the neck situated behind the sternocleidomastoid muscle
Boundaries
o anteriorly – posterior border of sternocleidomastoid
o posteriorly – anterior border of trapezius
o base – middle 1/3rd of clavicle
o apex – superior nuchal line where the 2 muscles meet
o roof – investing layer of deep cervical fascia
o floor – prevertebral layer of deep cervical fascia covering splenius capitis, levator scapulae, scalenus medius
Divisions – divided by inferior belly of omohyoid into larger upper part (occipital triangle) & smaller lower
Cervical plexus
Formed by ventral rami of upper cervical nerves. (C1 gives no cutaneous branches)
Branches:
Superficial branches-
1. Lesser Occipital (C2)
2. Great auricular (C2, C3)
3. Transverse cutaneous nerve of the neck (C2, C3)
4. Supraclavicular (C3, C4)
Deep branches –
Muscular branches to:
1. Rectus capitis anterior (C1)
2. Rectus capitis lateralis (C1, C2)
3. Longus capitis (C1-C3)
4. Lower root of Ansa cervicalis
Communication branches:
1. Grey rami from the superior cervical ganglion to C1-C4 nerves.
2. Branch from C1 joins the hypoglossal nerve
3. Branch from C2 to sternocleidomastoid & branches from C3 & C4 to the Trapezius
communicate with accessory nerve.
This is a thin nerve loop that lies embedded in the anterior wall of carotid sheath over the lower part of larynx.
It supplies the infrahyoid muscles.
Formed by a superior and inferior root.
Superior root is the continuation of the descending branch of the hypoglossal nerve derived from C1.
Inferior root derived from C2, C3. This root winds around the internal jugular vein and continues anteroinferiorly to join
the superior root in front of the common carotid artery.
Distribution:
superior root to the superior belly of omohyoid
Ansa cervicalis to the sternohyoid, the sternothyroid and the inferior belly of omohyoid
Thyrohyoid and geniohyoid are supplied by separate branches from the first cervical nerve through the hypoglossal
nerve.
3) Carotid sheath
a) is attached superiorly to the base of the skull
b) fuses with the pericardium inferiorly
c) lies deep to the prevertebral fascia
d) encloses the jugular vein and vagus nerves
e) encloses the external carotid artery
At the junction between head and neck there is a circular arrangement of lymph nodes.
Submental nodes – submental triangle Drain superficial tissues
Submandibular nodes – digastric triangle of head & neck
Preauricular(parotid) nodes – within the gland / deep or superficial to capsule
Mastoid nodes – on the mastoid process
Occipital nodes – apex of posterior triangle of the neck
Mandibular and buccal nodes
Retropharyngeal nodes – behind the pharynx – back of nose, pharynx, auditory tube
All lymph from horizontal and vertical groups drain into deep cervical nodes.
o Stylomandibular ligament
o Stylohyoid ligament
o Sphenomandibular ligament
o Pterygomandibular raphe
o Pterygomaxillary ligament
o Petrosphenoid ligament
Nose
Consists of external nose and nasal cavity, Skin is abundant in
sebaceous glands Dorsum
External nosebony & cartilage framework
Bones
2 nasal bones
frontal process of maxilla Tip
Cartilages
lateral Processes of septal cartilages
Base
major alar cartilages
minor alar cartilages
Alasolely of fatty tissue at its free lower border
Lateral wall
frontal process of maxilla (mainly)
perpendicular plate of the palatine bone
medial pterygoid plate
ethmoid labyrinth with superior and middle conchae
inferior nasal conchae
nasal bone
lacrimal bone
Cartilaginous part
Meatus
Passages beneath the
overhanging conchae
Paranasal sinuses
open into meatus
1. Superior meatusposterior ethmoidal air cells
2. Middle meatus● Ethmoidal bulla middle ethmoidal air cells
hiatus semilunaris (A deep semicircular sulcus below bulla)Frontal sinus (anteriorly)
Anterior ethmoidal air cells (middle)
Maxillary air sinus (posteriorly)
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3. Inferior meatusnasolacrimal duct
Spheno-ethmoidal recess (just above the superior conchae) sphenoidal air cells
* Roof
horizontal – made by cribriform plate
anteriorly – frontal bone
posteriorly – sphenoid bone
* Floor
Hard palate = Palatine process of maxilla + horizontal plate of palatine bone
Soft palate
Mucous membrane
Olfactory epithelium - thin
confined to superior conchae and adjacent upper part of septum
Respiratory epithelium - thick (mucous secretions)
Little’s area
Anterior inferior part of the septum
Has rich arterial supply
Anastomoses between
Superior labial branch of facial artery
Greater palatine artery
Branch of sphenopalatine artery
Forms the Kiseselbach’s plexus
A common site for nosebleed
(epistaxis)
Blood supply of the nasal cavity
Include vessels that originate from both
the internal and external carotid arteries
Vessels that originate from branches of
external carotid artery
Sphenopalatine(major blood
supply),greater palatine, superior labial
and lateral nasal arteries
3. Ethmoidal sinus
Numerous, small, intercommunicating spaces (8-10)
Lie within the labyrinth of ethmoid bone
Divided in to anterior, middle and posterior groups
Clinicals
related to frontal lobe - frontal lobe abscess
C.S.F rhinorrhea
4. Sphenoid sinus
Either side of midline, in body of sphenoid
Drain above superior conchae (spheno-ethmoidal recess)
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Clinicals
In pituitary tumor, Pituitary gland may be excised through fibre-optic trans-nasal trans-sphenoidal approach
(endoscopically)
LARYNX
Extent
In the anterior midline of neck, from root of tongue to
trachea.
In adult male C3 – C6
Constitution
Cartilage
Paired- Arytenoid, Corniculate, Cuneiform
Unpaired- Thyroid, Cricoid, Epiglottic.
Ligaments
Membranes
Cartilage
Thyroid
Cricoid. Hyaline cartilages
Arytenoid
Epiglottis
Cuneiform. elastic fibrocartilages
Corniculate
Extrinsic membranes/ligaments
Thyrohyoid membrane
Has an aperture for,
o Superior laryngeal artery
o Superior laryngeal vein
o Internal laryngeal branch of superior
laryngeal nerve
Form the lateral wall of piriform recess
Hyoepiglottic ligament
Cricotracheal ligament
Intrinsic membranes/ligaments
Quadrangular membrane
Thin fibro elastic membrane
Between arytenoid cartilage & epiglottis
Lower border is a free margin, thickened to
form the Vestibular ligament (false vocal
cords)
Cricothyroid ligament/membrane
Mainly elastic tissue
Anteriorly in the midline, thick band called
Median Cricothyroid ligament
Free upper margin forms the Vocal Ligament
(True vocal cords) inserting to the vocal
process of arytenoid cartilage
Cavity of Larynx
Muscles
Clinicals
1. Bilateral complete damage to Recurrent Laryngeal Nerves
Vocal cords in cadaveric position
Phonation lost
Breathing difficult
2. Bilateral partial damage of Recurrent Laryngeal Nerves
Vocal folds completely adducted
Breathing lost (Outer fibres supply abductors)
3.Laryngotomy: The needle is inserted in the midline of cricothyroid membrane,below the thyroid prominence.This
is done as an emergency procedure.
Oral cavity can be divided into oral cavity proper (Inner larger)
and vestibule (outer smaller )
PALATE
Separates the oral cavity from the nasal cavity
1.Hard palate:
Palatine plate of maxilla- anterior 2/3
Horizontal plate of palatine bone- posterior 1/3
2.Soft palate:
Divide naso & oro pharynx
Anterior surface marked by median
raphe uvula at posterior edge
* Muscles
tensor veli palatini (tenses soft palate) Framework by the aponeurosis
levator palatine (elevation)
palatoglossus
palatopharyngeus inserted to the aponeurosis
muscular uvulae
* Lymph drainage
tip bilaterally submental nodes
remaining anterior 2/3 unilateral Submandibular Jugulo-omohyoid
posterior 1/3 bilateral jugulo-digastric
Sensory Supply
Introduction
Fibromuscular tube
Anteriorly incomplete open into nasal cavity, oral cavity and larynx, posteriorly in front of prevertebral muscle.
Acts as a common entrance for RS & GIT
Base of the skull=> => Soft palate=> => Tip of Epiglottis => =>Esophagus
1.Nasopharynx 2. Oropharynx 3. Laryngopharynx
[Pharyngeal isthmus][C6]
Extent
Pharyngeal wall
Muscles
1. Nasopharynx
2. Oropharynx
Lingual Tonsils
In the mucosa covering the posterior 1/3 of the tongue
3. Laryngopharynx
Nerve supply
Motor
All muscles by =>CN10 - Vagus
Except Stylopharyngeus by =>CN9
Sensory
Nasopharynx – V2
Oropharynx – CN 9
Laryngopharynx – CN 10
Clinicals
2) In Palatine tonsillitis
3) Tonsillectomy
- Lymphoid tissue is removed with the capsule - Paratonsillar V. may be damaged
- Structures preserved
Superior constrictor => as it is separated from the capsule by loose areolar tissue Internal Carotid A. =>as it lies within Carotid sheath
covered by fatty tissue
Submandibular region
Area between mandible & hyoid bone including floor of mouth & root of the tongue
includes the suprahyoid muscles (digastric, stylohyoid, mylohyoid, geniohyoid), submandibular & sublingual gland &
submandibular ganglion
* Superficial part
Situated in the digastric triangle
Enclosed between 2 layers of deep cervical fascia
Relations
lateral surface
- Submandibular fossa
- Insertion of medial pterygoid - Facial artery
Medial surface
- Lies against the mylohyoid muscle.
- Behind it hyoglossus, lingual nerve, hypoglossal nerve
* deep part
Continuous with superficial part round the
Lies deep to mylohyoid
Superficial to hyoglossus & styloglossus
posterior border of mylohyoid Anteriorly
extends up to posterior end of sublingual
gland
*Submandibular duct
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Emerges from anterior end of deep part
Runs forward on hyoglossus between hypoglossal & lingual nerves
Lingual nerve crosses at anterior border of hyoglossus
Lingual nerve double crosses at the duct. 1. medial to lateral 2.lateral to medial
Opens lateral to the base of the frenulum of the tongue
* Blood supply
- facial artery
- drains to common facial / lingual vein
* Innervation
Secretomotor
Geniculate ganglion
Facial nerve
Lingual nerve
Clinical
In excision of submandibular gland incision is carried out 2.5 cm below the base of the mandible to preserve marginal mandibular
nerve
Injury to spine of sphenoid may impair secretions from salivary glands
Bimanual method.
SUBMANDIBULAR GANGLION
Parasympathetic peripheral ganglion
Relay station for secretomotor fibers to submandibular &
sublingual salivary gland
Topographically related to lingual nerve
Functionally related to chorda tympani nerve
Lies on hyoglossus muscle
Sensory fibers reach the ganglion through lingual nerve
4. The pharynx
a) Extend from the base of the skull to the 4th cervical vertebra. b) Is supported superiorly by the pharyngobasilar fascia.
c) Is related posteriorly to the prevertebral fascia.
d) Is related anteriorly to the pretracheal fascia.
e) Has a muscular attachment to the pterygomandibular raphe.
Nerve supply
Blood supply
Outer surface- Deep auricular branch of maxillary artery
Inner surface – anterior tympanic branch of maxillary artery
posterior tympanic branch of maxillary artery
stylomastoid branch of posterior auricular artery
Middle ear/tympanic cavity
Narrow, air filled space located in the petrous temporal bone
Cube shaped with six walls
Roof/tegmental wall – formed by tegmen tympani, separates middle ear from middle cranial
fossa and temporal lobe of the brain
Floor/jugular wall – formed by a part of temporal bone, separates middle ear from the superior
bulb of the internal jugular vein
Tympanic canaliculus transmit tympanic branch of glossopharyngeal nerve
Anterior/carotid wall –
i. superior part has the opening of the canal for tensor tympani muscle
ii. Middle part has the opening for the auditory tube
iii. Inferior part-formed by a thin plate of bone which forms the posterior wall of carotid
canal, separates middle ear from internal carotid artery.
Lateral wall of the middle ear cavity is formed by the tympanic membrane mainly and a part above it
is formed by the squamous temporal bone.
The part of the middle ear cavity above tympanic membrane is known as epitympanic recess.
It contains head of malleus and incus.
Mastoid Antrum
CLINICAL ANATOMY
Otitis media (middle ear infection)
Throat infections commonly spread through auditory tube to the middle ear and cause otitis
media.
Pus from the middle ear can take one of the following courses.
01. May discharge into external ear following rupture of tympanic membrane.
02. May erode the roof and spread upwards causing meningitis and brain abscess.
03. May erode the floor and spread downwards causing thrombosis of sigmoid sinus and internal
jugular vein.
Tympanic04. May spread
nervous plexusbackwards causing mastoid abscess.
Membranous labyrinth –
i. Epithelium is specialized to form receptors for
sound(organ of corti), receptors for static
balance (maculae), receptors for kinetic balance
(cristae)
ii. Contains 3 parts
a. organ of corti (anteriorly)
b. Utricle and saccule with maculae (within vestibule)
c. Semicircular ducts with cristae (posteriorly)
Blood supply – Mainly from labyrinthine branch of basilar artery and partly from stylomastoid
branch of posterior auricular artery.
Bony part –
i. Forms posterior 1/3 of the tube, 12mm long.
ii. Lie in petrous temporal bone near tympanic plate.
iii. Lateral end open on the anterior wall of middle ear and the medial end is narrow and jagged.
iv. Relations – superior: canal for tensor tympani, medial: carotid canal, lateral: chorda tympani,
auriculotemporal nerve, spine of sphenoid and temporomandibular joint.
Cartilaginous part –
i. Forms anteromedial 2/3 of the tube and 25mm long
ii. Lies in sulcus tubae (a groove between greater wing of sphenoid and apex of petrous temporal)
iii. Made up of a triangular plate of cartilage which forms the superior and medial walls. Lateral wall
and floor are completed by a fibrous membrane.
Blood supply – Arterial supply by ascending pharyngeal artery, middle meningeal artery and
artery of pterygoid canal.
Veins drain into pharyngeal and pterygoid plexuses of veins.
Nerve supply –
at the ostium : by pharyngeal branch of pterygopalatine
ganglion
cartilaginous part: by nervus spinosus branch of mandibular
nerve,
bony part: by tympanic plexus.
Glossopharyngeal nerve
Cervical spine lesions, Tongue –
other neck lesions and posterior 1/3 lesions
geniculate herpes.
After chickenpox clears, the virus lies dormant in the nerves. If they reactivate and effect the facial nerve.
A painful red rash (fluid filled blisters) in, on and around the ear.
Facial weakness/ paralysis on same side
Walls
Roof – orbital plate of frontal bone & lesser wing of sphenoid
Lateral – zygomatic & greater wing of sphenoid
Floor – orbital plate of maxilla, zygomatic, palatine bone
Medial – anterior lacrimal crest on frontal process of maxilla, posterior lacrimal crest on lacrimal, orbital plate
of ethmoid, body of sphenoid
Clinicals
1. In blow out fracture, orbital floor or medial wall may be damaged.
2. Fracture of floor causes herniation of orbital fat into maxillary sinus
3. Entrapment of an extra-ocular muscle causing diplopia
4. Injury to infra-orbital nerve
Openings
Supra orbital notch - supraorbital nerve & vessels
Infraorbital groove - infraorbital nerve & vessels. Lodges the orbitalis muscle
Nasolacrimal canal - nasolacrimal duct
Inferior orbital fissure - maxillary & zygomatic nerves, branch of inferior ophthalmic vein, sympathetics
(gap between lateral wall and floor)
Superior orbital fissure - L, F, T, S, O, N, I, A
(gap between lateral wall and roof)
Optic canal - optic nerve & ophthalmic artery
Anterior & posterior ethmoidal foramina – at the junction of roof and medial wall. Transmits the anterior & posterior
ethmoidal nerves & vessels
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Orbital Fascia
Eye lids
Covered in front with loose skin and behind with
conjunctiva.
Eye lids meets at medial and lateral canthi.
Fibrous framework is orbital septum, thickened at the
margins of lids to form tarsal plates.
Upper & lower eye lids
Layers (from superficial to deep)
1. Skin
2. Loose connective tissue
3. Orbicularis oculi – palpebral part
4. Tarsal plates
5. Tarsal glands
6. Conjunctiva
Orbital septum
Attached to margins of orbit forming palpebral fissure between eye lids.
Above and below the fissure form superior and inferior Tarsal plates.
At the medial end – medial palpebral ligament
At the lateral end – lateral palpebral ligament
Levator palpebral superioris is attached to superior tarsal plate.
Tarsal/meibomian glands embedded within tarsal plates
Lacrimal apparatus
Concerned
with secretion & drainage of tear fluid
Components-lacrimal gland & ducts, lacrimal canaliculi, lacrimal sac, nasolacrimal duct
Lacrimal gland
A serous gland situated in the lacrimal fossa
(in the upper lateral part of the orbit)
J shaped
Indented by the tendon of levator palpebrae
superioris
Has orbital part & palpebral part
Orbital part - large & deeper
Palpebral part - smaller & superficial
8-12small ducts drain the gland
Ducts open into superior Conjunctival fornix
secretions spread over the surface of the eye
lacrimal canaliculi drain tears to the lacrimal
sac via lacrimal papillae
Lacrimal sac lies in lacrimal groove formed by
the maxilla and lacrimal bone.
Nasolacrimal duct begins at lower end of
lacrimal sac
Naso-lacrimal duct opens into inferior Meatus
of nose.
Small accessory lacrimal glands are found in the conjunctival fornices
Supplied by lacrimal branch of ophthalmic artery& lacrimal nerve
secretomotor fibres from superior salivary nucleus which travel in greater petrosal nerve
pterygopalatine ganglion
Lacrimal nerve
Extra-ocular muscles Superior rectus
Muscles of the eye Inferior rectus
Intra-ocular muscles Medial rectus
Lateral rectus
Superior oblique
Mnemonic - LR6SO4 Inferior oblique
Extra-ocular muscles
Muscle Origin course insertion Innervations
Annular tendon
Lateral rectus -
(tendinous ring around To the sclera, anterior to
abducent (LR6)
4 recti the optic canal and the the equator of the
Other recti –
medial part of the eyeball
Oculomotor (CN3)
superior orbital fissure)
Tendon runs through
pulley in trochlear Sclera behind
Body of sphenoid
fossa. Then Equator. Below Trochlear (CN4)
Superior oblique (just above the
down, back, left superior, (SO4)
tendinous ring)
below & lateral recti
superior. rectus
Maxilla, lateral to Up, back, left, below Sclera behind equator,
Inferior oblique lacrimal groove Inferior rectus, deep between inferior and Oculomotor (CN3)
(medial side of orbit) to lateral rectus lateral rectus
Levator palpebrae
Superioris
Lesser wing of Anterior Surface of
superior tarsus, skin of
Lower – smooth Sphenoid Oculomotor (CN3)
eyelid, Upper margin of
muscles supplied by (apex of the orbit)
superior tarsus
internal carotid
venous plexus
superior rectus (turns up and in) +inferior oblique (up and out) = vertical upward movement
inferior rectus (down and in) + superior oblique (down and out) = vertical downward movement
Superior rectus + superior oblique = intortion
Inferior rectus + inferior oblique = extortion
II – optic nerve
Nerve of sight
Made up of axons of ganglionic layer of retina
Passes through optic canal to enter the middle cranial fossa
Enclosed in 3 meningeal sheaths
Relations:
1. Ciliary ganglion is between optic nerve & lateral rectus
2. Pierced by central artery of retina, inferomedially
3. Crossed inferiorly by the nerve to medial rectus
4. Crossed superiorly by ophthalmic artery, nasociliary nerve & superior ophthalmic vein
Ciliary ganglion
Lies at the apex of the orbit just lateral to optic nerve bet nerve and lateral rectus.
Has 3 roots.
Motor root – from nerve to inferior oblique (inferior branch of oculomotor)
They are Preganglionic parasympathetic fibers from Edinger Westphal nucleus
Supplies sphincter pupillae & ciliary muscle
Sensory root – branches of nasociliary nerve; supply eye but not conjunctiva.
Sympathetic root – from internal carotid plexus; vaso-constrictor fibers to vessels of eye.
Branches – short ciliary nerves which contain fibers from all 3 roots.
Supplies blood vessels & dilator pupillae
VI – abducent nerve
Arises from between pons & medulla
Passes forwards to enter cavernous sinus
Lies inferolaterally to internal carotid artery
Enters superior orbital fissure
Supply Lateral rectus (LR6)
Trigeminal nerve
Ophthalmic division
Zygomatic
Maxillary division
Infra-orbital
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Vessels of the orbit
Ophthalmic artery
Branch of internal carotid artery
Runs through optic canal inferolaterally to optic nerve within its Dural sheath.
In orbit the artery pierces the dura mater & crosses above the optic nerve from lateral to medial along with
nasociliary nerve anterior to it.
Terminates by dividing into supratrochlear & dorsal nasal branches
Branches
Central artery of retina - supply optic nerve and retina (Posterior ciliary capillaries supply the choroid coat of
eye, they also supply outer layers of retina but there is no anastomosis bet central artery and them)
Lacrimal artery
from main trunk (branches accompany all the branches of nasocilliary, lacrimal and frontal nerves)
i. Ciliary branches
ii. Supraorbital & supratrochlear
iii. Anterior & posterior ethmoidal
iv. Medial palpebral branches
v. Dorsal nasal
Establish connections between external and internal carotid systems.
Ophthalmic veins
Superior ophthalmic vein
Commences above the med palpebral ligament
Passes back above optic nerve
Drain to cavernous sinus via superior orbital fissure
Communicate with angular vein at its commencement.
Eye ball
Formed by segments of 2 spheres of different size – sclera-corneal junction
Anterior – transparent 1/6th – cornea
Posterior – opaque 5/6th – sclera
Optic nerve enters 3mm nasal to posterior pole
3 coats
1. Fibrous coat
anteriorly transparent cornea & posteriorly opaque sclera – sclerocorneal junction
Sclera
is tough
outer surface is covered by Tenon’s capsule
deep part of limbus contains canal of Schlemm
maintains shape of eyeball
receives insertion of extraocular muscles
posteriorly pierced by optic nerve
dura sheath continues
Cornea
avascular
layers
Epithelium
Basement membrane
Connective tissue
Descemet membrane
Endothelium
Cornea is supplied by
Short ciliary nerves
Long ciliary nerves
2. Vascular coat
consists of choroid, ciliary body and iris
Choroid
thin
pigmented
highly vascular
pierced by optic nerve
lines the inner surface of the sclera
anteriorly connected to iris by ciliary body
Iris
4 layers
i. anterior mesothelial lining
ii. connective tissue with pigment cells (few melanin granules)
iii. smooth muscle
iv. posterior pigmental cell layer (packed with melanin granules)
3. Neural coat
Retina
outer pigmented
Inner neural
Continuous with optic nerve
anterior pole is called ora serrata
posterior pole is called macula lutea
Central artery
Temporal Temporal
Upper Lower
Nasal Nasal
Lens
Biconvex obliteration of iridocorneal angle
Enveloped by lens capsule; an elastic membrane
between vitreous body & aqueous humor impaired reabsorption
more curved posteriorly
Anterior surface is kept flattened by the tension of suspensory ligament increased intra-ocular tension
Aqueous Humor GLUCOMA
filtered plasma
secreted into posterior chamber from vessels of iris & ciliary body
reabsorbed through canal of Schlemm
Clinicals
Oculomotor nerve paralysis
Ptosis – paralysis of levator palpebrae superioris
When the lid manually lifted up, eye is looking down and out - unopposed action of lateral rectus and superior
oblique
Diplopia (double vision)
When looking out diplopia disappears - lateral rectus intact
Pupil is dilated and doesn’t react to direct light reflex or accommodation - interruption of parasympathetic fibres
Consensual light reflex of opposite eye works.
Abducens nerve paralysis
Can’t look outwards - paralysis of lateral rectus
diplopia
Trochlear nerve paralysis
Can’t look downwards - superior oblique paralysis (patient complain of diplopia when reading or difficulty in
going downstairs
Extortion effect due to inferior oblique (to compensate extortion, patient tilts the head towards the opposite
shoulder)
Spinal segments
Spinal meninges
3 coverings
Dura mater, Arachnoid mater, Pia mater
Spinal nerves
Clinicals-
Lumbar Puncture
To obtain CSF
Spinal cord ends at lower border of L1
Subarachnoid space extends to the lower border of S2
Below 1st lumbar vertebrae can be used to do a lumbar puncture. Usually done between
4th/5th
Flexed position – open the space between adjoining laminae
Structures that are pierced,
o Skin
o Superficial fascia
o Supraspinous ligament
o Interspinous ligament
o Ligamentum flavum
o Areolar tissue with the internal vertebral venous plexus
o Dura mater
o Arachnoid mater sub arachnoid space
1) Longitudinal vessels
Two for each spinal segment in embryonic stage (one from each side)
Derived from various parent vessels depending on level
Vertebral
Costocervical
Posterior intercostal
Lumbar
Lateral sacral
In adult many segmental arteries are absent and the remaining ones
form anastomoses with ASA &PSA
Variable in number & position
Eg: Lower cervical
Lower thoracic
Upper lumbar
Arteria radicularis magna of Adamkiewicz - largest, arise from lower intercostal or upper
lumbar aortic branch on left side, unilateral, major supply to lower 2/3
Anastomotic connection deep to pia mater between ASA, PSA and radicular arteries are capable of
supplying peripheral areas of the spinal cord, hence the sparing of sacral regions of anterolateral
tracts and lateral corticospinal tracts in ASA interference.
Anterior & Posterior midline longitudinal veins and pair of longitudinal veins behind anterior and
posterior nerve roots
Basivertebral veins
Segmental veins
Internal structure
Nucleus dorsalis
Tract – Group of fibers in CNS that have common origin, course and termination
Nucleus – Group of nerve cells that have common cellular features and giving rise to fibers
that have common path, termination and function
Decussation – Fibers from right cross to left side and fibers from left cross to right
Ipsilateral – Fibers that enter spinal cord pass on the same side
Contralateral – Those who cross to opposite side
Ascending tracts
Dorsal column
o Fasciculus gracilis - Tract of Goll
o Fasciculus cuneatus – Tract of Burdach
Lateral column
o Lateral spinothalamic
o Anterior and posterior spinocerebellar
o Spinoreticular
Ventral column
o Anterior spinothalamic
o Spinotectal
o Spino-olivary
General arrangement
First order neuron (UMN) – Has cell body in the cerebral cortex. Axon descends to spinal
cord.
Second order neuron – Internuncial neuron situated in anterior gray column.
Third order neuron (LMN) - In anterior gray column. Innervates skeletal muscles.
- Originate primarily in the cerebral cortex and numerous sites within the brain
stem
- Control of the movements, muscle tone, posture, modulation of spinal reflexes
Lateral column
o Lateral corticospinal tract
o Rubrospinal tract
Ventral column
o Anterior corticospinal tract
o Vestibulospinal tract
o Tectospinal tract
o Reticulospinal tract
o Olivospinal tract
Most corticospinal fibers synapse with internuncial neurons, which, in turn, synapse with α
motor neurons and some γ motor neurons
Only the largest corticospinal fibers synapse directly with the motor neurons.
UMN lesion
Types of paralysis
Hemiplegia- paralysis of one side of the body
Monoplegia- paralysis of one limb
Diplegia- paralysis of 2 corresponding limbs
Paraplegia- paralysis of both legs
Quadriplegia- paralysis of all 4 limbs
Mid CN 3
brain CN 4 Mesencephalic
Pons CN 6
CN 7 Motor
CN 5
Main sensory
Medulla CN 8
CN 9
Spinal nucleus
CN 10 (NA, NTS, DNV)
CN 11
CN 12
Medulla oblongata
Gross appearance
Levels of olives
th
Section through the inferior part of 4 ventricle
Increased amount of gray matter is present at this level
Olivary nuclei complex
Nuclei of vestibulocochlear, glossopharyngeal, vagus, accessory, and hypoglossal nerves and the arcuate
nuclei
Vestibulocochlear nuclei
4 vestibular nuclei
o Medial vestibular nucleus o Lateral vestibular nucleus
o Inferior vestibular nucleus o Superior vestibular nucleus
2 cochlear nuclei
o Anterior cochlear nucleus
o Posterior cochlear nucleus
Nucleus ambiguus
Clinicals
Vascular disorders
Blood supply
Posterior inferior cerebellar artery (from vertebral artery)
Medullary artery (from vertebral artery)
Anterior inferior cerebellar artery (from basilar artery)
Pons
Gross appearance
Connects the medulla oblongata and midbrain
Anterior to cerebrum
Pons – “bridge” that connect right and left hemispheres
The anterior surface is convex from side to side
Shows many transverse fibers that converge on each side to form the middle cerebral peduncle
Shallow groove in midline – basilar groove, basilar artery is lodged there
Trigeminal nerve emerges from the anterolateral surface of pons
In the groove between medulla and pons the abducent, facial and vestibulocochlear nerves emerge
Posterior surface is covered from cerebellum
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It forms the upper half of the floor of the fourth ventricle and is triangular in shape
The posterior surface is limited laterally by the superior cerebellar peduncles and is divided into symmetrical
halves by a median sulcus
Internal structure
Pons is commonly divided in to
1. Tegmentum – posteriorly
2. Basal part – anteriorly
Internal structure of the pons is considered at 2 transverse levels
1. Transverse section through the caudal part, passing through the facial colliculus
2. Transverse section through the cranial part, passing through the trigeminal nuclei
Transverse section through the caudal part, passing through the facial colliculus
Medial lemniscus rotates as it passes from medulla to pons to the most anterior part of the tegmentum with
its long axis running transversely
The medial lemniscus is accompanied by spinal and lateral lemnisci
Transverse section through the cranial part, passing through the trigeminal nuclei
Pontine hemorrhage
The pons is supplied by the basilar artery and the anterior, inferior, and superior cerebellar arteries
3. paralysis of conjugate ocular deviation the abducent nerve nucleus and the medial
longitudinal fasciculus
1. the pupils may be “pinpoint” ocular sympathetic fibers
2. bilateral paralysis of the face and the limbs corticospinal fibers and facial nerve nucleus
Bilateral
Midbrain
Gross appearance
Connect the pons and the cerebellum with the forebrain
The midbrain is traversed by a narrow channel, the cerebral aqueduct
On the posterior surface are four colliculi, rounded eminences that are divided into superior and inferior pairs
by a vertical and a transverse groove
o Superior colliculus - centers for visual reflexes
o Inferior colliculus - lower auditory centers
The trochlear nerves emerge from the posterior surface of midbrain, below the inferior colliculi
The superior brachium passes from the superior colliculus to the lateral geniculate body and the optic tract
The inferior brachium connects the inferior colliculus to the medial geniculate body
Interpeduncular fossa - deep depression in the midline
It is bounded on either side by the crus cerebri
Many small blood vessels perforate the floor of the interpeduncular fossa - the posterior perforated substance
The oculomotor nerve emerges from a groove on the medial side of the crus cerebri
Midbrain
Vascular lesions of midbrain
Weber syndrome
Cause: Occlusion of a branch of a posterior cerebral artery
There is ipsilateral ophthalmoplegia – damaged medal
longitudinal fasciculus
Contralateral paralysis of the lower part of the face, the
tongue, and the arm and leg
The eyeball is deviated laterally
There is drooping (ptosis) of the upper lid and the pupil is
dilated and fixed to light and accommodation.
Benedikt’s syndrome
Similar to Weber syndrome
But the necrosis involves the medial lemniscus and red
nucleus
Contralateral hemianesthesia and involuntary movements
of the limbs of the opposite side
Lateral lemniscus superior olivary & trapezoid body →medial geniculate body
Note
Medial longitudinal fasciculus→ connect CN 3, 4, 6, 8
Applied neuroanatomy
Brainstem lesions
ipsilateral cranial nerve damage
contralateral hemiparesis
contralateral sensory loss in the body
Brainstem lesions
2. Sixty-year-old hypertensive female patient complains of imbalance& difficulty in speaking. She also complains of
nausea & vertigo. On examination she was found to have right sided palatal paralysis, loss of pain & temperature
sensation over the right side of the face. There were also positive cerebellar signs on the right side.
a) Where is the most possible site of the lesion?
b) What is the most possible cause?
c) Explain the above signs & symptoms
d) What other clinical features would you expect to find in this patient?
3. Draw & label a cross section at the trigeminal level of the pons to show the position of the ascending &
descending tracts (50 marks)
Give the commencement & the termination of these tracts (50 marks)
4. Draw a labeled diagram of the transverse section through the pons at the level of the facial nucleus (40)
On what anatomical basis would you differentiate between UMN lesion & LMN lesion of the facial nerve (20)
5. Draw & label a diagram of the midbrain at the level of inferior colliculus (30)
Describe the trochlear nerve from its origin to its termination (70)
T/F
1. Facial colliculus is formed by facial nucleus.
2. Facial nerve curves over the 6th cranial nerve to form facial colliculus.
3. Spinal lemnisci are most posterior in the lower part of the mid brain.
4. Trochlear nerve leaves the brainstem on its dorsal aspect.
5. Hypoglossal nerve leaves the brainstem between olives & inferior cerebellar peduncles.
~Spinal(SVE) Trapezius,
sternocleidomastoid
XII Hypoglossal(GSE) - Tongue muscles - Hypoglossal canal
Corticonuclear tract
Pyramidal cells (precentral gyrus) corona radiata genu of the internal capsule CN nucleus
Bilateral connections are present for all the motor nuclei except,
1. Part of the facial nucleus that supply the muscles of the lower part of the face
2. Part of the hypoglossal nerve that supply the genioglossus muscle
Therefore, unilateral corticonuclear lesions will not produce symptoms except in the above nerves.
Second order neuron – Cells and axons of the cranial nerve nucleus
Axons cross the midline and synapse with the thalamus/nuclei of termination/another sensory nuclei
Central processes of olfactory hair cells in the olfactory mucosa pass through the cribriform
plate to synapse with mitral cells in olfactory bulb.
Axons of mitral cells pass as olfactory tract to uncus (1ry olfactory cortex)
Fibers do NOT relay in thalamus
Bilateral anosmia – due to fracture of anterior cranial fossa associated with CSF rhinorrhea.
CN 2 - OPTIC NERVE
Fibers=axons of the ganglionic cells
Leave the eye at the optic disc (medial to the center- blind spot)
Fibers are myelinated. BUT by oligodendrocytes (comparable to CNS- a tract not a nerve)
Course
Intraneural
Courses anteriorly Through red nucleus
Exit from Anterior surface of mid brain
Intracranial
Exit between the 2 cerebral peduncles in the Inter peduncular fossa,
Between superior cerebellar & posterior cerebral arteries
Crossed by posterior communicating artery
Runs along the free edge of tentorium cerebelli
Enters the Middle cranial fossa
Runs in the Lateral wall of the cavernous sinus (above CN 4)
Divides into superior & inferior divisions
Enters the Orbit through middle part of the superior orbital fissure (SONIA)
Distribution
Motor –superior division (+sympathetic)
1. superior rectus
2.levator palpebrae superioris
Superior cervical ganglion → Postganglionic sympathetic fibers → Internal carotid cavernous plexus →
Superior division of oculomotor nerve → Smooth muscle part of the LPS (Muller muscle)
Parasympathetic fibers
motor fibers
Most slender CN
Only CN to leave the posterior surface of the brain stem
Nuclei- Trochlear nucleus
Anterior part of the grey matter around cerebral aqueduct
At the level of the inferior colliculus
Connections → Cor conuclear fibers from both hemispheres
→medial longitudinal fasciculus
→visual cortex
Course
Intraneural
1. Posteriorly around grey matter
Intracranial
1. Exit from Dorsal aspect of the mid brain
2. Decussate (attached to superior
medullary velum)
3. Courses Ventrally around the superior
cerebellar & cerebral peduncles
4. Between superior cerebellar &
posterior cerebral arteries
5. Runs in the Lateral wall of the
cavernous sinus (b/w CN3 & CN51)
6. Crosses over CN 3
Extracranial
1. Orbit through lateral part of the superior
orbital fissure (LFT) Distribution -Superior oblique
muscle (turns eye downwards & laterally)
2. in the orbit lies medial to the frontal nerve on
Superior oblique
Clinical
Diplopia on looking downwards
Extortion effect
Main sensory-
-posterior part of pons
-lateral to the motor nucleus
-continues with spinal nucleus
touch & pressure
Spinal-
-continues -superiorly with main sensory nucleus
-inferiorly with substantia gelatinosa of the spinal cord
-extent: whole length of medulla oblongata and inferiorly to the C2 segment of spinal cord
-pain & temperature
Mesencephalic—
midbrain –proprioception from
1)Muscles of mastication
2) Facial muscles
3) Extraocular muscles
These fibres bypass trigeminal nucleus (They are dendrites of unipolar cells)
Motor-
-pons, medial to main sensory
nucleus -Supply: - muscles of
mastication
-anterior belly of Digastric
-mylohyoid
-tensor veli palatini & tensor tympani
Course-
Leaves the anterior aspect of the pons as a small motor root & a large sensory root
Trigeminal ganglion
Lateral wall of cavernous sinus, inferior to Trochlear nerve & superior to maxillary nerve
post.ethmoidal
infratrochlear ant.ethmoidal
foramen rotundum
zygomaticotemporal
infraorbital foramen
face
sensory root to
pterygopalatine ganglion
Fuse to form main trunk which lies in infratemporal fossa on the tensor veli palatini,
Sensory to deep to lateral pterygoid
buccinator Meningeal (nervus spinosus) medial pterygoid
(only sensory branch)
nerve to medial pterygoid Tensor veli
Buccal
otic ganglion palatine &
Tensor tympani
masseteric
CLINICALS
Motor div. –by asking the patient to clench his teeth & feeling for the contracting masseter.
& asking the patient to move the jaw from side to side
TRIGEMINAL NEURALGIA
Sensory root is divided preserving fibres of the ophthalmic div. to avoid damage to the cornea.
Lingual nerve can be damaged in extracting the malplaced wisdom tooth as the nerve lies in
contact with the medial surface of the 3rd molar tooth.
Intracranial
1. Longest intracranial course
2. Ascend on the clivus in the pontine cistern
3. Sharp bend over the superior surface of the petrous temporal bone(crosses apex of petrous
temporal bone
4. Runs anteriorly Through cavernous sinus (inferolateral to internal
carotid artery)
Extracranial
1. Orbit →middle part of the superior orbital fissure (inferolateral to CN 3 & nasociliary) (SONIA)
2. Enter the ocular surface of the lateral rectus muscle
Clinical
Complete paralysis
1. Medial (convergent) squint
2. Diplopia
False localizing sign in raised intra cranial pressure
Due to
1. long course
2. Sharp bend over petrous temporal bone
-Downward shift of brainstem due to raised intracranial pressure
Accommodation reflex
When eyes are directed from a distant to near objects
1. Medial recti contract -Occular axis converge
2. Ciliary muscle contract -Lens thickens & refractive power increases
-direct light waves to the thickest central part of the lens
3.Pupils constrict 1. Optic nerve
2. Optic chiasma
3. Optic tract
4. Lateral geniculate body
5. Optic radiation
6. Visual cortex
7. Eye field of the frontal cortex
● CN 3 nucleus →medial rec
● Edinger-Westphal nucleus of both sides
CN 3
Ciliary ganglion
Short cilliary nerves
Constrictor pupillae & ciliary muscle
Corneal reflex
Light touching of cornea results in blinking of the eye (V1→MLF→VII)
Trochlear nerve
nuclei-
3. Main motor
lacrimatory
2. Parasympathetic in pons
sup. Salivatory
3. Sensory - NTS
Main motor
–lower part of the pons (at the level of facial colliculus)
•Part of nucleus that controls the muscles of lower half of the face receive corticonuclear fibres only
from contralateral cerebral hemisphere.
•Upper part from both cerebral hemispheres.
Lesion 1
Lesion 2
Parasympathetic--
same level
-fibers from hypothalamus
Sensory-
Taste- anterior 2/3 of tongue
Floor of mouth
Palate
Taste sensation travels through axons of cells situated in geniculate ganglion. (1st order)
Central processes synapse on cell bodies of NTS.
Efferents (2nd order neurons) from NTS cross the medial plane and ascend to VPM nucleus to
thalamus.
From the thalamus fibers (3rd order neurons) pass through internal capsule, corona radiata
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to taste area of cortex.
NTS VPM of
Lingual Chorda Facial thalamus
nerve tympani nerve
Tongue Geniculate cortex
Course- ganglion
Intracranial-
-Consists of motor & sensory root
-motor fibers travel posteriorly around the medial side of the abducent nucleus. (facial colliculus)
-sensory root + parasympathetic root-Nervus intermedius
Emerges through Ponto medullary junction (CP angle)
below the canal for lateral semicircular canal Crosses the neck of the
malleus & pars flaccida of
bend downwards at the posterior wall of tympanic cavity tympanic membrane in the
middle ear
vertically downwards medial to aditus
nerve to stapedius Corda tympani(6mm above
exit from the stylomastoid foramen styomastoid foramen)
posterior auricular, occipitalis
temporofacial cervicofacial
Clinical notes
SYMPTOMS SITE OF LESION
Internal strabismus Pons
Hearing loss IAM
Loss of lacrimation Facial canal before geniculate ganglion
Hyperacusis Facial canal before giving nerve to stapedius
Loss of taste in ant. 2/3 of tongue + lack of salivation Facial canal before giving corda tympani
Paralysis of muscles of facial expression extracranial
VESTIBULAR
MLF
COCHLEAR
CP angle
Parotid gland
Between the internal jugular vein & the internal carotid artery carotid branch (carotid sinus)
Between internal & external carotid arteries pharyngeal branches pharyngeal plexus
Clinicals
Clinical testing
gag reflex - on tickling the posterior wall of the pharynx there is reflex contraction of
pharyngeal muscles
testing the taste sensibility of the posterior 1/3 of the tongue
Course
Between olives & inferior cerebellar peduncles
Through the middle part of the jugular
foramen anterior to C.N 11
Joined by the cranial part of accessory
Nuclei
1. Nucleus ambiguus
2. Spinal nucleus (lateral part of the anterior grey column-C1-C5)
Cranial root
B/w olives & inf cerebellar peduncle (posterolateral sulcus)
Unite with the spinal root
Middle part of the jugular foramen
Separate from the spinal root
Fuse with Vagus below inferior ganglion
Distributed through its branches to palate, pharynx, larynx
Spinal root
B/w ventral & dorsal roots of spinal cord up to C5
Enters the cranium through foramen magnum
Unite with the cranial root
Middle part of the jugular foramen
Separate from the cranial root
Descend b/w internal jugular vein & internal carotid artery
Deep to styloid process
Deep to sternocleidomastoid
Pierce the posterior border of it near its middle
Enter the posterior triangle
Pass deep to ant border of trapezius 5cm above clavicle
Supply sternocleidomastoid & trapezius
Clinical
Ask the patient to shrug the shoulders against resistance
Ask the patient to turn the chin to opposite side against resistance
Outer cortex
Intracerebellar nuclei:
Basilar artery
Superior cerebellar artery
Anterior inferior cerebellar artery
Posterior inferior cerebellar artery
Cerebellum has no direct neuronal connections with the lower motor neurons, but exerts its influence
indirectly through the cerebral cortex and brainstem.
CLINICALS
Signs & symptoms are limited to the same side of the body.
1. Hypotonia
2. Postural changes & alterations of gait
3. Ataxia- disturbance of voluntary movement.
-Decomposition of movement.
(Muscle groups fail to work harmoniously)
-Past pointing with gross corrections.
4. Dysdiadochokinesia-inability to perform alternating movements regularly and rapidly
5. Disturbance of reflexes
-pendular knee jerk
6. Disturbance of ocular movements
Nystagmus-rhythmical oscillation of eyes
7. Disorder of speech-Dysarthria(slurred speech)
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THE CEREBRUM
Diencephalon – central core
Divided into 2 parts Telencephalon – cerebral hemispheres
The largest part of the brain, Situated in the anterior and middle cranial fossae
Developed from the forebrain
Each hemisphere has a covering of gray matter, the cortex and internal masses of gray matter, the basal nuclei,
and a lateral ventricle
Cerebrum
Diencephalon
Extent – from interventricular foramen of Monro to commencement of cerebral aqueduct.
Inferior surface – anterior to posterior – optic chiasma, infundibulum with tuber cinereum, mammillary
bodies
Superior wall – roof of 3rd ventricle
Lateral wall – internal capsule
Medial wall – thalamus, hypothalamus (lateral wall of 3rd ventricle)
Relations
● Anterior - Interventricular foramen of Monroe
● Posterior - Forms pulvinar which overhangs superior colliculus
telachoroidea, fornix
choroid plexus of lateral ventricle
● Superior -
body of the caudate nucleus (thalamus forms part of the floor of the body of lateral
ventricle)
Hypothalamus
● Inferior - tegmentum of mid brain
3rd ventricle
● Medial - interthalamic connection (gray matter)
internal capsule
● Lateral - lentiform nucleus
● Poster superiorly - Epithalamus (pineal gland + 2 habenular nuclei)
3rd ventricle
Slit like cleft between 2 thalami
Anterior wall – lamina terminalis with anterior commissure
Posterior wall – opening of cerebral aqueduct,
posterior commissure
pineal recess
habenular commissure
Roof – ependymal + telachoroidea,
Choroid plexus of 3rd ventricle,
More above - fornix & corpus callosum
Floor – optic chiasma,
Tuber cinereum
infundibulum
mammillary bodies
cerebral peduncles
tegmentum
Lateral wall – thalamus
hypothalamus
Communicate,
o Anteriorly – lateral ventricle (via interventricular foramen)
o Posteriorly – 4th ventricle (via cerebral aqueduct)
Regarding the thalamus
Relations
● Anterior - optic chiasma
lamina terminalis
anterior commissure
● Posterior - tegmentum of the mid brain
● Superior - thalamus
● Inferior - optic chiasma
tuber cinereum & infundibulum
mammillary bodies
● Medial - 3rd ventricle
Hypothalamo - hypophyseal tract
Supraoptic nucleus - Vasopressin
Paraventricular nucleus - oxytocin
Clinical syndromes of hypothalamus
Carried by axons to the pituitary
Obesity/wasting
Hypophyseal portal system Sexual disorders
Carries releasing & release inhibitory hormones to the pituitary Sleep disorders
(GnRH, GHRH, GHIH)
Hyperthermia/hypothermia
Formed by the superior hypophyseal artery of the internal carotid
Diabetes insipidus
Epithalamus
consists of the habenular nuclei and the pineal gland
Subthalamus
Lies inferior to the thalamus
Superior to the tegmentum of the mid brain
Frontal lobe
o Precentral area
Primary motor area (4) -
carry out the individual
movements of different
parts of the body
Premotor area, secondary
motor area - store
programs of motor activity
assembled as the result of
past experience
o Frontal eye field - control
voluntary scanning
movements of the eye and
is independent of visual
stimuli
o Motor speech area of Broca
- formation of words by its
connections with the
adjacent primary motor
areas
o Prefrontal cortex - the
makeup of the individual's
personality
Parietal lobe
o Primary somatic sensory
cortex (SI)
o Secondary somesthetic area
(SII)
o Somesthetic association
area–stereognosis
Occipital lobe
o Primary visual area (17) -
afferent from LGB
o Secondary visual area (18) -
relate the visual information
received by the primary visual area to past visual experiences, thus enabling the individual to recognize and
appreciate what he or she is seeing
o Occipital eye field - reflex and associated with movements of the eye when it is following an object
Temporal lobe
o Primary auditory area (41, 42)
o Secondary auditory area (22) – interpretation of sounds and for the association of the auditory input with
other sensory information
o Sensory speech area of Wernicke - permits the understanding of the written and spoken language and
enables a person to read a sentence, understand it, and say it out loud.
1. Caudate nucleus
Separated almost entirely by the internal capsule
2. Lentiform nucleus
I. Globus pallidus
II. Putamen
3. Amygdaloid nucleus
4. Claustrum
Lentiform nucleus
Corpus Striatum
Caudate nucleus
Caudate nucleus
C shaped
Closely related to lateral ventricle
Lateral to thalamus
Laterally internal capsule
Lentiform nucleus
wedge shaped
Medially – internal capsule –
separates it from caudate nucleus
and thalamus
Laterally – external capsule –
separates it from claustrum
Parkinson’s disease
1. Resting tremor (pill rolling tremor)
2. Lead pipe rigidity (cogwheel, plastic)
3. Bradykinesia (slurred speech,
expressionless face, can’t initiate
movements)
4. Postural instability (Shuffling gait)
Commissural fibers
1. Corpus callosum- At the
bottom of the longitudinal
cerebral fissure
2. Anterior commissure-
Rostrum (continuous with
the lamina terminalis)
3. Posterior commissure
4. Hippocampal
commissure - Genu, body,
splenium
5. Fornix – from
hippocampus to
mammillary bodies
Blood supply
1. Middle cerebral artery- medial & lateral striate central branches
2. Anterior cerebral artery- central branches
3. anterior choroidal artery
Anterior limb: middle cerebral artery (superior half) & anterior cerebral artery (inferior half)
Genu: middle cerebral artery
Posterior limb: middle cerebral artery (superior half) & anterior choroidal artery of the internal carotid artery
(inferior half)
Lesions
Cause: high blood pressure
Even a small lesion causes severe damage
contralateral hemiparesis or hemiplegia
Supplied by the
2 internal carotid arteries
2 vertebral arteries
Ophthalmic Artery
Middle Cerebral Artery
Largest branch
Supplies;
Internal Carotid Entire lateral surface of hemisphere
(except the part supplied by anterior
cerebral artery)
All the parts of the Internal capsule
via lateral & medial striate arteries
Lentiform and Caudate nuclei
Vertebral Artery
Vertebral arteries are major arteries of the neck
branch of 1st part of the subclavian artery
Ascends through foramen transversarium of upper 6 cervical vertebrae (not through C7)
Grooves the superior surface of posterior arch of atlas
Enters the skull through Foramen Magnum
Pierces dura and arachnoid maters to enter the sub arachnoid space (cerebellomedullary cistern)
2 vertebral arteries join up to form the Basilar Artery at the lower border of Pons.
Basilar Artery
Ascend in a groove on the anterior surface of the Pons (pontine cistern)
Pontine Arteries
Supplies;
Basilar Artery Pons
Labyrinthine Artery
Accompany Facial & Vestibulo-Cochlear
nerves to Internal Acoustic Meatus
Supplies;
Inner ear
Medulla Pons
Vertebral artery Basilar artery
Ant. and post. spinal arteries Anterior inferior cerebellar
Posterior inferior cerebellar artery artery
Basilar artery Superior cerebellar artery
Cerebellum
Mid brain Anterior inferior cerebellar
Basilar artery Circle of Willis artery
Superior cerebellar artery (Regions supplied) Posterior inferior cerebellar
Posterior cerebral artery artery
Superior cerebellar artery
Anterior cerebral artery occlusion – Contralateral Hemiparesis & hemi-sensory loss involving leg & foot.
Middle cerebral artery occlusion – Contralateral Hemiparesis & hemi-sensory loss involving face & arm (+
Aphasia if left-sided lesion) (legs are spared)
Posterior cerebral artery occlusion – Contralateral Homonymous Hemianopia with macula sparing due to
collateral supply from middle cerebral artery.
Aneurysms in posterior communicating artery can compress oculomotor nerve (surgical oculomotor nerve
palsy)
Occlusion of the posterior inferior cerebellar artery (PICA) or vertebral artery causes Lateral Medullary
Syndrome (of Wallenberg)
Occlusion of the medullary branch of vertebral artery (or anterior spinal artery) causes Medial Medullary
Syndrome
Affect the Hypoglossal nerve, Medullary Pyramids and Medial Lemniscus
Occlusion of a branch of the posterior cerebral artery that supplies the midbrain causes Weber syndrome
Ipsilateral occulomotor nerve palsy
Contralateral hemiparesis
Lateral ventricle
3rd ventricle
Slit like cleft between the 2 thalami
The interthalamic adhesion runs through the ventricle
Communicate with the lateral ventricles anteriorly by the interventricular foramen (of Monroe)
Communicate with the 4th ventricle posteriorly by the cerebral aqueduct of Silvius
Cerebral aqueduct
Narrow channel which connects the 3rd ventricle with the 4th ventricle
No choroidal plexus
FORMATION
From choroid plexus of the
ventricles
CLINICAL NOTES
1. Papilledema
Intracranial subarachnoid spaces extend forward around the optic nerve
High CSF pressure compress the retinal wall → bulging forward of the op c disk causes edema of
the disk
2. Hydrocephalus - abnormal increase in the volume of CSF within the skull
Communicating hydrocephalus – due to obstruction of interventricular foramen or cerebral
aqueduct by tumors
Non-communicating hydrocephalus – due to increased formation or decreased absorption of CSF
Sympathetic Parasympathetic
Autonomic ganglia
Basic structure
I. greater splanchnic (5-9 II. lesser splanchnic (9-11 III. least splanchnic
thoracic ganglions) thoracic ganglions) nerves (12th thoracic
It descends and pierces the crus It descends with the greater ganglion)
of the diaphragm to synapse with splanchnic nerve and pierces the The least splanchnic nerve (when
the ganglia of the diaphragm to join with the ganglia present) pierces the diaphragm,
i. celiac plexus in the lower part of the celiac and synapses with the ganglia of
ii. renal plexus plexus. the renal plexus
iii. suprarenal medulla.
Ganglion impar
Afferent →Without synapsing in ganglion via white rami communicans → Posterior root ganglion
(myelinated)
afferent component of local reflex arc Central axons
Supra-renal medulla
A few preganglionic fibers, traveling in the greater splanchnic nerve, end directly on the cells of the
suprarenal medulla. These medullary cells, which may be regarded as modified sympathetic excitor
neurons, are responsible for the secretion of epinephrine and norepinephrine.
The sympathetic chain continues upwards from thorax by crossing the neck of the first rib
Then ascends embedded in the posterior wall of the carotid sheath to the base of the skull
No white rami communicans from cervical part of sympathetic chain
Preganglionic fibres origin from lateral grey horn of T1-T4 & ascend to the cervical ganglia.
3 ganglia –Superior, Middle, Inferior
Superior cervical ganglion (fusion of C1-C4 ganglia)
Largest
Lies opposite C2 and C3 vertebrae
Sends grey rami communicans to C1-4 spinal nerves
Middle cervical ganglion (fusion of C5-C6 ganglia)
Lies level with C6 vertebra
Sends grey rami to C5 and 6 nerves
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Inferior ganglion (fusion of C7-C8 ganglia)
Lies level with C7 Tucked behind the vertebral artery
Frequently fuses with the first thoracic ganglion to form stellate ganglion at the
neck of the first rib.
Grey rami pass from it to C7 and 8 nerves
SYMPATHETIC PARASYMPATHETIC
Action Prepares body for emergency Conserves & restores energy
Outflow T1 - L2(3) Cranial nerves III, VII, IX, & X;
S2,3 & 4
Preganglionic fibres Myelinated B Myelinated B
Ganglia Paravertebral (sympathetic trunks), Small ganglia close to viscera
prevertebral (ex: celiac, superior (eg: otic, ciliary) or ganglion cells
mesenteric, inferior mesenteric) in plexuses
(eg: cardiac, pulmonary)
Neurotransmitter within ganglia Acetylcholine Acetylcholine
Postganglionic fibres Long non-myelinated C Short non-myelinated C
Characteristic activity Wide spread due to many post-ganglionic Discrete action with few post
fibres & liberation of epinephrine & ganglionic fibres
norepinephrine from supra renal medulla.
Neurotransmitter at postganglionic Norepinephrine at most endings & Acetylcholine at all endings
endings acetylcholine at few endings (sweat glands)
Higher control Hypothalamus Hypothalamus
Large collections of sympathetic and parasympathetic efferent nerve fibers and their
associated ganglia, together with visceral afferent fibers, form autonomic nerve plexuses.
Thorax
1. Cardiac plexus
Sympathetic – cardiac nerves, fibers from upper thoracic ganglia
2. Pulmonary plexus
Parasympathetic – vagal fibers
3. Esophageal plexus
Abdomen
1. Coeliac plexus Sympathetic – Greater, lesser, least splanchnic nerves, upper two
2. Superior mesenteric plexus lumbar splanchnic nerves
3. Inferior mesenteric plexus Parasympathetic – vagal fibers (coeliac branch of posterior gastric
nerve)
The postganglionic fibers arise from the peripheral plexuses and are distributed to the
smooth muscle and glands of the viscera.
Submucous/Meissner plexus between mucous membrane and control of the glands of the
circular muscle layer mucous membrane
Due to interruption of the sympathetic nerve supply to the head and neck.
Causes
- Lesion in the brain stem or cervical part of the spinal cord- damage to the descending tracts from
hypothalamus (Reticulospinal tract)
3. Frey’s syndrome
– Nerves will supply the sweat glands instead of the salivary tissue (sweating at the time of salivation)
– Nerves will supply the lacrimal gland instead of submandibular and sublingual (tearing with salivation)
called crocodile tears
4. Hirschsprung’s disease
– Aganglionic segment in the colon
– No peristalsis
– Proximal colon distended
5. Vagotomy
– Delayed gastric emptying
– Diarrhoea
In all the following ganglia only the parasympathetic fibers are relayed.
1. CILIARY GANGLION
Location: - Near the apex of the orbit. Between the optic nerve & the tendon of the lateral rectus
Topographically - related to optic nerve
Functionally - related to oculomotor nerve
Parasym. root
Sensory root Sympathetic root
Edinger Westphal
nucleus Trigeminal nerve Sup. cervical
ganglion
Oculomotor nerve
Inferior division
Ciliary
Ganglion
Short ciliary
nerves
Dilator pupillae&
Sphincter blood vessels
pupillae & eyeball (vasomotor)
Ciliaris
Parasympathetic root
Inferior Salivatory
nucleus
Tympanic plexus
Mandibular nerve External carotid plexus (middle meningeal artery)
Lesser petrosal
nerve
Auriculotemporal
nerve Nerve to Medial
Pterygoid
(Middle Cranial
cavity) Tensor veli
palatini &
Tensor tympani
Auriculotemporal
Parotid gland
Nervus Intermedius
Maxillary nerve Nasal branches
{ Medial posterior superior
Facial nerve nasal nerves ( largest one
Sensory roots called nasopalatine nerve ) and
Lateral posterior superior
nasal nerves }
Geniculate ganglion
Nerve of
pterygoid canal Pharyngeal branches
Zygomaticotemporal
Postganglionic fibres
nerve
Superior cervical
ganglion Lacrimal nerve Lacrimal gland
Sympathetic root
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4. SUBMANDIBULAR GANGLION
● Topographically related to Lingual nerve
● Functional component of Facial nerve (Chorda tympani branch)
● Location :- Lies on the Hyoglossus muscle,
Chorda tympani
Lingual nerve External carotid plexus
(facial artery)
Lingual nerve
Submandibular gland
a) Supplies the sphincter pupillae muscle through its zygomatico temporal fibres
b) Supplies secretomotorfibres for the lacrimal gland
c) Gives passage to sympathetic fibres
d) Distributes secretomotorfibres to the glands of the nose, palate and nasopharynx
e) Receive fibres from the maxillary nerve
Chemical transmitters
Shows ductless secretion into blood/interstitial fluid
Act on target organs distant or nearby
Has specific receptors
Regulate cellular activities in multiple places simultaneously
Maintains homeostasis
Hormones
Most hormones in the body Gonadal hormones Thyroid, adrenal medullary hormones
Anterior & Posterior pituitary Adrenocortical hormones Epinephrine, NE
Hormones, Insulin, Glucagon
PTH
Synthesis
RER Golgi Packed to from cholesterol Derivatives of tyrosine
vesicles Exocytosis By SER
Storage
As prohormone in the Are not stored Thyroid-Bound to thyroglobulin in
secretory granules follicles
Catecholamine-in the secretory
granules
Secretion
Exocytosis diffuse through the Thyroid- first pinocytosis then
(Ca2+/cAMP dependent) membrane diffuse through membrane
Catecholamine-Exocytosis
Transport
Dissolved in plasma Bound to plasma protein Thyroid - Bound to plasma
(Biologically active) (Biologically inactive, TBG (biologically inactive)
Only free form is active) Catecholamine - Dissolved in
plasma (Biologically active)
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Receptors & Activation Systems
Ion-channel
linked
G-protein
Cell membrane receptors
linked
Enzyme
Receptors linked
Within
cytoplasm
Intracellular receptors
Within
nucleus
Ion-Channel Linked Receptors
Messenger binds to receptor
Influx of ions
α subunit dissociates
JAK2 phosphorylation also activates several other enzyme systems leading to more rapid effects of leptin
Cellular response
Receptor molecules
inactivated
Inactivation / Clearance
1. Metabolic destruction by the tissues
2. Binding with the tissues
3. Excretion by liver (Bile) or kidney (urine)
Ultradian rhythm –
Episodic/ pulsatile secretion in repeated cycles within 24 hrs. e.g. – Growth hormone
Circadian rhythm –
Secretion following day & night cycles (responding primarily to light & darkness) e.g. – Cortisol, melatonin
Infradian rhythm –
Periods longer than 24 hr cycles. E.g. – FSH, LH, Estrogen
1. Radioimmunoassay (RIA)
A known quantity of antibody specific to the above antigen is added to the assay
Antigens present in the sample is bound with the antibodies in the assay
It displaces radiolabeled antigens from the antibodies, making them 'free' antigens
The 'free' antigens are separated from the assay and measured
The absorbance or fluorescence or electrochemical signal (e.g., current) of the plate wells is measured
to determine the presence and quantity of antigen.
Specific Antibody
Primary afferents/ first order neurons (receptor to the second order neuron)
- Sensory fibers from head area (trigeminal) join the anterolateral and lemniscal systems
in the brain stem
- Rest of the body – along spinal nerves
Secondary afferents/ second order neurons (along ascending tracts of the spinal cord t o
Dorsal horn acts as a ‘gate` - Action potentials in sensory nerve fibers translated into
Action potentials in ascending tracts; passage dependent on the nature and pattern
of impulses – modified by the inputs from the descending tracts
- First order neurons synapse with second order neurons in the dorsal horn
- Second order neurons cross the midline and ascend in the ventral spinothalamic tract
- Synapse in the thalamus – third order neurons to sensory cortex
- First order neurons synapse with second order neurons in the dorsal horn
- Second order neurons cross the midline and ascend in the lateral spinothalamic tract
- Synapse in the thalamus – third order neurons to sensory cortex
Lateral spinothalamic tract – Pain and temperature – discrete pathways in the tract
Descending Tracts
Motor Unit
− Components - each single motor neuron and all the muscle fibers innervated by it
− The number of muscle fibers in a motor unit varies (muscles concerned with
fine movements - lesser number of fibers for each motor neuron and vice
versa
Idea and complex plan (memory, emotions, motivation etc…. Areas - supplementary
and association cortex……)
Pyramidal tracts
All pyramidal fibers converge from the surface of the brain like a fan - corona radiata
These come down and join together to form the internal capsule at the level
of the thalamus
Some fibers are densely packed in the internal capsule, lesions in this region
produce dense weakness (paresis) of the contralateral side
Pyramidal tracts start crossing to the opposite side at the level of medulla
Rubrospinal tract – lateral Excites the flexors and inhibit the extensors
Reticulospinal tract
Sensory Receptor
Specialized dendritic endings of afferent nerve fibers which convert various forms of energy into
action potentials in sensory neurons.
Sensory Organ
Sensory receptors and associated non-neural cells that surround them
Adequate stimulus
The particular form of energy to which a receptor is most sensitive
Almost not sensitive to the normal intensities of other forms of energy.
Chemo R
Nociceptors
Thermal R
(Pain-Temp)
Mechano R
Polymodal R
b) Adequate stimulus
Is the type of energy that a receptor is most sensitive?
Receptors has a very high threshold for other modalities while lowest threshold is
for the adequate stimulus
a) Law of projection
• The sensory pathway extends from the receptor to the cortex
• If we stimulate anywhere along this pathway
• The conscious sensation produced is always referred to the location of the receptor
4. Identifying Duration
As long as the AP come to the brain
Adaptation represses AP & decreases duration
Cortical plasticity
• When a stimulus of constant strength is applied to a receptor, the frequency of action potential
generation decreases over time
Degree of adaptation
Pain: Unpleasant
Emotional
Withdrawal
Treatable
Pain Afferents:
Aδ & C
Lateral spinothalamic tract S1
S11
Cingulated gyrus, Cerebellum, Insular cortex, Amygdala, PAG,
Reticular formation
Pain types
Inflammatory pain
• Due to tissue damage
• Chemical mediators like bradykinin, cytokines, and prostaglandins are released
• They act on pain receptors and dorsal horn, producing
REFERRED PAIN
• Irritation of a viscus or a deep somatic structure produces pain perception in another distant
somatic area
E.g.: -
O Myocardial pain is referred to the arm and neck (T1-T4)
O Pain in the knee joint is referred to the hip joint
O Subdiaphragmatic → p of shoulder (C3-C5)
O Ureter → tes s
O Appendix/ SI → Paraumbilical (T10)
2. Convergence of peripheral and visceral pain fibers on the same second order neuron. (In the
dorsal horn)
• Somatic pain is more common than visceral pain
• Brain has learnt that impulses coming in this pathway as produced by the somatic structure
• When the visceral pain fibers discharge, the brain cannot differentiate
• And identifies as coming from the somatic structure
• And also, pain can be referred to scars in that dermatome
3. Also, visceral pain may facilitate the firing of the somatic nerve ending
which in turn stimulate the 2nd order neurons.
Thus, brain identifies it as coming from the somatic fibers .
Stimulation of periaqueductal grey matter (PAG) (by higher centers and by pain conducting C fibers via
Hypothalamus) in mid brain activates Enkephalin releasing neurons that project to,
Serotonin Catecholaminergic/noradrenergic
E.g.:-
O Rubbing on the site of pain
O Acupuncture
O Psychological factors
Release of opioids
• Opioids are peptides
• Endogenous opioids are
enkephalin and endorphin
• Exogenous opioids are morphine,
pethidine… etc.
• They bind to opioid receptors
• Opioid receptors are produced in
dorsal root ganglia cells
• And transported centrally and
peripherally along their nerve
fibers
Morphine→ Descending tr.→ IN
→ Opioids
Psychological methods
• Distraction
• Stress analgesia
Other
• Aspirin (NSAIDs) and paracetamol
• Cannabinoids
• NMDA antagonists
• TRPV1 receptor antagonists
• TENS
SPECIAL SENSATIONS
Itch (Pruritus)
• Due to repeated local mechanical stimulation
• Chemicals involved are kinins, histamines (antihistamines reduce pruritus)
• Specific receptors are present
• Pathway – spinothalamic tract, thalamus and cortex
• has an emotional component
• Itching ↑ - CKD, Atopic dermis HIV, Hepatic diseases.
Tickle
• Due to repeated light touch
Synthetic Sensations
Vibration
• Stimuli – A pattern of rhythmic pressure stimuli
• Pacinian corpuscles – fast vibration Meissner’s corpuscles – slow vibration
• Pathway – dorsal column, thalamus, cortex
• Tested by using 128 Hz tuning fork to the skin of fingertip, tip of toe or a bony prominence
• Loss of vibration (associated with proprioception) is an early sign of degeneration of dorsal
columns. (Buzzing sensation)
• Ability to feel vibration; Pallesthesia
• E.g.:- DM, Pernicious anemia (vit B12)
Stereognosis
• Ability to identify objects by handling without looking at them
• Touch, pressure and large cortical component
• Affected when dorsal column or parietal cortex is damaged
Sensory cortex
Primary sensory Cortex (SI) – Post central gyrus
Secondary sensory cortex (SII) – Walls of sylvian
fissure SI projects to SII
Sensory homunculus
Thalamic projections are arranged representing body parts
Legs on the top and head at the foot of the gyrus
Size of the cortical area proportional to the number of receptors in the part (large area for
hand)
Face bilaterally represented
Cells are arranged in vertical columns responding to specific sensory modality from a
particular region
Information mainly from opposite side of the body
Premotor cortex
- Sets posture at the start of a movement (mainly proximal muscles)
- Organized somatotopically
- Projects into brain stem, motor cortex, descending motor pathways
Damage to small area of the motor cortex results in taking over the function of that area by the
adjacent undamaged cortex with return of function
Reflex: an automatic response to a stimulus occurring by a relatively simple neuronal network. (Reflex arc)
Reflexes
A) Monosynaptic reflexes B) Polysynaptic reflexes
Reaction time – time between the application of the stimulus and response. (20-24ms)
Central delay – Time taken for the reflex activity to transverse the spinal cord. (0.6-0.9ms)
Intrafusal
fibers
nuclear chain
Nuclear bag
(static)
Dynamic Static
II (many)
Ia (single)
Static
Dynamic Static
Dynamic Static
Dynamic response: very sensitive for velocity, speed information, quick connective movements.
Static response: steady, state length information.
Antagonist relaxes
Increase in sensitivity of
Collaterals of α-γ linkage
muscle spindle
Spontaneous γ discharge
discharge keeps
the muscle tone
Increased by
o Anxiety
o Stimulation of skin by noxious agents
o Jendrassik’s maneuver
o Descending fibers from
Reticular facilitatory area (Pons)
Vestibular nuclei
Decreased by
o Descending fibers from
Motor cortex
Basal ganglia
Cerebellum
Reticular inhibitory area (medulla)
- co-activation
Descending tracts from higher centers will stimulate both α and ϒ motor neurons
simultaneously.
To keep the muscle spindle sensitive throughout the contraction. (to transmit
sensory information)
α-γ linkage/servo-assisstance
Stimulated alpha fibers send colaterals to gamma fibres and activate them to maintain the
sensitivity of the muscle spindle.
Net effects
Muscle tone
Flaccid Spastic
Occurs when the motor nerve to muscle is cut Occurs when the γ efferent
discharge is high
Polysynaptic reflexes
- Withdrawal reflex
- Shorter pathways initiate the reflex.
Longer pathways maintain the reflex.
Can be inhibited by brain
Stimulus - noxious (painful)
higher centers.
Receptors - nociceptors (free nerve endings)
Afferents - A, C fibers
Effect - flexor contracts
Extensor relaxes
Cortical pathway for awareness, memory.
A pre-potent reflex
Ant other reflex activity taking place at that spinal level at that moment is suppressed.
After discharge
Continuation of reflex withdrawal even after cessation of sensory receptor firing.
This is due to
1. Presence of short and long pathways
2. Presence of reverberating pathways
Posture
Way of stand/walk/sit
Postural reflexes; produced, maintained, restored by a series of coordinated reflexes.
Cortex, brain stem, basal ganglia, cerebellum
Stimulus → gravity, visual, stretch, pressure on the body
Sense organs → muscle spindle, proprioceptors, eyes, ears
Stance reflex
Postural reflexes Static
(Spinal cord Righting reflex
Brain stem)
Stretch Other
(Most important postural reflex) Placing reaction
Phasic
(cortex)
Hopping reaction
Afferents
1. Corticostriate projections - from cortex
2. Thalamostriate projecti0ns – from intralaminar nucleus of thalamus
2 Main circuits
1. Putamen circuit – executing patterns of motor activity
2. The caudate circuit – Cognitive control of sequences of motor patterns
1. Reticular Formation
2. Red Nucleus
3. Vestibular Nucleus
4. Inferior Olive Nucleus
Efferents
Thalamus receives inhibitory impulses from Globus pallidus and substantia nigra, which
in turn project to the cerebral cortex completing the feedback loop.
Excitatory projection to the prefrontal & premotor cortex.
Hyperkinetic disorders
Huntington’s chorea
There are excessive abnormal movements include
Chorea – rapid involuntary dancing movements Sydenham chorea - Due to Rheumatic
Athetosis – continuous, slow writhing movements fever
Ballism – sudden, intense, violent jerky movements of the body
Dystonia – especially axial muscles are contracted for longer periods
Hypokinetic disorders
Poverty of movement
Treatment
Dopamine does not cross blood brain
barrier
Therefore, L-dopa is used as it crosses
the blood brain barrier
Huntington disease
Has two lateral cerebellar hemispheres joined by a medial vermis. Anatomically divided in to
anterior lobe
posterior lobe
flocculonodular lobe
Functional Divisions
Vestibulocerebellum
Includes nodulus in vermis and flocculus in hemispheres
Has vestibular connections
concerned with equilibrium and eye movements
Spinocerebellum
Formed by rest of the vermis and adjacent medial portions of the hemispheres
Receives proprioceptive inputs from the body and copy of motor plan from
motor cortex
Compares the plan with performance and smooths and coordinates the
movements
Vermis is concerned with the control axial and proximal limb muscles
Hemispheres are concerned with the control of distal limb muscles
Neocerebellum
Formed by the rest of the lateral portions of the hemispheres
Concern with the planning and the programming of the movements
Spinocerebellum via
-fastigial
-emboliform
-globose nuclei
Neocerebellum via
-dentate nucleus
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Features of cerebellar disease (occurs in same side of the body, No paralysis, No sensory loss)
1. Ataxia
Incoordination of the movements
Lateral lobe lesions produce - ataxia of the limbs
Midline lesions in vermis produce - truncal ataxia\ Not made worse by
closing the eyes
2. Disturbances of posture and gait
head tilted to the side of the lesion; patient tends to fall to
the side of the lesion- ‘drunken gait’
3. Dysathria / scanning speech (slurred speech) - defects of skilled movements
4. Dysmetria
inability to predict the extent of a movement
also called past pointing
when attempting to touch an object with the finger overshooting to
one side
5. Intention tremor
6. Rebound phenomenon
inability to stop the movements suddenly
7. Dysdiadochokinesia
inability to perform rapid alternating opposite movements
8. Nystagmus
involuntary movements of the eyeballs
9. Muscle hypotonia
10. Pendular knee jerk
loss on influence on stretch reflexes movement continuous as a series
of flexion & extension movements at the knee joint.
11. Decomposition of the movements
inability to perform movements involving more than one joint
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Lesions in the motor system
UMN Vs LMN
FEATURE LMN UMN
Muscle Mass Decreased(due to loss of MEPPs) Less decreased
Muscle Power Decreased Decreased
Muscle Tone Decreased-flaccidity Increased(Due to increased γ
discharge)-spasticity
Tendon Reflexes Absent Exaggerated
Ankle Clonus Absent Present
Babinski sign Absent Present
Fasciculation Present Absent
Fibrillation Present Absent
1. The stretch reflex and inverse stretch reflex of the same muscle (alternates).
Initially due to stretch (along with increased γ efferent discharge), the muscle strongly
contracts.
The ankle will plantar flex.
But this contraction will increase the tension in the tendon of the same muscle.
Impulses from the Golgi tendon organ will cause relaxation of the muscle.
Since the force on the ankle is maintained, the ankle will return to its dorsiflexed state.
This cycle repeats.
2. It can occur even without the inverse stretch reflex. (without Golgi tendon discharge)
Stretch causes muscle contraction-plantar flexion.
But as the muscle contracts, the spindle is unloaded and ankle is pushed back into the
dorsiflexed state.
This cycle repeats.
3. It can also occur as a result of repetitive sequential contraction of flexors and extensors.
Due to damage to the descending cortical tracts that activate the Renshaw cells
(which inhibits the extensor)
Spinal shock
Paralysis of skeletal/ smooth muscles below the level of lesion
Loss of tone in skeletal muscles
Loss of bladder, bowel function – due to interruption of descending autonomic pathways
Loss of sensation below the level of lesion
Loss of tendon reflexes
Reason;
Cessation of excitatory inputs on stretch reflex by descending pathways Duration of
spinal shock depends on the degree of encephalization of motor functions (human
normally 2 weeks)
Mass reflex
Stroking any part of the limb or perineum cause evacuation of bladder and bowel.
Due to afferent stimuli irradiating to the autonomic centers of bladder and bowel function
Intentional mass reflex
Could be lethal
Can even cause retinal detachment due to excess autonomic activation and increased pressure
Inhibition of cerebral cortex/ corticospinal tract, basal ganglia, rubrospinal tract on discharge
motor discharge due to the hyperactivity of the medial tracts (vestibular nuclei and
reticular facilitatory area)
Destruction of dorsal horns – theses hyperactivity of the extensors is gone. Also there is a direct
activation of α motor neurons independent of γ loop
Decerebrate rigidity seen in uncal herniation (uncus of the temporal lobe herniates into subtentorial
region of midbrain and compresses midbrain)
Uncal Herniation
Before;
− Decreased consciousness
− Lethargy
− Poor pupil reactivity
− Hyperactive reflex
− Bilateral Babinski
After;
− Pupil fixation
− Waxing & Waning respiration with apnoea
− Medullary function loss and breathing ceases
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Decorticate rigidity
Flexion of the upper extremities – Facilitation of flexors in upper limb by rubrospinal pathway Extension
of the lower limb – Facilitation of extensors in lower limb by reticulospinal and vestibulospinal pathway
Reticulospinal facilitatory and inhibitory tracts are intact ascending sensory fibers activate the
reticulospinal facilitatory tract.
Autonomic Dysreflexia
Widespread vasoconstriction
Relayed via IX & X to Detected by baroreceptors (mostly in Splanchnic
brain vasculature)
Smell & Taste both show early adaptation. Threshold increases with age.
Taste Bud
Sense organ for taste.
Adults - 3000-10,000 taste buds (child >>elderly)
Tongue – vallate, circumvallate and fungiform papilla
Pharynx, Palate, epiglottis, proximal esophagus
Von Ebner’s glands secrete saliva into the cleft around papillae
Composed of gustatory receptors and sustentacular cells.
Gustatory Receptor
Receptor potential
initiated
Post-Receptor
actions
Taste threshold
Different substances have different thresholds.
Crude intensity discrimination – needs 30% change
Flavor - Mainly synthesized from basic 5 tastes, Smell, Pain, Consistency, Temperature
Olfactory pathway
Olfactory receptor cells Mitral & tufted cells
Olfactory Cortex
(Bipolar cells) (Olfactory bulb)
Inhibition
Periglomerular cells
& Granular cells
cAMP
Phospholipase C
Smell also has a products of phosphatidyl inositol hydrolysis
rapid adaptation
Depolarization of membrane
Taste
Ageusia – absence of taste sensation
Hypogeusia – diminished taste sensation
Dysgeusia – unpleasant perception of taste
Smell
Anosmia – inability to smell
Hyposmia / Hyper-osmia –diminished / enhanced olfactory
sensation
Dysosmia –distorted sensation of smell
T/F
a) Monosodium glutamate is used as an artificial sweetener
b) Receptors for bitter taste are localized to the posterior aspect of the tongue
c) Taste fibers relay in the nucleus of tractus solitarius
d) Taste perception has a high intensity of discrimination
e) Vagus carries afferent from taste receptors
3 chambers
– Anterior
– Posterior
– Vitreous
Separated by 2 groups
– Iris
– Zonule and lens
Functional anatomy
2 types of fluids
Aqueous humour
Vitreous humour
Aqueous humour
Retina
• Extends anteriorly almost to the ciliary
body
• Organized in layers with different types
of cells
• Contain photoreceptors (rods and
cones)
• Has retinal blood vessels and optic
nerve fibers.
Nourishments-
Bipolar & ganglion cells –retinal vessels
Receptors -capillary plexus of choroid.
(This is why retinal detachment is cause so
much damage to the receptors)
• Blind spot/optic disc:
o Site where optic nerve leaves the eye
o No photoreceptors, do not response to
light
• Macula:
Yellowish pigmented spot near the posterior
pole of eye
• Fovea:
o Centre of macula
o No rods, cones only (tightly packed)
o Has the highest visual acuity
o No blood vessels overlying receptors
• Extrafoveal portion of retina: Mostly rods
*Ganglion cells are the only output of retina, and their axons form the optic
nerve
1. Rods
2. Cones
Bind GTP to the G protein (transducin) Retinal separates from opsin (bleaching)
Activate phosphodiesterase
Cyclic GMP regeneration
Decreased intracellular cGMP
Light reduces concentration of
Na+ and Ca2+ in photo receptors
cGMP dependent Na+ channel of outer segment blocked
Activates guanylyl cyclase
Hyperpolarization Inhibits phosphodiesterase
Generates cGMP
Decreased release of glutamate
Neural response
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Photo pigment
Rods & Cones Opsin is a G protein coupled receptor. The
Rhodopsin G protein is called Transducin
Opsin Retinal
RODS CONES
Extremely sensitive to light (detect a single Higher threshold for stimulation (up to 100-
photon of light) fold less sensitive than rods)
Scotopic vision Photopic vision
vision in dark bright light
Can’t determine Can
Details
Boundaries
Colours (black & white vision)
Less visual acuity Greater visual acuity
Saturate in even moderately bright light and Remain photosensitive even in the
remain nonfunctional most of the day extremely bright light.
Image formation
R C
Photoreceptors and horizontal
cells-
H
Hyperpolarising
Bipolar cells
B B Hyperpolarising or
Depolarising
Optic chiasma
Optic tract
Optic radiation
Visual cortex
When the ciliary muscles contract near objects focus on the retina, distant objects focus in
front of the retina.
When the ciliary muscles relax distant objects focus on the retina, near objects focus behind
the retina.
However, human can see the both objects due to the accommodation.
Accommodation
Process by which the curvature of the lens is increased (up to 12 in youth)
Done by the ciliary muscles.
• When the ciliary muscles contract lens relaxes and curvature increased.
• When the ciliary muscles relax lens tenses and curvature decreased.
Near point of vision
• is the nearest point to the eye at which an object can be brought in to clear focus by
accommodation
• Reduces throughout the life – Cause presbyopia
• Headache occurs with aging
Strabismus (squint)
Visual images do not fall on corresponding retinal points. (Misalignment of eyes)
Amblyopia
Refractive error in image is blurred Decreased vision in affected eye
one eye & distorted (permanent)
Binocular vision
Nasal fields
Temporal fields
Central - tangent screen
B
A
Near response
3-part response occurring when an individual looks at a near object
Accommodation
Convergence of axes
Pupillary constriction
3 kinds of cones
Each have a different photo pigment maximally sensitive to one of the primary colours.
Colour perception determined by relative frequency of impulses from different cones.
colour vision depend on colour of other objects in visual field
Colour blindness
Blind site –residual response to visual stimuli after bilateral destruction of occipital cotex
Shortest distance by which two lines can be separate & still be perceived as two lines.
If the patient can’t recognize any of the letters, numbers or shapes at 6m, 3m, 1m distances due
to poor vision,
1. Finger counting
2. Perception of light sources
3. Detecting hand movements
are done
Thirst mechanism
Center- anterolateral areas of hypothalamus
Stimuli
a) Plasma osmolality (Hypertonicity)- via osmo-receptors in ant.
hypothalamus
b) ECF volume(hypovolemia)- via baroreceptors in heart & blood vessels
-via angiotensin II (acting on subfornical organ & OVLT)
c) Dryness of pharyngeal mucosa/ mouth
d) Psychological factors
e) Social factors
f) Prandial drinking-intake of water is increased during eating
This increases due to
Learned or habit response
plasma osmolality when food is absorbed. When protein
uptake, products of protein metabolism causes an osmotic
dieresis. So, the amount of water needed is large.
Due to action of one or more GIT hormones on the hypothalamus
Summary
Thirst
11) Regulation of food intake – to maintain the body weight in a given set point
Orexigenic stimuli stimulate food intake, circulating levels during fasting
NPY- neuropeptide Y
MCH- melanin concentrating hormone
AGRP
Orexin A & B
Ghrelin (release from stomach when it is empty)
Anorexigenic stimuli inhibit food intake
α- MSH- melanin stimulating hormone
CART- cocaine & amphetamine regulating transcript
CRH- corticotrophin releasing hormone
PYY- peptide YY
CCK
GLP-Glucagon like peptide
Leptin
Insulin
Neural signals
-GIT (via vagus) regarding stomach filling
-cerebral cortex (smell, sight, taste)
Hormonal signals
GIT – CCK, PYY, Insulin
Adipose tissue - Leptin
2) Satiety center
- Ventromedial nuclei
- Stimuli sense of satisfaction
- Destruction- Hyperphagia - hypothalamic obesity
2) Lipostatic hypothesis
Food in gut
4) Thermostatic hypothesis
↑Secretion of polypeptides
↓Body tempstimulate appetite
Inhibit feeding center
↑Body tempinhibit appetite
Inhibit food intake
Both Oxytocin and Vasopressin are secreted from the posterior pituitary (neurohypophysis).
Tympanic reflex
(Eg. Gunshots)
Cochlea
Perilymph Endolymph
↑[Na+] ↓[K+] ↓[Na+] ↑[K+]
Composition similar Composition similar
to CSF, serum & ECF to ICF
(maintained by Stria
Vascularis)
Within scala Within membranous
vestibule and scala labyrinth
tympani
Sound Localization
Pitch Discrimination
● Average person distinguishes about 2000 pitches
● Trained musicians can distinguish even more.
● Pitch discrimination most sensitive in 1000Hz – 3000Hz range.
● Planum Temporale is the cortical area responsible for pitch discrimination.
Masking
● Presence of one sound decreases the ability to hear other sounds.
● Due to the relative or absolute refractoriness of previously stimulated receptors and nerve fibers to
the new stimuli.
● The degree to given tone masks others are related to its pitch.
Inputs from,
1. Vestibular system
2. Proprioception
3. Vision
4. Cutaneous exteroceptors
5. Cerebellum
Vestibular system
● Maintains position of head in static and dynamic states.
● 5 groups of hair cells,
1. Utricle
Maculae (hair cells & otolithic membrane)
2. Saccule
3. 3 semicircular canals – Crista ampullaris
● Semicircular canals –
Lie in 3 perpendicular planes
Detect rotational acceleration
Cannot sense the effect of gravity
Linear
Horizontal Utricle
Dynamic Equilibrium
Rotational Semicircular canals
Linear Acceleration
Rotational Acceleration
Mechanism of Action
When rotation commences in one direction
Cupula pushed towards the opposite direction than what it used to before.
Central connections
● Vestibulocerebellar –Balance
● Vestibulospinal – Send impulses to motor neurons & facilitates tone of extensors
● Vestibulothalamocortical –Conscious awareness of position & movement of head
● Vestibulo-ocular pathway – medial longitudinal fasciculus
Vestibulo-ocular reflex
Physiological Nystagmus
SLOW COMPONENT
When head rotation starts the eyes move together slowly in a direction opposite to that of head rotation maintaining
a visual fixation. (Vestibulo-Ocular reflex)
FAST COMPONENT
When the limit of this movement is reached, the eyes quickly snap back to a new fixation point and the repeats the
slow component.
By convention, the direction of Nystagmus is considered to be the direction of the fast component.
Pathological Nystagmus
Pathological nystagmus is when nystagmus occurs when the head is not rotating.
Occurs due to abnormalities in the vestibular system.
Caloric Test
“COWS”
C O – Cold water induces nystagmus to the opposite direction than the ear to
which water was instilled.
W S - Warm water induces nystagmus to the same direction
Vertigo
● Sensation of rotation in the absence of rotation due excessive stimulation of the vestibular system.
Motion sickness
● Due to prolonged and excessive stimulation of the system
Core temperature (36.3 – 37.1 0c) is closely represented by rectal temperature – varies least with
environmental changes
Surface (skin)
Temperature
(29.5 – 33.9
Rectal temperature
°C)
Scrotal Temperature
32 °C
The normal human core temperature undergoes a regular circadian fluctuation of 0.5 – 0.7 0C
Balance between heat production and heat loss determines Body temperature
Heat loss
Cutaneous vasodilation37 0C
Increase Heat
Sweating 370C
loss
Increased respiration
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Fever/Pyrexia
“As if thermostat is reset” - to a new point above normal body temperature
Protective response which inhibits pathogen growth and increase antibody production
Inflammation
Endotoxins from bacteria (exogenous pyrogens)
Pyrogens released from degenerative tissues
Fever
Hypothermia
Fat cells contain several small droplets of fat Fat cells contain only a single large droplet of
fat
Fat cells as well as blood vessels have an
extensive sympathetic innervation Principal sympathetic innervation is solely on
blood vessels
Fat cells contain many mitochondria
1 method of oxidation which generates ATP
2 methods of oxidation
Oxidative phosphorylation which generates
ATP
Uncoupled oxidative phosphorylation
which doesn’t generate ATP, but produce
HEAT
Heat stroke – Body temperature higher than 41.10c. Neurological dysfunction occur.
Complete spinal cord transection at neck above sympathetic outflow impairs internal body
temperature regulation
Micturition reflex: an autonomic spinal cord reflex, facilitated and inhibited by higher brain centers in the
cerebral cortex or brain stem.
Self – regenerative reflex – initial contraction of bladder activates stretch receptors in the bladder and
posterior urethra which causes a further increase in reflex contraction of the bladder.
Then the reflex fatigue and regenerative reflex cycle ceases & bladder relaxes
Cycle
1. progressive & rapid↑ of pressure
2. sustained pressure
3. return to basal tone
Urine is made in the kidneys and comes down to the bladder for storage.
Oblique passage through the bladder wall keeps the ureters closed except during peristaltic waves which bring in
urine.
During contraction of detrusor muscle, reflux of urine from the bladder to the ureter is prevented.
Abnormally short oblique passage, valve malfunctions results in Vesicoureteral reflux (back flow of urine from
bladder to ureter)
Once micturition reflex has occurred but not emptied, nervous elements of the reflex usually remain inhibited for a
few minutes to 1 hour till the next reflex
As the bladder progressively fills, reflexes occur more frequently and powerfully
Innervations
- Pelvic nerves (S2, S3, S4) - Sensory → detect degree of stretch of bladder wall
Preganglionic parasympathetic Motor → (parasympathe c) postganglionic fibres to
detrusor muscle
- Pudendal nerve (S2, S3, S4) – skeletal motor fibers to external sphincter
- Hypogastric nerves - sympathetic innervations (No part in micturition)
Sphincters – Internal muscle bundles on either side of urethra prevent reflux of semen in to the
bladder during ejaculation (sympathetic innervations, no parasympathetic innervation)
External ring of skeletal muscles, voluntary control of micturition
↑ Pressure in bladder → stretch receptors s mulated →Micturi on reflex excited → ext. sphincter inhibited →
voiding of urine
Voiding can be initiated without straining even when the bladder is nearly empty by the effect of higher centres
Cystometrogram
By cystometry
When the bladder is filled, volume increases. So, the R of viscus increases. This causes a decrease in
intramural pressure (P). P is maintained by increasing muscular tension (T) of the bladder wall. So, P returns
to basal level.
Abnormalities in micturition
1. Deafferentiation
Sacral dorsal roots are damaged or tabes dorsalis (Tabetic bladder)
All reflex contractions of the bladder are abolished. But intrinsic myogenic contractions to stretch
can happen,
Results in atonic neurogenic bladder– distended, thin walled and hypotonic & Overflow
incontinence (non-periodically emptying- dribbles a bit when filled to capacity)
2. Denervation
Both afferent and efferent nerves are destroyed. By damage to cauda equina.
Results in autonomous bladder. Bladder becomes shrunken and hypertrophic, dribbling urine
present under denervation hypersensitivity
3. Spinal cord transection
During spinal shock, bladder is flaccid and unresponsive
Results in overflow incontinence
After spinal shock, voiding reflex returns gradually with denervation hypersensitivity resulting in spastic
neurogenic automatic bladder. no voluntary control and no inhibition or facilitation from higher centers
Voiding can be initiated in such patients by mild mass reflex
4. Nocturnal micturition (enuresis) – normal until 3 to 7 years
Formation: -
Choroid plexus of lateral ventricles / other ventricles (60% - 70% CSF)
Ependymal surfaces of ventricles
Perivascular spaces
Plexus of cells that produces the cerebrospinal fluid in the ventricles of the brain.
The choroid plexus consists of modified ependymal cells.
Ependymal tissue surrounds the capillaries of the choroid plexus separating them from the
cerebral ventricles.
Ependymal cells filter water and other substances from capillary blood and transport them
across the ependymal layer into the brain ventricles.
This clear fluid is the cerebrospinal fluid (CSF) that fills the cavities of the cerebral
ventricles, the central canal of the spinal cord, and the subarachnoid space of the
meninges.
Composition
CSF is almost identical with perilymph & with brain ECF
Color of CSF – “clear”, Plasma – “yellow”
protein in CSF [20 mg/dL] <<<< blood [ 6000 mg/dL]
K+, Glucose in CSF < blood
osmolality in blood = CSF
pH CSF < blood (due to CO2 in CSF)
Absorption: -
Through arachnoid villi into cerebral venous sinuses
Smaller villi into spinal veins
Through the cribriform plate into cervical lymphatics
Rate of absorption depends on intra- ventricular pressure
Absorption is unidirectional (bulk flow)
When CSF pressure is elevated
o Possibly increased expression of aquaporin channels in choroid plexus and cerebral micro
vessels.
o More and more arachnoid villi open up
Below 68 mmH2O absorption stops
CSF pressure
Lumbar CSF pressure 70 – 180 mmH2O (Average normal – 112 mmH2O)
CSF pressure can go up by laughing, sneezing, coughing & straining
Head injuries
Cerebral damage results with blows to the skull
Decreased cerebral perfusion & cerebral ischemia shift of cerebral contents within the skull
hypoxia mid line shift
hypercarbia herniation
hypoglycemia cranial nerve palsies
cerebral vasodilation pressure on vital centers
cerebral oedema irregular HR, RR
convulsion loss of consciousness
loss of consciousness death
death
Lumbar puncture
Safest level to enter the needle to withdraw CSF is between L3 – L4
5 ml is maximum volume
In increased ICP lumbar puncture should not be preformed
Headache after lumbar puncture due to traction of vessels & nerve roots from which the brain
hangs stimulate pain fibres
Pain relieved by sterile isotonic saline into subarachnoid space
A "traumatic tap" occurs if the needle inadvertently has entered an epidural vein during
insertion.
Xanthochromia is the yellow discoloration indicating the presence of bilirubin in the
cerebrospinal fluid.
Xanthochromia is usually caused by red blood cell degeneration in the CSF as would be
seen in subarachnoid hemorrhage (SAH).
Easily penetrated – water, lipid soluble free hormones, L – Dopa, 5 – hydroxytryptophan, CO2, O2,
Alcohol, Anesthetics, NH3
Slow penetration – Urea, Dopamine, Serotonin
Specific transport systems – Na+, K+, Cl-
Impermeable – plasma proteins, water, non-lipid soluble large organic molecules
Transporters
o Facilitate passive penetration into the brain tissue
Eg: glucose – GLUT1
Reverse Transporters
o Transports drugs and peptides back into the cerebral vessels
Eg: P – glycoprotein (multi drug nonspecific transporter)
Effects of inhibition of this transporter??
Functions of BBB
Maintains homeostasis of brain ECF
Prevent entry of toxic substances to brain
Prevent escape of neurotransmitters
Clinical Relevance
Immature BBB
Neonatal jaundice – kernicterus
Occurs due to elevation of unconjugated bilirubin
Bilirubin conjugation is impaired due to the immaturity of the liver.
Neonatal hyperbilirubinaemia will cause lipid soluble unconjugated bilirubin to cross the BBB
which is not matured fully.
Deposition of bilirubin in basal ganglia causes kernicterus/bilirubin encephalopathy.
Disruption of the BBB
Head injuries
Cerebral Infections
Tumors
Selectivity of the BBB
Pharmacological agents – degree of penetration
o Antibiotics for cerebral infections
o Anesthetics
o L-Dopa
o CNS side effects of drugs – eg: antihistamine
o Drugs that act outside BBB
Electrical events of the brain are recorded as patterns by placing electrodes on pial surface of cortex.
Measured in microvolts (Doesn't record the action potentials but summation of dendritic postsynaptic
potentials)
Frequency increases with high degree of activity but becomes asynchronous and voltage drops
50-100 microvolts
δ θ α β Υ
<4 4-7 8-13 13-30 30-80
Alpha (α) Beta (β) Gamma (γ) Theta (ϑ) Delta (δ)
Awake but rest with Mentally alert Focused attention Large amplitude Large slow waves
mind wandering Marked in frontal aroused slow waves Deep sleep in adults
Eyes closed region Involved in high Early
marked in parieto- mental activity Seen in children childhood(infancy)
occipital area Seen in infants Perception Abnormal if in adults
Problem in awareness (raised
Gradually appears solving ICP)/Brain disease -
during adolescence Fear & tumor, haematoma,
consciousness encephalopathy
Block /
desynchronization -
by opening eyes.
(Replace α waves
with fast irregular
waves of low
voltage- β waves)
1. age
2. sleep/awake status
3. level of consciousness –
metabolic abnormalities, head
trauma, sleep onset latency
4. Epilepsy
α frequency
Low blood glucose
Low body temperature opposite
↑ PaCO2
↓cortisol
Arousal Sleep
Sensory system stimulation * stimulation of sleep zones
- Up to midbrain level - slow wave sleep
Activation of MB reticular area * pontine reticular area
Mid-thalamic neurons are partially depolarized * Mid-thalamic neurons are hyperpolarized.
(Electrical state of the thalamo-cortical neurons influences the sleep-wake cycle)
REM NREM
4 stages
Rapid eye movement (irregular muscle
1 - drowsy, α waves start to disappear, low
movements)
voltage fluctuations, theta waves, δ waves
Occurs after 90m of onset of sleep
intermittent
Voluntary activity of muscle Inhibited -motor 2 - light sleep, sleep spindles-sinusoidal waves
paralysis (12-14 Hz), short bursts of waves-k
Tone of neck muscles reduced complexes
Snoring 3 - δ waves appear, dreams, deep sleep
4 - very deep sleep δ waves prominent. No
Tooth grinding
dreams
Bizarre imagery, illogical thoughts, not stored in
memory Vital signs decline (BP, HR, RR) more regular –
Digestive system activity decreased. stage 3 & 4 has skeletal muscle activities,
Body temperature, BMR, HR, RR, BP & irregular reflexes intact
O2 consumption in brain BMR, sympathetic activity
EEG pattern is very irregular (Rapid low voltage) increased release of GH
Sleep is not interrupted & threshold for Arousal
increased. (Paradoxical sleep)
Penile erection/nocturnal emission
Sleep cycle
Sleep starts off with NREM
NREM REM NREM……….
- 4-6REM periods per night.
- Cycle repeated-90min intervals
- More REM & less Stage 3,4 towards morning
% of REM ↓ with age
- Premature infants 80%
- Full term neonates 50%
- Adults 25%
- Elderly 20%
circadian rhythm – Regulated by suprachiasmatic nucleus (SCN) of hypothalamus according to the impulses
coming from retino-hypothalamic tract.
Neurochemical mechanisms
Melatonin – Secretion regulated by efferents from SCN
PGD2 Serotonin
PGE2
Caffeine
Why do we sleep??
Poorly understood.
o Replenishment of brain glycogen stores
o Memory is consolidated
o Facilitation of learning and memory, cognition
o Maintain metabolic-caloric balance
o Immune competence
Disorders of sleep
- Insomnia-insufficient or nonresponsive sleep in spite of adequate opportunities
- Narcolepsy - sudden onset of REM sleep
- Sleep walking/somnambulism - during NREM
- Sleep apnoea - Day time sleepiness due to fragmented sleep at night, caused by upper airway obstruction.
- Parasomnias- disorders associated with arousal from REM or NREM sleep – Somnambulism, Nocturnal enuresis,
Night terrors
Explicit memory initially required for a task can become implicit when a task is
learnt.
Eg: riding a bicycle
Memory disorders
Amnesia (Retrograde & anterograde)
Dementia - Alzheimer’s
- Senile dementia
Retrograde amnesia - After a sudden shock, trauma to head or after being anesthetized
people forget what happened just before the incident
.
Neurogenesis occurs in brain mainly in hippocampus & olfactory bulb throughout the life.
Disorders of speech
1. Non fluent aphasia - lesion in Broca’s area: slow speech words hard to come
Limit to 2, 3 words
Features of lesions
Categorical hemisphere Representational hemisphere
Language disorders Astereognosis – Inability to identify
Fluent, non fluent and anomic aphasia objects by feeling
Acalcuia Agnosia - Inability to identify objects by
difficulty in mathematics particular sensory modelity
Patients are disturbed and often depressed Unilateral inattention and neglect
about their disability prosopagnosia
Patient are unconcerned and euphoric about their
disability
Functions
1. Involved in emotions 2. Autonomic responses
Cognition (higher functions) – 3. Sexual behavior
as an awareness of sensation 4. Rage and fear
and cause 5. Motivation and addiction
Affect-the feeling itself 6. Connections-learning and memory
Conation-the urge to take
action
Physical changes-BP, PR,
sweating
Endocrine system
A system of ductless glands that secrete hormones.
Endocrine system
GH FSH*/LH* corticosteroids
Bones aldosterone
Muscles cortisol
Adipose tissue Ovary Testis
Estrogen androgen
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Mechanisms of hormone release
Functions of hormones
Primary sex determination is NOT
Growth & development Promote cell division
determined by hormones.
Increase whole body mass
Limit cell division
Short polypeptides
PG
Prostacyclin
Eicosanoids TH
LT
Lipid
Derivatives Steroid Cortisol
hormones Aldosterone
Estrogen
Progesterone
Androgen
Calcitriol
Noradrenaline Catecolamines
Adrenaline
OR
Step 3: - coupling of DIT and DIT
DIT + DIT T4
Mineralcorticoid glucocorticoid
•Aldosteron •cortisol
(Regulate salt & water excretion (Affect CHO/Protein/Lipid metabolism
by kidney) in a manner opposite
to insulin)
•corticosteron
e
Calcitriol
Actions of Calcitriol
Calcitriol
Increased absorption of Ca+2 and phosphate Increased release of Ca+2 and phosphate to the ECF
Protein
There are 3 types of receptors.
1. Membrane bound
2. Cytoplasmic
3. Nuclear
Fits / tightly binds with the active site of the hormone
Convert the signal to a response.
Highly specific for a particular hormone.
Tissues have their own pattern of distribution of receptors.
Ex: Liver has glucagon receptors but skeletal muscles doesn’t have
The number of receptors in a cell is not constant.
1. Up regulation-
Increased gene expression
2. Down regulation
Inactivation
Separation of the receptor from the surface
Destruction within lysosomes
Decreased production/repair
Hormones are categorized by their solubility.
Hydrophilic Ex: - catecholamine, peptide, eicosanoids
Membrane bound receptors
↓
The binding of the G protein to the receptor causes the replacement of GDP by GTP
↓
GTP hydrolyzes to GDP
↓
α subunit dissociate from the others.
↓
α subunit bind to phospholipase C
↓
Activation of phospholipase C
↓
Phosphatidylinositol bisphosphate hydrolyze into Diacylglycerol (DAG) and inositol triphosphate (IP3)
↓
IP3 release stored Ca+2 from ER
DAG opens Ca+2 ion channels and increase Ca+2 influx (via PKC)
↓
Increased Ca+2 levels inside the cell
↓
Calmodulin binds with Ca+2
↓
Activate PKs
↓
Activation of enzymes
Α → α1 and α2
Adrenergic receptors
Β → β1 and β2
Many antihypertensive drugs are β blockers. They block the binding site of catecholamine to
β receptors. Eg: Propranolol (Blocks β1 and β2)
The binding of a hormone to the receptor directly activate its inherent enzyme activity.
Ex: - insulin receptor is a kinase by itself
The insulin receptor has 2 α chains on the outside of the membrane and 2 β transmembrane
chains.
The transmembrane β chains have tyrosine residues on the cytosolic surface.
Importance
Provides energy and metabolic intermediates.
Provides ATP directly by substrate level phosphorylation
Emergency energy supply in hypoxia - does not need O2
Myocardial infarction.
Strenuous exercise in skeletal muscle
Tumor cells
Major energy supply of RBC (lack of mitochondria)
Provides NADH which provides ATP by ETC – oxidative phosphorylation
Provides intermediates for other metabolic pathways
Maintain blood glucose level in the body.
Aerobic – glucose to pyruvate
Anaerobic – glucose to lactate
Transporters of glucose
Occurs in cytosol - Glucose is polar – can’t cross membranes – need transporters (tissue specific)
Passive transporters (Na+ independent unipolar - Facilitated diffusion) - along conc. Gradient
GLUT transporters – exist in 2 conformation states
1. Phosphorylation of glucose (commits glucose for further metabolism in the cell, by trapping
glucose)
Hexokinase/glucokinase
Glucose Glucose - 6-P
AMP
F-2,6-BP – most potent activator
PFK 2 +
PFK 1
F-6-P F-1,6- BP
-
ATP
Citrate
PFK 2
F-6-P F-2,6- BP
FBP 2
Adenylate
cyclase
Glucagon cAMP Active protein kinase A phosphorylates the bifunctional enzyme
Pyruvate kinase
PEP Pyruvate
+ Feed forward regulation
F-1,6-BP
When blood glucose level is low, HEPATIC pyruvate kinase is phosphorylated (via cAMP) and thereby
inactivated inhibiting glycolysis and driving gluconeogenesis.
Fate of pyruvate
Pyruvate
Aerobic Anaerobic
CO2 /H2O/ATP/
NADH/FADH
Lactic Acidosis
Causes:
1. Low O2 concentration as a result of collapse of circulatory system due to
MI
Pulmonary embolism
Severe haemorrhage
Shock
2. Inhibition of ETC - reduce oxidation of NADH
Hypoxia
Inherited diseases of mitochondria
Absence of ATP/ADP translocase
RBCs entirely depend on glycolysis for ATP production as they lack mitochondria. In the deficiency of
the enzyme ATP production by glycolysis is reduced. Premature lysis of RBCs occurs due to inability of
maintaining ion pumps in the cell membrane. Hemolytic anemia results. (prickle cells, jaundice and
splenomegaly)
Role of 2,3-BPG in RBCs made from 1,3-bisphosphoglycerate in response to chronic hypoxia. (high
altitudes, etc.) Binds with beta chain of hemoglobin and reduces its affinity for oxygen. More oxygen is
released in the tissues.
Irreversible reaction, which occurs in mitochondrial matrix. (but not a part of TCA cycle)
Pyruvate needs to enter the mitochondrial matrix, so a specific transporter helps
to cross the inner mitochondrial membrane -H+ symport by pyruvate translocase
Needs aerobic conditions (O2) - (to regenerate NAD+ and FAD+ via ETC)
Catalyzes by Pyruvate Dehydrogenase enzyme (PDH), which is a multi-enzyme complex
(multiple copies of three enzymes) in the mitochondrial matrix
Decarboxylation
cAMP insensitive.
Dehydrogenation
PDH requires 5 co-enzymes Trans acetylation
CoA (vitamin B5) PHD kinase and
NAD (vitamin B3) PDH phosphatase
Lipoic acid
FAD (vitamin B2)
TPP (vitamin B1)
(mnemonic – CFL Nethi Torch)
CoA CO2
Impaired activity of PDH Accumulation of Pyruvate Excessive lactate production Lactic Acidosis
Treatment - give a Ketogenic diet (rich in lipids and low in carbohydrates)
If O2 is adequate, rate of respiration & TCA cycle depends on energy status, which is
reflected by utilization of ATP.
Continuity of TCA cycle depends also on regeneration of electron acceptors.
Also, enzymes are responsive to energy status:
ATP/ADP
NADH/NAD+
ATP
LCFACoA
Isocitrate DH
Isocitrate α ketoglutarate +NADH +CO2
- +
ATP ADP
NADH
Succinate dehydrogenase
Embedded in inner Mitochondrial membrane (complex II in ETC)
NADH formation
Isocitrate DH
Isocitrate αKG
NAD+ NADH + H+
α KGDH
αKG Succinyl CoA
NAD + NADH + H+
Malate DH
Malate OAA
NAD+ NADH + H+
succinate thiokinase
Succinyl CoA succinate
GDP GTP
FADH2 formation
Succinate DH
Succinate Fumarate
FAD+ FADH2
Energy Production
By intermediate reaction (PDH),
For one molecule of Glucose,
2x NADH 2 x 3 = 6 ATP
By TCA cycle,
For one molecule of Acetyl CoA,
1 x FADH2 1 x 2 = 2 ATP
3 x NADH 3 x 3 = 9 ATP
Substrate level phosphorylation 1 GTP
12 ATP
active in liver, adipose tissue, adrenal cortex, RBC, lens, corneal cells
6 phosphoglucono lactone
Glu -6- P -DH
hydrolase
Glucose-6-P 6-phosphogluconolactone 6-phosphogluconate
Glyceraldehyde-3-P
Ribulose-5-P Ribose - 5- P
Fructose-6-P
NADPH
Ratios of reduced/oxidized forms in cytosol of hepatocytes favor:
Functions of NADPH
1) Detoxification
A. Maintains the stability of the cell membrane. (esp.in RBCs)
Metabolic reactions formation of free radicals. Eg: peroxides, superoxides
Attack lipid bilayer and cause lipid peroxidation Cell membrane breakdown (hemolysis)
H2O2 is reduced by glutathione. NADPH reduces Oxidized glutathione into its reduced form.
G-Glutamate
C-Cysteine
G-Glycine
X linked
G6PD → main regulatory enzyme in HMP
Production of NADPH in RBC is entirely dependent on HMP. (occurs in all cells, but most
severe at RBCs)
In G6PD deficiency, lack of NADPH → Can’t reduce oxidized glutathione → Can’t maintain
stability of RBC membrane → Hemolysis.
Commonly manifests when exposed to oxidative stress
Oxidant drugs Eg: antimalarial (primaquine), herbicides
Favism (fava beans)
Infection (from oxidants produced during inflammation)
Ionizing radiation
O2 dependent mechanism
.
Respiratory burst
Reactive Oxygen species
O2- , H2O2 , OCl-, OH-
2) Reductive biosynthesis
NO synthesis
NADPH NADP+
NO synthase
Arginine Citrulline
O2 NO
Functions of NO
Relax smooth muscle
Prevent platelet aggregation
Act as a neurotransmitter in brain
Mediate tumoricidal & Bactericidal action in macrophages
Sorbitol Pathway
Reduction of monosaccharides to polyol by Aldolase reductase –an alternative mechanism for
metabolizing sugars in tissues. (Ex- lens, retina, liver, kidney, ovaries, seminal vesicles, Schwann
cells)
Fructose Metabolism
Fructokinase Aldolase B
Fructose Fructose-1-P Glyceraldehyde
DHAP
Advantages
Than glucose,
Insoluble
low osmotic activity
no influx of water into cell
Than Fats,
Can provide energy under anaerobic conditions by glycolysis
(FAs can’t net produce glucose)
Formation of glu-1-PO43- no ATP is needed to channel glucose into glycolysis
Importance
Liver glycogen : - Maintain blood glucose level between meals- lasts 24h in fasting
Muscle glycogen: - Provide energy for muscle to perform strenuous exercise (aerobic & anaerobic)
Glycogen synthesis
Glucose activation
Glucose Glucose-1-P
UDP-Glucose pyrophosphorylase
Glucose-1-P + UTP UDP-Glucose + PPi (Pyrophosphate)
(Activated form)
PPi + H2O 2Pi
Therefore, all reactions producing PPi are shifted to right & almost irreversible
Chain elongation
Glycogen synthase
(Glycogen)n + UDP-Glucose (Glycogen)n+1 +UDP
Glucose is added to non-reducing ends. → α-1-4-glycosidic bonds
Branching enzyme cuts a string of glycogen (8-10 glycosyl units) from the growing end and
grafts onto the 6th C atom of a glucose residue in the chain. →α-1-6-glycosidic bonds
Further elongation by glycogen synthase.
Liver
Muscle Use to HMP pathway
Glucose 6-phosphatase s
Allosteric
Two types
Covalent Hormonal
Hormonal regulation
Synthetic Pathway
Glucose – 6- P
Degradative Pathway
Ca2+- Calmodulin
Complex
+
Glycogen phosphorylase Glycogen phosphorylase
Kinase b Kinase a
(Inactive) (Active)
Glycogen Phosphorylase
Muscles a
ATP (Active)
Muscles
G–6-P
AMP
Liver
ATP
G–6–P Glycogen phosphorylase
Glucose b
(Inactive)
6 © 2017 A/L Repeat Campaign
LIVER MUSCLE
Glycogen acts as a glucose reserve. Glycogen acts as an energy reserve.
Maintains blood glucose level – buffers glucose Provide ATP for muscle action.
End product is glucose. End product is Glucose-6-phosphate.
Glucose-6-phosphatase enzyme is present. Glucose-6-phosphatase enzyme is absent.
Hormonally regulated by glucagon, insulin, Insulin, epinephrine. (no glucagon influences.)
epinephrine.
Receptors: insulin, glucagon, adrenergic (α,β) Insulin, β adrenergic.
2nd messengers: 2nd messengers:
cAMP, Ca2+, IP3, DAG cAMP, Ca2+
Ca2+ released from SER due to epinephrine via α1 Ca2+ released from SER during muscle
receptors activates phosphorylase kinase contraction activates phosphorylase kinase
without phosphorylation (partially without phosphorylation (partially
active)→activates glycogen phosphorylase active)→activates glycogen phosphorylase
AMP has no role in regulating glycogen AMP directly activates glycogen phosphorylase
phosphorylase without phosphorylation.
Glucose allosterically inhibits glycogen Glucose has no action in regulation of glycogen
phosphorylase. phosphorylase.
Glycogen stores: Glycogen stores:
Increased- during well-fed state. Increased- during resting state
Depleted- during fasting. Depleted-during muscle contraction.
Protein turnover
Body Proteins
(400g)
Synthesis of
Dietary Proteins
non-essential
A.A (Varies) (100g)
AA
Pool
(100g)
Catabolism Synthesis of other
of A.A N containing
(Varies 14%) compounds (30g)
Body proteins
(400g)
Clinical
Redistribution HB level
Dietary AA pool Degradation
to meet Reduce
Protein of HB
reduce essential resulting
Reduce
needs anaemia
Degradation of Proteins
Protein Degradation
Cytosol Lysosome
Selectively degrade Non selectively degrade
Proteins tagged with ubiquitin Using acid hydrolases
Recognized by proteasome Extracellular, membrane associated,
It unfolds, deubiquinate and cut the glycoproteins and long lived
protein into AA by proteases intracellular proteins are degraded.
Degradation of regulatory proteins with
short half-life or misfolded proteins.
Target intracellular proteins
1) Ubiquitination
2) Oxidation of amino acid residues
3) PEST sequence
4) N terminal amino acid residues
1) Ubiquitination
Ubiquitin is recycled.
2) Oxidation of amino acid residues
3) PEST sequence
Repeated sequence of P E S T
Pro, Glu, Ser, Thr, are known as pest sequences
Usually half-life less than 2 hours
Target proteins for rapid degradation.
Hydrolyze by ubiquitin-proteasome system
Proteins with and amino terminal of Phe, Leu, Tyr, Trp, Lys, Arg
Have short metabolic half life
Nitrogen balance
States of balance
3. Negative N Balance
Intake < output (loss)
Starvation / Fasting
Trauma (protein malnutrition, diet low in essential amino acids)
Wasting
Poorly controlled diabetes - because amino acids degraded to gluconeogenesis.
Transamination
Pyruvate glutamate
ALT
Alanine α KG
OAA glutamate
AST
Asp α KG
ALT & AST Important in diagnosis of liver and heart damage, because they are normally
intracellular enzymes.
Oxidative Deamination
NAD(P)+ NAD(P)H + H+
Glu α KG
GDH NH4 +
NAD(P)+ NAD(P)H + H+
Glu α KG
(+) Glutamate Dehydrogenase
Some AAs (-) NH4+
(+) (-) (-)
LOW
Energy GTP High ATP NADH
High Energy
Urea cycle
Urea
(Transamination) (Oxidative
deamination)
α Keto acids are metabolized and can be used to replenish the TCA cycle.
1) Transamination
2) Oxidative decarboxylation (branched chain keto acid dehydrogenase - TPP, NAD, FAD, lipoic
acid, CoA)
3) Dehydrogenation.
AMP deamination
Adenosine is a coronary
vasodilator.
Production of Ammonia
Toxicity of NH3
1) Depletion of α KG
2) Inhibition of Glutaminase
Glutaminase Glutamate
Glutamine isozyme
Glutamate
NH3
GABA
+
NH4 inhibits Glutaminase
Therefore [glutamate]↓ [Glutamine]↑
Glutamate is an excitatory neurotransmitter
Low neurotransmitter levels synaptic transmission impaired
Glutamate is required for GABA synthesis
Gln is osmotically active
Accumulation leads to brain oedema. (brain swelling and cell death)
NH4+ NH3 + H+
Transport of NH3
Glutamine
ATP ADP
Glutamate Glutamine
Glutamine Synthatase
NH3
H 2O
Glutamine serves as a fuel for gut, kidney and cells of immune system.
It removes ammonia in brain by producing glutamine.
Formation of Alanine by the transmission of pyruvate produced from aerobic glycolysis etc. (in
skeletal muscles)
Irreversible.
1st two reactions occur in mitochondria and others in cytosol.
Occurs in liver and transported to the kidney.
3 ATP used (needs energy)
1st N from ammonia and 2nd N from Asp. (Asp is an immediate precursor of Glutamate)
C from CO2 / HCO3-
Arginase is present only in liver.
Dietary ornithine is requiring for continued activity of urea cycle but not dietary aspartate
Act as both ammonium and bicarbonate disposal.
From all the excretion products 80% is disposed as urea.
Urea diffuses from liver transport to kidney and excreted in urine.
Portion of urea diffuse from blood to intestine.
Bridge between
gluconeogenesis
TCA cycle
Malate
OAA
Glucose
OTC deficiency
↑ Carbomyl phosphate & NH3
↑ CPS II activity
↑ [Orotic acid] - Orotic aciduria
In the cytosol,
Carbomyl Phosphate + Asp Orotate Uridine
Often mental retardation and death.
X linked
Membrane associated ornithine permease.
Ornithine permease / translocase / ORNT deficiency.
Skeletal muscle
Uptake of amino acids for protein synthesis
Major site for amino acid pool
Release of amino acids during starvation mainly alanine
and glutamine (During starvation,
Acetyl Co A↑ from FA oxidation → Inhibit PDH → ↑ Pyruvate → Alanine (from
Transamination)
Kidney
Major site of production of Ser
Uptake of Gln NH4+ production for acid base regulation
Also produce the Ala.
Brain
Uptake of Branched Chain Amino Acids (Val, Leu, Ile)
Val as an energy source
Degradation of Branched chain amino acids (BCAA)
Transamination
Oxidative decarboxylation (branched chain keto acid dehydrogenase – TPP, NAD, FAD, lipoic
acid, CoA)
Dehydrogenation
Leucine Acetoacetyl CoA
Valine
Propionyl CoA Succinyl CoA
Isoleucine
MS MTHFR
(-) Cystathionine
Vitamin B6
CGL
Cysteine
Deficiency of vitamins required for the conversion to methionine (Vit. B12, Folate)
hyperhomocystenemia (increased level of total HC in urine and plasma.)
homocystenemia
Tripeptide
Widely distributed cytosolic antioxidant
Protect cells from oxidative damage
Takes part in amino acid transport across membranes, in kidney tubules
Reductant (maintain stability of RBC membrane)
Conjugate with drugs to make them water soluble
Synthesis of leukotrienes
Cofactor for enzyme reactions
Rearrangement of disulfide bonds
Insulin
Creatine phosphate
Creatinine
Creatinine clearance
Serotonin
A neurotransmitter in brain
involved in mood, sleep, appetite, temperature regulation
Serotonin is produced from tryptophan
When a protein meal is taken, all amino acids are available in blood; traffic jam occurs in
amino acid transport system so tryptophan the bulkiest amino acid is taken up very
slowly, serotonin production is low, so protein meals cause alertness
When a carbohydrate rich meal is taken, insulin secretion is increased, will lower the
amino acid concentration in blood, so tryptophan easily enters brain cells, so
carbohydrates will induce sleep.
NO production
Arginine + O2 Citrulline + NO
NOS
Physiological functions
relaxation of smooth muscle
inhibition of platelet aggregation
neurotransmission
cytotoxicity
Reduced NO production
hypertension
impotence
susceptibility to infection
artherogenesis
Increased NO production
septic shock
inflammatory diseases
neurotransmission
cytotoxicity
Types of NO Synthase
1) neuronal nitric oxide synthase (nNOS, isoform I) (Ca2+ and Calmoduin dependent)
2) inducible nitric oxide synthase (iNOS, isoform II)
3) endothelial nitric oxide synthase (eNOS, isoform III) (Ca2+ and Calmoduin dependent)
1) Neuronal nitric oxide synthase (nNOS, isoform I)
Ca2+ dependent, used for neuronal communication
NO in the heart
Alkaptonuria
Homogentisic oxidase
Homogentisic acid Maleyactoacetic acid
Phenyl acetate
Phenyl pyruvate
Phenyl lactate
Phenylalanine
Phenylalanine hydroxylase
Tissue proteins
Tyrosine Melanin
Catecholamine
Fumarate
Acetoacetate
Autosomal recessive
Deficiency of phenylalanine hydroxylase.
Accumulation of phenylalanine
Deficiency of tyrosine
↑[Phe] ssues, plasma, urine
↑Phenyl lactate, Phenyl acetate, Phenyl pyruvate
Cause;
mental retardation
Failure to talk and walk
Seizers hyperactivity tremor
Microcephaly
Hypopigmentation because high [Phe] competitively inhibit hydroxylation of Tryosine by
tryosinase.
Treatment- low [Phe] diet. Supply Tyr in diet.
The disorder of the oxidative decarboxylation of alpha keto acids derived from
Branched chain AAs which are Valine, Isoleucine, and Leucine caused by the missing or
defect of branched-chain dehydrogenase.
The levels of branched-chain amino acids and corresponding alpha keto acids are
markedly elevated in both blood and urine.
The urine has the odor of maple syrup.
Asparaginase
Asparagine Aspartate
This reduce Asparagine available for Leukemic cells since they cannot synthesize it by their
own.
Cause death of leukemic cells. (Refer Enzymes note)
Importance of gluconeogenesis
Glucogenic substrates
Lactate: The Cori cycle- from exercising skeletal muscle, mitochondria less cells (RBC)
Amino acids: Except leucine & lysine (which are ketogenic) all other A.A are glucogenic.
Eg: glucose- alanine cycle
Alanine, Glutamine are the major sources of Glucose during fasting
Amino Acid α KG OAA
Glycerol: glucagon activates HS lipase→hydrolyses TAG in Adipocytes→ glycerol & Fatty acids
Glycerol → transports to liver → forms DHAP (glycerol Kinase is not present in
adipocytes)
Fatty Acid → Acetyl Co A → no net production of glucose (not glucogenic)
Odd chain F.A → propionyl Co A → glucogenic
Glycolysis Gluconeogenesis
Hexokinase Glucose 6 Phosphatase
PFK1 FBP 1
Pyruvate Kinase Pyruvate Carboxylase and PEP Carboxykinase
Regulation of gluconeogenesis
OAA cannot cross the mitochondrial membrane. It’s done via following shuttles.
PEP Carboxykinase
In both Cytosol and Mitochondria
If Substrate Alanine, Cytosolic PEP CK (not subject to allosteric regulation)
If substrate Lactate, Mitochondrial PEP CK (NADH already produced, no need of
malate/aspartate shuttle)
Use GTP
OAA PEP
GTP GDP
F6P
+F26BP -F26BP
+AMP -AMP
PFK1 F1,6BPase
-ATP +ATP
-Citrate +Citrate
-H+
F1,6BP
Dephosphorylation of G6P
G6P Glucose
G6Pase
Liberate free glucose
Primarily a function of liver to buffer blood glucose level (liver, kidney)
G6Pase is absent in brain and muscle
G6Pase is present in ER lumen of hepatocytes and renal cells
Genetic defects in either G6Pase or T1 (G6P transporter) lead to;
↓
increase in glycogen synthesis
↓
glycogen storage disease (Von Gierke’s disease)
↓
Severe fasting Hypoglycemia
2) Energy state
↑ATP / AMP
PK inhibited. PEP guided to form glucose
PFK 1 is inhibited
F 1,6 Bisphosphatase activated
↓ATP/AMP
PK activated
PFK 1 activated Gluconeogenesis Inhibited
F-1,6- bisphosphatase inhibited
↑ADP
Pyruvate Carboxylase and PEP Carboxykinase inhibited
3) Allosteric regulation
Acetyl CoA activates PC
AMP & F-2,6 BP inhibit fructose-1,6-bisphosphatase
Citrate & ATP activates Fructose 1,6 Bisphosphatase
4) Covalent Modification
Glucagon - Phosphorylate Pyruvate Kinase and inactivates it
Phosphorylate PFK 2 and inactivate it.
So F 2,6 Bisphosphate level is reduced.
Allosteric regulation
Lowers F2,6BP level so activates F1,6BP and inhibits PFK
Covalent modification
Elevation of Cyclic AMP increase cyclic AMP dependent PK activity PK
phosphorylated PK is inactivated
Alcohol DH AldehydeDH
CH3CH2OH CH3CHO CH3COONAD+
Pyruvate & OAA and DHAP for gluconeogenesis decrease & hence the rate of GNG decreases
which leads to (Fasting) Hypoglycemia & (Hyperuricemia)
NADH accumulates. Prevents Lactate Pyruvate. (Lactic acidosis.) Uric acid excretion ↓
when NADH↑ Fatty acid bio synthesis increases Fatty Liver
Cytosolic NADH is transported to mitochondria via Malate-Asp shuttle
It is necessary for OAA transportation from mitochondria to cytosol
Limits availability of malate & OAA for gluconeogenesis
Because lactate and Urate
compete for the same
*Ethanol Metabolism – 2nd pathway: transporter for secretion
MEOS from renal tubules
Oxidize NADPH to NADP+.
Oxygen free radicles.
Glutathione regeneration reduced.
Alcohol DH
CH3CH2OH CH3CHO
MEOS
Purines
1) De Novo Synthesis - base can`t synthesize separately always built upon a PRPP
2) Salvage Pathway
3) Catabolism - no breakage in purine ring just a conversion
Pyrimidine
1) De Novo Synthesis - primary base orotate is synthesized separately & attach to a PRPP
2) Salvage pathway (few pyrimidines - bases in treating Orotic aciduria)
3) Catabolism - ring is broken
PURINE METABOLISM
Adenine, Guanine
Double ringed structures
Cannot be opened in human cell
Purine ring primarily constructed in liver
1) De Novo Synthesis
Regulation
Active sites
Substrate specific
sites
Clinical
HGPRT Deficiency
HGPRT is an enzyme in the salvage pathway of purine metabolism, which catalyzes the
following reactions,
Guanine + PRPP GMP + PPi
Hypoxanthine + PRPP IMP + PPi
Purine autism
25% of autistic patients may overproduce purines
To diagnose, must test urine over 24 hours
Pink urine due to uric acid crystals may be seen in diapers
Excess nucleotides should be degraded, but most of the ingested (dietary) nucleic acids are
degraded & excreted, because the enzymes which need for purine catabolism are present in
the mucosa of the gut.
Major sites of purine catabolism,
Dietary nucleic acids → intes ne mucosal cells
De-novo synthesized nucleic acids → primarily degraded in liver
Xanthine is the point of convergence for the catabolism of purine bases, & it’s converted to Uric
acid by Xanthine Oxidase.
AMP Deaminase
AMP IMP XMP GMP
5’nucleotidase NH3
Hypoxanthine Guanine
Xanthine oxidase
Xanthine
Xanthine oxidase
[-]
[-]
All known ADA mutants structurally perturb active site. (ADA contains a “TIM Barrel” structure)
ADA enzyme is present in all the cells, but it’s highly active in lymphocytes.
So,
↑ Adenosine, AMP and dATP level
dATP inhibit Ribonucleotide Reductase (RNR)
↓ deoxyribonucleo de levels
DNA synthesis interrupted
↓ T cell B cell growth
Treatments,
Bone marrow replacement, enzyme replacement done (Gene therapy)
Without treatments - die at age 2
Gout (Hyperuricemia)
Hyperuricemia is increased levels of uric acid in blood, which leads to accumulation of urate
crystals in synovial fluid lead to gouty arthritis, especially in cooler areas like distal limb joints.
a) Primary hyperuricemia
3. Combined
High alcohol intake
Von Gierkes disease (overproduction, reduce renal excretion)
PRPP amidotransferase
PRPP Phosphoribosyl amine
Glutamine Glutamate
These two are glutamine antagonists
Mercaptopurine The reaction cannot go ahead without glutamine
Azaserine (diazo acetyl – L – serine) So purine synthesis is blocked at PRPP.
PRPP accumulates
PYRIMIDINE METABOLISM
Thymine, Cytosine
Uracil (only in RNA)
Single ringed structures
Can be opened in human cell
Easily opened and degraded to soluble β-alanine and β-amino isobutyrate
1) De Novo Synthesis
Prokaryotic cells
Mitochondrial enzymes
Orotate
Orotate
PRPP
Orotate phosphoribosyl transferase
irreversible
2Pi PPi OMP
H2O
OMP decarboxylase ← - UMP, CMP
CO2
UMP
Two domains of one enzyme - UMP synthase
Deficiency;
Anaemia
Increased excretion of orotate in urine
UDP dUDP
Ribonucleotide reductase
UTP
dUMP
CTP Synthase
(add amino group from glutamine)
CTP
Methylene H4 folate
[Permanently
bind to enzyme]
[-] 5-FdUMP
Thymidylate
Tetrahydrofolate
synthase
[-] Methotrexate
Dihydrofolate
NADPH + H+ reductase
Dihydrofolate
dTMP
NADP+
5 florouracil
[Thymine analogue
- suicide inhibitor]
Orotic aciduria
OTC
Ornithine Citrulline
Carbamoyl phosphate
HMP pathway
2) Salvage of pyrimidines
3) Pyrimidine Catabolism
Easily opened and degraded to soluble liver -alanine and -amino isobutyrate
Cytosine Thymine
NADPH
-Alanine
In living systems numerous metabolic pathways are operating simultaneously, and also they are
connected with each other.
So, each pathway needs to be able to “sense” the status of the other pathways.
Metabolism attempts to fulfill 3 needs of the organism,
ATP
Reducing power (NADPH, NADH)
Building blocks for biosynthesis
Glucagon plays a role in lipolysis in adipose tissue but the major activators of HSL, are the
Catecholamines.
Both Insulin & Glucagon affects the gene transcription of related enzymes.
Metabolic Pathways
Glycolysis Gluconeogenesis
Glycogen Synthesis Glycogen Breakdown
FA & Cholesterol synthesis FA β oxidation
TCA Cycle HM Pathway
Urea Cycle AA metabolism
Major Intermediates
1) Pyruvate
Alanine
Lactate
(LDH)
OAA (PC)
Glucose
AA (Gluconeo
Degradation genesis)
Lactate
(LDH)
NAG
synthesis
(Urea cycle)
AA
(degradat TCA Cycle
ion)
KB FA
(ketolysis) synthesis
Acetyl
CoA
FA (beta KB
oxidatio) synthesis
Pyruvate Cholesterol
(PDH) synthesis
Aerobic
Glycolysis
Ethanol
Oxidation
ETC
NADH
Beta
Oxidation
Pyruvate
to lactate
PDH
Reaction TCA Cycle
Compartmentalization
Metabolic fate of certain molecules depends on their location, which is regulated by location of
their relevant transporters & enzymes.
Portal blood is rich in absorbed nutrients and insulin secreted from pancreas.
Carbohydrate
G6P ↑
G6PD Activated
↑ HMP Pathway
NADP/NADPH ↓
LCFA ↑
Glucose 6
phosphate ↑
↑ Glycolysis FA Synthesis
Fat
a) Increased FA synthesis
↑ HMP ↑ NADPH
Proteins
Metabolism of all amino acids except Branched Chain Amino Acids (Val, Leu, Ile)
Liver AA catabolizing enzymes with high Km
Therefore, only excess AA are catabolized
Liver t-RNA charging enzymes low Km
Ensures metabolism of AA for hepatic protein synthesis
a) ↑ Protein synthesis
Only a transient increase in synthesis of hepatic proteins resulting in replacement of any
proteins that may have been degraded during fasting period.
b) ↑ AA degradation(excess)
More AAs are present than the amount that the liver can use in the synthesis of proteins
Excess is not stored but either released to blood or deaminated.
Resulting C skeletons
Carbohydrate
Carbohydrate
Skeletal muscle is unique in being able to respond to substantial changes in the demand for
ATP that accompanies muscle contraction.
↑ glucose uptake by GLUT 4
↑ Glycolysis - to provide energy needs.
↑ Glycogen synthesis (Particularly if glycogen stores have been depleted as a result of
exercise.)
Lipids
Amino acids
↑ Protein synthesis
↑ uptake of branched chain AAs (principle site for degradation of the BCAA)
Brain
Carbohydrate
Lipids
2) Fasting state
Two priorities: -
1. Need to maintain adequate plasma levels of glucose to sustain energy by metabolism of
brain, RBC & other glucose requiring tissues.
2. Need to mobilize FAs from adipose tissue & the synthesis & releasing of ketone bodies from
the liver to supply energy to all other tissues.
Liver
Carbohydrate
↑ glycogen degradation
Glycogen phosphorylase - activated
(↑ Glucagon and epinephrine levels→ phosphorylates glycogen phosphorylase)
Glycogen is nearly exhausted after 10-18 hours of fasting
Hepatic glycogenolysis is a transient response to early fasting
↑ gluconeogenesis
Substrate
Proteins → Gluconeogenic AA
TAG → Glycerol
Muscle → Lactate
F-2, 6-BP
Gluconeogenesis ↑ Glycolysis ↓
Lipids
a) ↑ FA oxidation
Liver cannot utilize ketone bodies - liver lacks thiophorase, an enzyme needed for its
degradation.
Carbohydrate
Lipids
Carbohydrate
↓ Uptake
Lipids
Proteins
During the first few days, there is some breakdown of protein → AAs → gluconeogenesis
Mostly Alanine & Glutamine
Catabolism of branched chain AAs
By several weeks’ rate of proteolysis decreases
After several weeks of starvation, when ketone bodies also reduce, proteolysis begins
Brain
Carbohydrate
Carbohydrate
Glutaminase
& GDH
BCAA breakdown (Muscle) → Glutamine α-KG + NH3
Diabetes Mellitus
2 types: -
1) Type 1 diabetes
2) Type 2 diabetes
1. Hyperglycaemia
Hyperglycaemia
Accelerated hepatic
gluconeogenesis using amino acids
obtained from peripheral tissues
2. Hypertriacylglycerolemia
Insulin resistance
Decreased ability of the target tissues (liver, adipose and muscles) to respond to
normal circulating concentrations of insulin.
Caused by weight gain and obesity.
Insulin resistance itself does not cause type 2 DM. Initially with insulin resistance,
insulin secretion by β cells increase causing hyperinsulinemia.
However, with time β cells dysfunction and insulin secretion decreases leading to type
2 DM.
1. Hyperglycaemia
Hyperglycaemia
Accelerated hepatic
gluconeogenesis using amino acids
obtained from peripheral tissues
Glucose homeostasis
The body naturally tightly regulates blood glucose levels as a part of metabolic
homeostasis.
In the Glucogenic state of the liver, when glucagon/insulin is high, action of glucagon
converts them to the phosphorylated form and activates them.
In lipogenic state, glucagon/insulin is low and these enzymes are inactivated.
Other enzymes are activated in lipogenic state
(Eg: - PFK2, glycogen synthase, ACC)
These enzymes are activated by dephosphorylation.
Metabolic Profiles
Liver
Skeletal muscle
Fuel(s)
Resting muscle - fatty acids
Highly active muscle
Initially - glycogen
During intense exercise - G-6-P, lactate
Adipose tissue
Brain
Heart Muscle
Kidney
Spermatogenesis – All the events by which spermatogonia are transformed into spermatozoa
begins at puberty.
CLEAVAGE
BLASTOCYST FORMATION
Fluid in the uterine
cavity penetrates the zona
pellucida into the intercellular
spaces of the inner cell mass.
Intercellular spaces
become confluent and forms a single cavity – blastocoel
At this time, the embryo is called the –
BLASTOCYST
BLASTOCYST
Outer cell mass (trophoblast) flattens to form the epithelial wall of the blastocyst.
Inner cell mass (embryoblast) is concentrated to a pole of the blastocyst.
The fluid filled cavity between the abembryonic pole and the embryoblast is the blastocoel.
HATCHING
The embryo getting out of the zona pellucida on the 5th day.
IMPLANTATION
On the sixth day.
Trophoblastic cells over the embryoblast pole penetrate into the uterine endometrium. (mucosa)
The endometrium is in the – SECRETORY PHASE
SECRETORY PHASE
o Coiled uterine glands
o Coiled uterine arteries
o Glycogen granules found in cells
Implantation occurs usually in the posterior (or anterior) wall of the uterus.
(Where it becomes embedded between the openings of the glands)
At the beginning – Blastocyst is partially embedded in the endometrial stroma. The embryonic pole of
the blastocyst is facing the endometrium.
The blastocyst is more deeply embedded in the endometrium and the penetration defect is closed by
a fibrin coagulum by day 9. Later the coagulum is replaced by endometrial surface epithelium.
Also, on day 9 syncytial vacuoles appear at embryonic pole, thus called lacunar stage of trophoblast .
Days 11 & 12
Uteroplacental circulation is established.
Cytotrophoblast
1. Columns of cells develop into the syncytium. - day 13
2. Known as ‘Primary Villi’ (outer layer of syncytiotrophoblast surrounding core of cytotrophoblast)
Therefore, the extraembryonic coelom separates the cytotrophoblast (lined internally by the
extraembryonic somatopleuric mesoderm) from the primitive yolk sac and amniotic cavity. (lined
externally by the extraembryonic splanchnopleuric and somatopleuric mesoderms respectively)
BUT the germ disc is connected to the trophoblast by a ‘connecting stalk’ made of extraembryonic
mesoderm.
Therefore, the only place where the extraembryonic mesoderm traverses the chorionic
cavity/extraembryonic coelom is the ‘connecting stalk’ - later becomes the umbilical cord
Extraembryonic mesoderm lining the inside of the cytotrophoblast is called the – chorionic plate
Therefore the exocoelomic cysts are found in the chorionic cavity / extraembryonic coelom
Secondary yolk sac is smaller than the primitive yolk sac.
Normal site of pregnancy: Posterior or anterior wall of the uterus
Sites of ectopic pregnancies: abdominal cavity, ovary, uterine tubes
GASTRULATION
Process that establishes the three germ layers (ectoderm, mesoderm, and endoderm) of the embryo
Therefore now,
The ectoderm is in continuation with the amnioblasts
The mesoderm is in continuation with the extraembryonic mesoderm (both splanchnopleuric and
somatopleuric)
The endoderm is in continuation with the cells of the secondary yolk sac
OROPHARYNGEAL MEMBRANE
Tightly adherent ectoderm and endoderm
Gives rise to the opening of the oral cavity in the
future
PRECHORDAL PLATE
Derived from some of the cells that
migrate through the primitive node in
the midline
Induction of the forebrain
development
located between notochord and
oropharyngeal membrane
NOTOCHORD
Represents the primitive skeletal
structure characteristic to the
chordates
Development of the Notochord
PRIMITIVE CHORD
A shallow groove in the ectoderm.
The migratory gateway of epiblast cells which form mesoderm and endoderm
CLOACAL MEMBRANE
Tightly adherent ectodermal and endodermal cells that later form the anal membrane and the
urogenital membrane (separated by the urorectal septum).
After the appearance of the cloacal membrane the posterior wall of the yolk sac forms a small
diverticulum which extends into the connecting stalk called – allantoenteric diverticulum /
allantois
Secondary villus –
Mesodermal core, covered by
cytotrophoblast and
syncytium
Then differentiation of
mesodermal cells into blood
vessels, to form Tertiary villi
EXTRAEMBRYONIC CIRCULATION
o Blood and blood vessels are derived from the mesoderm
o Mesoderm in the core of secondary villi, chorionic plate, connecting stalk and intraembryonic
mesoderm are in continuity
o Therefore when blood vessels develop in each of the above structures, a connected
extraembryonic, and intraembryonic circulation is established
o I.e.; capillaries in tertiary villi capillaries in the chorionic plate capillaries in the connecting
stalk intraembryonic capillaries
o The connecting stalk will develop into the umbilical cord eventually
o Cytotrophoblastic cells penetrate the syncytium until it meets the decidua basalis of the
endometrium.
o Neighboring
villi are connected forming a thin outer cytotrophoblast shell.
o These villi + cytotrophoblast shell firmly attaches the chorionic sac to the endometrium.
o Villi that extend from the chorionic plate to decidua basalis – anchoring/stem villi
o Villi branching from the sides of stem villi – free villi
Major features of the external body form can be recognized by the end of this period.
ECTODERM
Neurulation
o Ventral pathway
Sensory ganglia
Sympathetic neurons
Enteric nervous system
Schwann cells
Cells of adrenal medulla
MESODERM
1. Paraxial mesoderm
2. Intermediate mesoderm
3. Lateral plate mesoderm
The mesoderm beside the midline thickens and forms the paraxial mesoderm.
Lateral plate mesoderm splits into two, giving rise to a cavity the intraembryonic cavity which becomes
continuous with the extraembryonic cavity.
The mesodermal layer continuous with the extraembryonic somatopleuric mesoderm (covering the amniotic cavity)
becomes the parietal/somatic mesoderm.
The mesodermal layer continuous with the extraembryonic splanchnopleuric mesoderm (covering the yolk sac)
becomes the splanchnic/visceral mesoderm.
The unsplit mesoderm connecting the lateral plate and paraxial mesoderm is called the intermediate mesoderm.
Paraxial mesoderm
Become organized into segments – somitomeres- mesodermal cells organized in concentric whorls. (In the 3rd
week)
Formation
of somitomeres is cephalocaudal
From
occipital region caudally somitomeres further organize into - somites at around 3 per day for 15 days
SOMITE DIFFERENTIATION
1. Presomite mesoderm – ball of mesoderm
2. Arrange into a donut shape by epithelization
3. Differentiation
a. Sclerotome – form the vertebrae and ribs
b. Dermatome – form the dermis of the back
c. Myotome – form segmental muscular component
INTERMEDIATE MESODERM
ENDODERM
Endoderm forms the ventral surface of the trilaminar germ disc, which is the roof of the yolk sac
1. Cephalic folding
Cephalic part of the germ disc (head fold) folding towards the middle of the disc
The endodermal germ layer is incorporated into the body to form the foregut
2. Caudal folding
Caudal part of the disc (tail fold) including the connecting stalk fold towards the middle
Endodermal germ layer is incorporated into the body to form the hind gut
The allantois initially incorporated to the connecting stalk develops a connection with the hind gut forming
the cloaca – (discussed later in system based embryology)
3. Lateral folding
Lateral parts of the germ disc fold toward the anteroposterior midline(axis)
After folding the yolk sac is connected to the midgut by the vitelline duct
Lower part of the anal canal is developed from the ectoderm and is called the proctoderm
The upper part of the anal canal is derived from the endoderm
These two parts are separated by the cloacal membrane
Cloacal membrane ruptures in the seventh week
Therefore the endoderm basically forms the epithelial lining of the primitive gut tube, intraembryonic portion
of allantois, and vitelline duct.
So far learnt -
• Tertiary (& some secondary) anchoring villi are extending from the chorionic plate to the
cytotrophoblastic shell
• Uteroplacental circulation established
o Cytological process of erosion of maternal blood vessels – endovascular invasion
▪
Cytotrophoblast cells undergo – epithelial to endothelial transition
▪
Invade terminal ends of maternal spiral arteries
▪
Create hybrid vessels (of maternal and fetal origin)
▪
Connect the vessels to ‘lacunae’ / intervillous spaces
▪ The hybrid vessels are large – sinusoids – low resistance
• Extraembryonic vascular system established
• Free villi extend from stem villi to intervillous spaces
o Develop as buds from stem villi
o Initial structure
▪ Vascular mesoderm covered by
Decidua Decidua Basalis (Maternal part of placenta Decidua capsularis (degenerate later,
– endometrium) fuse with decidua parietalis)
TWINS
1. Dizygotic twins
2. Monozygotic twins
Dizygotic Twins
Fertilization of two ova by two different spermatozoa
• Genetically different zygotes
• Can be of same or different sex
• No more than the resemblance of brothers and sisters – fraternal
• Implant separately in the uterus
• Has separate placenta and all other fetal membranes for each embryo
• BUT if implanted close together, placentae, chorionic sacs can fuse
o Erythrocyte mosaicism?
Monozygotic twins
Develops from a single fertilized ovum
• Identical (morphologically, genetically, of the same sex)
Depending on the stage of separation monozygotic twin placentae and fetal membranes differ
Separation at
• Two cell stage (Zygote divides to form two zygotes)
• Earliest separation
• Two zygotes
• Separate implantation
• Separate placentae
• Separate chorionic sacs
▪
As in dizygotic twins the placentae and chorionic sacs can fuse if implanted close
by
• Early blastocyst stage (separation occurs in the inner cell mass only)
• Common chorion
• Common placenta
• Separate amnions
• After the appearance of primitive streak, node (partial splitting of primitive node, streak)
• Conjoined twins (craniopagus, pygopagus, thoracopagus)
• Common chorion
• Common placenta
• Common amniotic cavity
space created between the two layers of lateral plate mesoderm constitutes the primitive body
cavity
Visceral (splanchnic) layer of lateral plate mesoderm Visceral layer of pleural pericardial
and peritoneal cavity
Clinicals
Ventral body wall defects
1) Cleft sternum – thoracic region 3) Gastroschisis – abdominal region
2) Omphalocoele 4) Bladder or cloacal exstrophy – pelvic region
Cantrell pentalogy
1- Cleft sternum
2- Ectopia cordis
3- Omphalocele
4- Diaphragmatic hernia
5- Congenital heart defects (VSD, TOF) & pericardial defects
Development of diaphragm
Diaphragm is derived from 4 components.
1- Septum transversum
Is a thick plate of mesoderm occupying the space between the thoracic cavity and the
stalk of the yolk sac.
It is developed at cervical segments.
And during cephalocaudal folding it descends to thoracic level.
By dragging its nerve supply from C3, C4, C5, spinal segments (phrenic nerve).
And forms the central tendon of the diaphragm.
2- Pleuroperitoneal membranes
• Closes the foetal communication between pleural and peritoneal cavities. Form a part of
the diaphragm
3- Dorsal mesentery of the esophagus forms the crura of the diaphragm.
4- Fetal body wall forms the peripheral muscular rim.
Respiratory system
4th week of gestation
Fuse
Clinicals
Oesophageal atresia with or without tracheoesophageal fistula
upper portion of the esophagus ending in a blind pouch and the lower segment forming a
fistula with the trachea
Isolated esophageal atresia and H-type TEF without esophageal atresia
TEF associated other defects
1. Vertebral abnormalities
2. Anal atresia
3. Cardiac defects
4. Tracheo-esophageal fistula
5. Esophageal atresia
6. Renal abnormalities
7. Limb defects
Tracheo-esophageal fistula
• Respiratory diverticulum formed by ventral wall of the foregut.
• 2 longitudinal ridges appear
3 2
Secondary bronchi
Last 2 months
• Number of alveoli increases steadily
• Amount of surfactant increases in last 2 weeks
After birth
• Growth of lung is due to an increase in number of respiratory bronchioles and alveoli
(due to increase in size)
• New alveoli are formed (5/6 of adult alveoli) during 1 st 10 years of postnatal life)
Clinicals
Respiratory distress syndrome
Insufficient surfactant in premature babies
Alveoli coalesce during expiration
Treatment – Artificial surfactant (glucocorticoids to stimulate surfactant production)
Heart, all blood vessels and all blood cells originate from mesoderm.
Cardiac progenitor cells which are in the splanchnic layer of the lateral plate
mesoderm forms cardiac myoblasts.
Also, blood islands (blood islands - The innermost cells of these blood islands
are hematopoietic cells that give
rise to the blood cell lines. The
outermost cells give rise to the
endothelial cell layer of blood
vessels) which appear in the
mesoderm
A horse-shoe shaped cluster of cells called the primary heart field is formed.
These cells form the atria, left ventricle & part of the right ventricle.
The secondary heart field which is present in the splanchnic mesoderm gives
rise to the rest of the ventricle & the outflow tract.
Blood islands unite and forms a horseshoe shaped endothelial lined tube
(Endocardial Tube) that is surrounded by cardiac
myoblasts.
Endocardial tube- Primary heart tube
Heart initially formed as two parallel tubes on
either side of embryo, anterior to the
Oropharyngeal membrane
As a result of growth of the brain and
cephalic folding of the embryo the cardiogenic
field is brought ventrally thoracic region
As a result of the lateral folding of the
embryo the two parallel tubes merge and forms
the Heart tube
2) Cardiac looping
Day 23-28
Cephalic portion bends ventrally, caudally & to the right
Caudal portion shifts dorsally, cranially & to the left
Two methods.
1. By 2 actively growing tissue mass that approach each other or single mass
approaching the other end until they fuse. These tissue masses are called
Endocardial cushions.
Primitive atrium and primitive ventricle are separated by the formation of endocardial
cushions that form AV septum.
Endocardial cushions appear in the atrioventricular canal as superior, inferior and two
lateral.
They approach each other and fuse forming the left and the right atrioventricular
orifices.
AV Valves
Each AV orifice Is surrounded by local proliferations of mesenchymal tissue and flow of
blood hollows them out and the AV valves are formed
Membranous portion
The two ventricles are connected by
interventricular foramen which is above
muscular portion of the ventricular septum
The interventricular foramen is closed by
fusion of inferior endocardial cushion with
muscular part of interventricular septum
Conus septum also helps
2 swellings appear in the Conus cordis (Supported by the Neural crest cells)
1. R: dorsal
Unite each other → Unite with the Truncus septum →
Conotruncal septum → 2 Outflow tracts for two ventricles and
roots of aortic and pulmonary arteries
2. L: ventral
Neural crest cells migrate through the 3, 4, 6 Pharyngeal arches. They are important in
craniofacial development.
Therefore, heart defects and craniofacial abnormalities are associated.
Semilunar valves
Conducting System
SA node – Initial pacemaker lies in the caudal part of the left cardiac tube.
Then in the sinus venosus and finally in the right atrium as the sinus venosus
is incorporated into the R atrium.
AV node and bundle of His – derived from 1. Cells in the left wall of the sinus venosus.
2. Cells from the atrioventricular canal.
4) Vascular development
Vitelline arteries -Forms 2 arteries of the GUT (Coeliac & Superior mesenteric arteries)
Inferior mesenteric artery is derived from the umbilical arteries.
Umbilical arteries – Earlier arises from the dorsal aorta
Later from the common iliac arteries
After left to right shunting most of left sinus horn disappears and the right horn
enlarges greatly. All that is left of this sinus horn is
Oblique vein of the L: atrium
Coronary sinus
At the sinoatrial orifice (Opening of the sinus venosus to right atrium, R: & L:
venous valves are present.
The only remaining part, Inferior part of the R: venous valve →→ Valve of IVC,
Valve of Coronary sinus
The right sinus horn expands and is absorbed into right atrium →→Sinus venarum
Crista terminalis divides the trabeculated part& Sinus venarum of the right atrium
In the left atrium Initially → 1 Pulmonary vein → The pulmonary vein and its
branches are incorporated to the L: atrium → 4 Pulmonary veins
So smooth walled part of the L: atrium → from Pulmonary veins
Vitelline veins→ Plexus around the Duodenum→ Portal vein and the liver sinusoids
Proximal part of the R vitelline vein forms the hepatic part of the Inferior vena cava
LV
Ascending aorta (Coronary & Common carotid arteries receive well
oxygenated blood)
Receives blood from Ductus arteriosus (Mixes with blood from the RV –
As lungs are collapsed, Blood flow in lungs are negligible)
Changes at Birth
1. Closure of umbilical arteries medial umbilical ligament
2. Closure of umbilical vein ligamentum teres hepatis
3. Closure of ductus venosus ligamentum venosum
4. Closure of ductus arteriosus ligamentum arteriosum
Functionally closed just after birth (Muscular contraction)
Anatomical closure 1-3 months
5. Closure of foramen ovale
Up to 1-year closure is reversible
Lungs are functioning → Pulmonary venous return ↑ →LA
Pressure ↑
Clinicals
Atrial septal defects (ASD)
Females: Males= 1:2
Can be due to
1-Ostium secondum defect –
Excessive cell death (Enlarged ostium secondum). Too short septum secondum
2-Complete absence of atrial septum
3-Ostium primum defects
VSD – Ventricular Septal Defects
Most common cardiac congenital defect Usually involves the membranous portion
Often associated with abnormalities in partitioning of the conotruncal septum.
Dextrocardia
Cardiac looping to left instead of right. Related to the laterality establishment.
Associated with - situs inversus (complete reversal of all organs)
- reversal of some organs.
Tetralogy of Fallot
Due to an unequal division of the conus
1. Pulmonary infundibular stenosis 3. VSD
2. Hypertrophy of the right ventricle 4. Overriding Aorta
Persistent truncus arteriosus
The conotruncal ridges fail to fuse. VSD is always present.
Intercostal arteries get dilated and torturous erode lower surface of the ribs
(notching of ribs)
Right arm pressure increases & lower limb pressure decreases radio-femoral delay
endoderm
MESENTERY
1. Ventral Mesogastrium – Derived from the Septum Transversum
Foregut (only) => divided by the liver
Ventral part – Falciform, Coronary, Triangular lig.
Dorsal part – Lesser omentum
2. Dorsal Mesogastrium – Divided by the spleen
Ventral part – Gastrosplenic lig.
Dorsal part – Lienorenal lig.
Duodenum => Dorsal mesoduodenum
Midgut => Mesentery proper
Hindgut => Dorsal mesocolon
FOREGUT
Derivatives – Lung, Liver, Gall bladder & Pancreas
Supplied by – Celiac artery
1. Oesophagus
Tracheo-oesophageal septum separates – Dorsal oesophagus from the ventral trachea
At first it is short. It elongates with the descent of heart and lungs.
Surrounding splanchnic mesoderm forms the muscular coating Lamina Propria, Mucosa, Submucosa and
Adventitia
Abnormalities
I. Oesophageal atresia and/or Tracheo-oesophageal fistula
Due to - Posterior deviation of tracheo-oesophageal septum
Dorsal wall of foregut pushed anteriorly
II. Oesophageal stenosis (usually in lower 1/3rd) – Failure to Recanalize
2. Stomach
At fourth week begins as a fusiform dilation in foregut.
Rotations
I. 900 Clockwise in longitudinal axis
- Left side become anterior =>
Left vagal fibers – Anterior vagal trunk
- Right side become posterior =>
Right vagal fibers – Posterior vagal trunk
II. In anteroposterior axis
- Pylorus => to right & upwards
- Cardia => to left & downwards
Growth Difference
Posterior wall > Anterior wall
- Greater curvature => to the left
- Lesser curvature => to the right
Spleen (mesodermal origin), in the 5th week grows in the left leaf of dorsal mesogastrium with the
rotation of stomach around longitudinal axis, dorsal mesogastrium rotates to the left. Mesogastrium
between spleen and dorsal midline of the body fuses with the peritoneum over the posterior abdominal
wall and disappears and connect to the body wall in left kidney.
3. Duodenum
Formed by – both foregut &midgut (Therefore blood supply by both coeliac and superior mesenteric
arteries)
- Due to rotation of the stomach, it becomes ‘C’ shaped & rotates to the right.
- Right surface of the dorsal mesoduodenum presses against the posterior abdominal wall and disappears.
- Become retroperitoneal [secondarily]
- Duodenal cap – intraperitoneal
- Solidification => recanalization
- Liver bud appears as an outgrowth of endodermal epithelium, at the distal end of foregut (3 rd to 4th week)
- Hepatic cells of the liver bud proliferate & penetrate septum transversum
- Mesoderm of septum transversum forms hematopoeitic cells, kupffer cells, connective tissue
- Invasion by liver cells into the septum transversum forms
Lesser omentum – between liver & foregut
Falciform, coronary, triangular lig. – between liver & body wall
- Cranial surface of the liver remains in contact with the original septum transversum & forms the bare area
of the liver
- Connection between the liver bud & the foregut form the bile duct
-Bile duct moves dorsally due to rotation of duodenum
- Ventral out growth from the bile duct gives rise to the gall bladder & cystic duct
5. Pancreas
Abnormalities
I. Annular pancreas
- Ventral pancreatic bud usually consists of right & left parts which fuse & rotates around the
duodenum
- If they fail to fuse, left part migrates in the opposite direction
- But the right part goes in the normal direction
- Duodenum surrounded by the pancreatic tissue =>
Obstruction
II. Accessory pancreatic tissue
-It may show all characteristics of pancreas
Frequently found in => Mucosa of the stomach
Meckel’s diverticulum
-Can be found anywhere from distal end of oesophagus to
tip of primary intestinal loop
MIDGUT
Supplied by – superior mesenteric artery
Elongation of the gut & mesentery proper => Primary intestinal loop
At the apex, communicates with the yolk sac via the vitelline duct
Rotation
When viewed from the front -
Counterclockwise around an axis formed by the superior mesenteric artery
I. While herniating - 900 [6th week]
II. While retracting - 1800 [10th week]
Retraction
-During 10th week due to decreased growth of liver and adequate expansion of abdominal cavity and
regression of mesonephric kidney
- Herniated intestinal loops return to the abdominal cavity
- Cecal bud => Conical dilation of the primary intestinal loop
Last part of the gut to reenter the abdominal cavity
Then lies below the right lobe of the liver, which descends into the right iliac fossa
Distal end of the cecal bud => Appendix
-first to reenter abdominal cavity proximal part of jejunum
Mesentery of ascending & descending colon press against posterior abdominal wall =>
to become retroperitoneal
Abnormalities
Mesentery defects
I. Mobile caecum – Persistence of mesentery of ascending colon, without fusing
HINDGUT
Derivatives – Distal 1/3rd of transverse colon, descending colon, sigmoid colon, rectum, anal
canal(upper part)
(Endoderm of Hindgut also forms internal lining of bladder and urethra)
Supplied by – Inferior mesenteric artery
Terminal part of hindgut enters the posterior part of cloaca.
Allantois enters the anterior part of cloaca.
Urorectal septum (a layer of mesoderm) separates anterior Allantois & posterior hindgut. Those which enter
the cloaca, grows caudally with the caudal folding of embryo. Tip of urorectal septum comes close to cloacal
membrane.
Cloacal membrane ruptures
o Anterior opening – for the urogenital sinus
o Posterior anal opening – for the hindgut
In between urorectal septum forms perineal body.
Anal canal
-Upper 2/3rd – From endoderm of hindgut. Supplied by Superior rectal artery (branch of inferior mesenteric)
- Lower 1/3rd – From ectoderm around proctodeum. Supplied by inferior rectal artery (branch of internal
pudendal)
Junction is delineated by pectinate line just below anal columns (Epithelium => Columnar to Stratified Squamous)
Abnormalities
I. Imperforated anus – Failure to breakdown the anal membrane
II. Congenital megacolon (Hirschsprung Disease)–Dilation of colon due to absence of parasympathetic
ganglia in the bowel wall. Defect in neural crest cell migration.
III. Rectourethral/Rectovaginal fistula
- When the urorectal septum does not extend far enough caudally
- When the cloaca is too small, causing the opening of the hindgut to shift anteriorly
IV. Rectoanal atresia
Urinary system
Kidney system
Three slightly overlapping kidney systems formed In cranial to caudal sequence (in nephrogenic ridge)
Pronephros
Mesonephros
Metanephros
1. Pronephros 2. Mesonephros
Appear at the beginning of the 4th week and completely
Appear during the regression of the pronephros (4th week)
regress at the end of the 4th week
In cervical region In thoracic & upper lumbar
Non functional Functional in intrauterine life
No duct system Duct system – mesonephric duct
Completely disappears – Not associated to form any Important to produce genital organs. Not associated to form the
urogenital structure definitive kidney
Duct System
Clinicals
Congenital polycystic kidney disease –(Autosomal recessive) – cysts form from collecting ducts
o Kidney- very large. Renal failure occurs in childhood
Adult polycystic kidney disease- (Autosomal dominant) – Cysts form from all segments of the nephron
o Usually renal failure occurs in adulthood
Duplication of ureter – early splitting of ureteric bud (partial or complete)
One ureter may be ectopic. In such cases it may open into,
o Vagina
o Urethra
o Vestibule
Abnormal locations of kidneys
o Pelvic kidney - Remain in the pelvis close to the common iliac artery.
o Horseshoe kidney - Lower poles fuse due to fusion of two metanephric masses in the midline. So
ascent is blocked by inferior mesenteric artery. Ureters pass anterior to the isthmus.
Cloaca is divided into Urogenital sinus (anteriorly) and anal canal (posteriorly) by the Urorectal septum
Tip of the urorectal septum forms the perineal body
Urogenital sinus
o Upper part - Urinary bladder
Allantois (continuous with the upper part of the urogenital sinus) Urachus
median Umbilical ligament
o Pelvic part prostatic urethra & membranous urethra
o Definitive urogenital sinus ( phallic part) associate to form external genitalia/penile urethra
Trigone of bladder
Mesonephric ducts move close together to enter the prostatic urethra and become ejaculatory ducts
Mesonephric ducts and ureter originates from mesoderm. Mucosa of the bladder formed by incorporation of
the mesonephric duct (so trigone is also mesodermal)
With the time, mesodermal lining of the trigone is replaced by endodermal epithelium
(Finally, inside the bladder is completely endodermal)
Urethra
o Epithelium is formed by the endoderm
o Smooth muscles – by the splanchnic mesoderm
o In males; epithelium of the prostatic urethra proliferate to form the Prostatic gland
o In females; cranial part of Urethra give rise to urethral and para-urethral glands
Development of Ovary
Genital ducts
1. Mesonephric duct (Wolffian duct) - Duct system of Mesonephros
2. Paramesonephric duct (Mullerian duct)
o Connects the peritoneal cavity with cloaca
o Crosses the mesonephric duct (lateral to medial)
Genital ducts in males (mainly - mesonephric duct)
o Efferent ductules – remaining parts of the excretory tubules of mesonephric mesoderm
o Vas difference
Ejaculatory duct mesonephric/wolfian duct
Epididymis
Vagina
Fornix + upper part –uterine canal (paramesonephric duct)
Lower part –urogenital sinus (sinovaginal bulb vaginal plate)
Clinicals – Defects of vagina and uterus
External genitalia
Indifferent stage
o Cloacal folds – Slightly elevated
folds around the cloacal
membrane
o Genital tubercle – Fused cranial
part of cloacal folds
th
In 6 week – Urogenital membrane
Cloacal membrane
Anal membrane
Urethral folds
Cloacal folds
Anal folds
Genital swellings- Pair of elevations on each side of urethral folds
Clinicals
Hypospadias – Fusion of the urethral folds is incomplete
o Abnormal openings of the urethra occur along the inferior (ventral) aspect of the penis
(Near the glans, shaft or base of penis)
Epispadias – (rare) A ventral body wall defect
o Urethral meatus is found on the dorsum of the penis
o Associated with exstrophy of bladder
Mesenchyme Structure
Pharyngeal Arches
All the muscular components of each pharyngeal arch has its own nerve and arterial
supply
4 pairs
5th is rudimentary
Epithelial endodermal lining give rise to several structures
Thymus migrates in caudal and medial direction pulling inferior parathyroid with it &
then fuses with the counterpart from opposite side. (Final position – Anterior part of
thorax)
Pharyngeal clefts
Clinical
Birth defects
1) Ectopic thymic and parathyroid tissue
Accessory glands remain in the migration pathway
May found in the neck
Inferior parathyroids may found at the bifurcation of the common carotid
artery
3) Cervical cysts
Remnants of cervical sinus
Found anywhere along ant. border of SCM, frequently just below the angle of
jaw
Become evident in child head
Tongue
Thyroid Gland
Epithelial outgrowth from floor of the tongue - Foreman cecum (between tuberculum
impar and copula)
Connected to the tongue by thyroglossal duct
Descends in front of pharyngeal gut in midline
Descend in front of hyoid bone, thyroid & cricoid cartilages
Positioned in front of trachea in 7th week - with an isthmus & two lobes
Ultimobranchial body (4th pouch) – incorporated into the gland – give rise to C cells
Starts function at the end of 3rd month
o Follicular cells thyroxine & triiodothyronine
o Parafollicular cells( C cells) Calcitonin
Clinical
Thyroglossal Cyst
o Always in the midline
o Cystic remnant of thyroglossal duct
o 50% under hyoid bone
Thyroglossal fistula
o Thyroglossal cyst connected to the outside by canal
o May be present at birth
Aberrant thyroid tissue
o Remnants of tissue along the migratory pathway
Development of face
Nasolacrimal groove
Between maxillary & lateral nasal prominence
Floor forms a solid epithelial cord
By canalization forms nasolacrimal duct with lacrimal sac
Development of palate
Primary palate
o Formed by intermaxillary segment
Secondary palate
o Formed by palatine shelves of maxillary bones
Palatine shelves
Two shelf like outgrowths
Forms main part of palate
At 6th week directed obliquely by sides of the tongue
Later ascends and fuse with each other and nasal septum
Anteriorly fuse with primary palate
Incisive foramen is the landmark between primary and secondary palates
Clinical
1.Facial clefts
Two types- anterior and posterior cleft deformities
Incisive foramen is the landmark
Anterior Posterior
Lateral cleft lip Secondary cleft lip
Cleft uvula
Cleft upper jaw
Nasal cavities
6th week – nasal pits deepen
Oronasal membrane which separates it from nasal cavity disappears
Primitive choanae formed
Secondary palate develops
Definitive choanae formed
MCQ
1. In the development of the face
A. Mandibular process is derived from the second pharyngeal arch
B. Maxillary process is developed from the first pharyngeal arch
C. Nasolacrimal canal develops along the line of fusion of the frontonasal and
maxillary processes
D. Part of the upper jaw bearing the incisor teeth develops from the frontonasal
process
E. Forehead is formed from the maxillary processes
2. Regarding the pharyngeal and branchial arches
A. Cartilage of the first arch is called Reichet’s cartilage
B. Mesoderm of the 2nd arch gives rise to muscle supplied by the maxillary
division of the third cranial nerve
C. Palatine tonsils are derived from the endoderm of the second pharyngeal
pouch
D. Branchial cyst form the persistence of the epicardial ridge
E. Only blood vessels remaining from the 5th aortic arch on the right side is the
proximal part of the subclavian artery
3. In the development of the pharyngeal arches
A. Nerve of the 4th arch is the superior laryngeal
B. External acoustic meatus is derived from the 2nd pharyngeal cleft
C. Sphenomandibular ligament is a remnant of the 2nd pharyngeal arch cartilage
D. Greater and lesser horns of the hyoid bone have the same origin
E. Larynx is derived from cartilage of the 4th and 6th arches
4. First pharyngeal arch
A. Gives rise to the malleus and the incus
B. Is innervated by the trigeminal nerve
C. Gives rise to the palatine tonsil
D. Gives rise to the muscles of facial expressions
E. Gives rise to the external auditory meatus
Answers
1-FTFTF
2-FFTFF
3-TFFFT
4-TTFFT
5-FFFTT
Central nervous system appears at the beginning of the 3rd week as neural placodes.
Lateral edges elevate and form neural folds
Neural folds fuse forming neural tube
Closure of cranial neuropore 25th day
Closure of caudal neuropore 28th day
Clinicals
Ossification defects in bones of skull
Human DNA
Mitochondrial genes
• The only organelles outside the nucleus that have their own DNA (extranuclear DNA)
• Circular rather than linear
• Double helix arranged as rings (2-10 rings)
• Unique sequences rather than repetitive
• Slightly different genetic code
• Exclusively transmitted to next generation by mothers through oocytes.
Chromosomal structure & function
Somatic chromosome complements consist of 46 chromosomes (23 pairs).
22 pairs are Autosomes.
23rd pair is a pair of sex chromosomes.
Male-46, XY Female-46, XX
Chromatosome: the nucleosome plus the H1 histone occupying the linker region
Depending on the position of the centromere, chromosomes have short arms(p) / long arms(q)
Metacentric –Centromere is in the middle (p=q), ex: - 1, 3, 16, 19 and 20
Submetacentric - Centromere is displaced from the center (p< q), ex: - 6-12, X
Acrocentric- centromere is at one end (p<< q), ex: - 13-15,21,22 & Y
Telomeres
• Are ends of chromatids
• Specific telomeric proteins binds to this site forming a cap
Functions;
• prevent abnormal end to end fusion of chromosomes ensure complete replication of ends
• assist chromosome pairing in meiosis
• maintain stability/link chromosomes to the nuclear membrane during interphase and help
establish internal structure
• may be involved in aging process
• G banding: Uses the Trypsin and Giemsa • High resolution banding to detect
stain to detect numerical defects. micro deletions.
• Light band: Active-lightly stained bands, • Detect structural defects.
G-C rich.
MEIOSIS
• Before cell entering the meiosis, each chromosome will replicate its DNA
• Each chromosome resulting two sister chromatids
• In prophase l
• Chromosomes become visible as threads
• Homologous chromosomes pair
• Formation of synapsis
• Cross over of chromosomal material
• Further condensation of chromosomes
• Homologous pair begin to separate but held together at the point of cross over -
chiasmata
Additionally,
Meiosis Prophase 1:
The process of meiosis differs in males and females. In males this is a continuous process which begins in the
mature seminiferous tubules of adolescents. In females by birth the process is arrested in prophase 1 in a stage
called Dictyotene. After menarche with each ovulation meiosis 1 is completed and meiosis 2 begins. Meiosis 2
completes only following the entry of the spermatozoon into the egg.
PROPHASE I
METAPHASE I
ANAPHASE I
TELOPHASE I
METAPHASE II
division
ANAPHASE II
Mutation
• A heritable change in genetic material in less than
1% of the population
[More than 1% polymorphism]
• Occur in a coding or non-coding sequence
Mutations
Chromosomal Disorders
I. Polyploidy
Presence of more than 2 sets of chromosomes Ex: - triploids - 69, XXX
69, XXY
69, XYY
tetraploids
Imprinting is shown in triploidy [phenotypic expression varies depending on whether the extra set of
chromosomes are paternal or maternal in origin]
maternal: - small fetus, placenta is not cystic
paternal: - large head, cardiac anomalies, cystic placenta
Triploidy (69 chromosomes) may result from a failure of meiosis in a germ cell or dispermy. Tetraploidy
(92 chromosomes) results from a failure of the first cleavage division after fertilization.
II. Trisomy
• Presence of 3 copies of a single chromosome
• commonest cause is nondisjunction in meiosis I (80%)
• secondly in meiosis II (20%)
• in either sex (oogenesis 80%, spermatogenesis 20%)
• in early mitotic division of the zygote, anaphase lag.
• Most triosomic embryos are lost in early pregnancy. Usually only
trisomies 13,18 and 21 survive
Sex chromosomes:
Klinefelter syndrome: - 47 XXY or 48XXXY or 49XXXXY
• Adult phenotype is basically male though
• Gynecomastia
• poor musculature, eunuchoid habitus
• Feminine body hair distribution small genitalia
• Tall stature
• Long lower legs / forearm scoliosis/osteoporosis varicose veins and ulcers
• Infertility due to azoospermia or subfertility due to oligospermia are evident.
• Only 47XXY is accompanied with advanced maternal age [ intracytoplasmic sperm injection
ICSI is done]
XYY syndrome
• Karyotype-[47, XYY]
• Affected males have a normal physical appearance
• Problems in motor coordination
• Above average stature
• Mildly impaired intelligence
• Aggressive behavior
Triple X Syndrome
• Karyotype-[47, XXX]
• Affected girls are physically normal
• Taller than average
• Arises form an error in meiosis 1
III. Monosomy- autosomal monosomies are lethal but monosomy for X is compatible with life.
Turners syndrome: - 45X
• Phenotype basically female but streaky ovaries can be diagnosed prenatally
• Neck webbing, cutis laxa, shield shaped chest, coarctation of aorta, lymphoedema of hands
and feet,
• Short stature and cardiac murmur in childhood.
• Iry or IIry amenorrhea, lack of IIry sexual characteristics
• Estrogen replacement therapy should be initiated at adolescence
• Normal mentality.
4. Mosaicism
• Presence of two or more cell lines with different karyotypes in a person
• caused by chromosomal nondisjunction during mitosis
• Clinical feature depends on proportion of abnormality to normal cells
• The abnormal cell line may be confined to a particular tissue if the aberration took place in
the late embryonic or fetal development
• To multiple tissues if the changes took place in very early development. Ex: 46, XX/47, XX,
+21
Structural anomalies
1. Deletion
leads to a loss of chromatin
terminal deletions
• Ex: - cri du chat syndrome: - deletion of tip of the short arm
of the chromosome [ 5p] malformed larynx [cat like cry].
• low birth weights and have failure to thrive.
• round faces, low set ears, profound learning disability, Hypotelorism, epicanthic folds
micro deletions
• syndromes-Very small deletions often detected by high resolution banding.
Imprinting is seen chromosomal 15q
paternal: Prader -Willi syndrome
maternal: Angelman syndrome
detected only by special high-resolution banding.
Interstitial deletions
2. Isochromosomes
Formed when a chromosome with two chromatids splits at right angles to the normal
length wise separation seen in normal division. Chromosomes will have both short arms or
both long arms. Ex: - 20% of Turner Syndrome individuals
Down syndrome (long arm trisomy and short arm monosomy)
II. Reciprocal
• Breakage and then exchange of segments of chromosomes. Point of exchange may be
anywhere along the chromosome.
• No loss of chromosomal material.
Ex: Philadelphia chromosome – deleted chromosome 22 in which long arm has been
translocated to the long arm of chromosome 9. Used to indicate prognosis of chronic
myeloid leukemia (CML) & acute lymphocytic leukemia.
The absence of the Ph chromosome in CML indicates bad prognosis.
III. Insertional
• Insertion of a deleted segment of a chromosome interstitially or inside another
chromosome following a break at that point
• Insertion of a deleted segment of a chromosome interstitially or inside another
chromosome following a break at that point
Other anomalies
Fragile X syndrome:
• More frequent in males
• Tip of the long arm of X is fragile.
• Speech delay, mental retardation with moderate educational sub normality. triangular
• Face, prominent mandibles, macrochidism, closely set eyes, large ears.
• Females with fragile x are mentally normal.
Birth defects
Genetic Non-genetic
(Mendelian inheritance)
Autosomal dominant
Vertical inheritance –Transmission of the trait
continues from generation without skipping.
Both sexes are affected equally.
Every affected child has an affected parent except for a
new mutation.
Affected heterozygous + normal homozygous = risk 50%
Autosomal Recessive
Only manifest in homozygous genes.
Horizontal inheritance.
Both sexes affected.
Normal parents, some normal offspring with affected
siblings among them.
Parental consanguinity increases the incidence.
Heterozygote male + heterozygote female. →25% risk
Carriers –usually normal, exception-sickle cell anemia
Certain racial groups →recessive genes at higher
frequency
If the recessive genes are alleles, all the children of two
affected parents are affected.
X- linked recessive
Y-linked
-Directly from father to son.
-No father to daughter transmission
-Hairy ears, webbed toes.
-Only males are affected.
Multifactorial Inheritance
Genes + environment → final outcome – occurrence of the disease depends on the environmental
conditions at which both the parents and offspring live.
Accounts for the majority of congenital malformations and responsible for many normal variations in
humans.
Mitochondrial Inheritance
Inheritance is matrilineal
- Only mothers transmit the condition to both sexes
Tissue rich in mitochondria are mostly affected
- Heart
- Striated muscle
- Kidney
- CNS
Dark-affected
Both 1 & 2 parents are affected but they
have an unaffected child
This is possible in Autosomal dominant
disorders & that is enough to identify.
Lymphocytes
T cells
4. Memory T cells
B cells
Structure:-
Lobulated.
Invested by loose collagenous capsule.
Interlobular septae arise from the capsule.
No afferent lymphatics.
Outer cortex – deeply basophilic
Inner medulla – eosinophilic
Immature T lymphocytes enter thymus through Post capillary venules
Thymic epithelium forms blood thymic barrier.
Cortex
- Highly cellular. T cells present.(maturing thymocytes)
- Mitotic figures present.
- Undergo further maturation as they move deeper.
(Cortex to medulla)
Medulla
- Dominant feature – Epithelial component
- Hassall’s corpuscles present
- contain dendritic cells
At the end of their journey through thymus mature T cells enter blood vessels and
lymphatics.
Thymus secretes hormones throughout life.(Thymosine)
LYMPH NODE
Structure:-
Bean shaped.
Surrounded by collagenous capsule.
Trabeculae extend from the capsule
Afferent lymphatics pierce the capsule.
Afferents drain in to subcapsular sinuses.
Then through cortical and medullary sinuses.
Lymph drains in to efferents at the hilum. One efferent usually
Blood vessels also enter and leave at the hilum.
Two zones : Outer cortex and central medulla
Lymphoid follicles
PALATINE TONSIL
Organized lymphoid tissue is found in all parts of GI tract except in the stomach.
Largest aggregates are Peyer’s patches of SI. (non encapsulated)
SPLEEN
Structure:-
Surrounded by a thin fibroelastic outer capsule.
Trabeculae extend into parenchyma.
Macroscopically-white nodules in a red matrix
White nodules represent white pulp.
Red matrix represent red pulp.
White pulp
- contains lymphoid aggregations.
- is of two types T cells & B cells.
- small fraction (5-20%) of total mass.
- T cell areas surround central arteries forming
periarteriolar lymphoid sheath (mainly TH cells).
- B cells form follicles.
Red pulp
- is vascular tissue.
- consists of parenchyma with an interconnected
network of venous sinuses.
Splenic vasculature
- Splenic artery branches repeatedly.
- Central arteries are surrounded by a cuff of lymphoid
tissue.(PALS) – Periarteriolar lymphatic sheath (contain
TH cells)
- Central arteries give off penicilliary arteries at right
angles.
- Penicilliary arteries terminate in 2-3 sheathed
capillaries.
- Sheathed capillaries are blind ending capillaries
surrounded by macrophages instead of endothelial
cells.
Epithelia - glands
Exocrine glands
Structure
Compound
1.Tubular 2. Acinar 3. Tubulo – acinar
- Brunner’s glands of - Pancreas - Submandibular salivary glands
duodenum 3 types of secretory units
I. branched tubular
II. branched acinar
III. branched tubular with
acinar ends(demilunes)
3. Epithelia
a) At region of adherent junctions the cytoskeleton is attached to the BM.
b) Gap junctions play an important role in cell recognition in embryonic development.
c) BM is a thickened area of connective tissue which has no fibers.
d) In apocrine secretion the entire cell disintegrates during secretion.
e) At region of adherent junctions the cytoskeleton is attached to the BM.
f) Gap junctions play an important role in cell recognition in embryonic development.
g) BM is a thickened area of connective tissue which has no fibers.
h) In apocrine secretion the entire cell disintegrates during secretion.
Origin: - Mesoderm
Types: - Loose connective tissue
Dense connective tissue
Adipose tissue
Bone & cartilage
Cells of immune system
Composition: - 1. Cells
2. Extracellular matrix
3. Blood vessels & lymphatics
II. Myofibroblasts
- Contractile function, tissue repair after damage
III. Adipocytes
Lipoblasts ==> Adipocytes
- Store energy
-Regulate fat uptake & release
Ground substance
- Transparent molecules
- Semi fluid gel
- Fibers are embedded
- Formed by GAGs
Fibers
- Collagen (secreted as tropocollagen)& elastin
Collagen – Type 1 fibrous supporting tissue
Type 2 hyaline cartilage
Type 3 (reticulin) supporting framework (Of lymphoid tissue, bone marrow)
Type 4 Basement membrane
Type 7-anchoring fibrills(link ECM to BM)
- Elastin – stretching & elastic recoil
Short, branching, secreted as tropoelastin
Deposition requires fibrillin
Basement membrane
Constituents- GAGs- heparin sulphate
Fibers- collagen type 4
Glycoproteins- fibronectin, laminin, entactin (Nidogen1)
Reticuloendothelial system/Macrophage phagocytic system
Function; - 1. Phagocytose particular matters, microorganism, affected cells
2. Store iron & certain metabolic products
6. T/F
a) Type I collagen is found in bone.
b) Reticulin fibers are formed from type II collagen.
c) Type III collagen is found in hyaline cartilage.
d) The arrangement of the tropocollagen is responsible for the branching pattern.
Excitable Tissue
Muscles (Contractile Tissue)
Histology
1. Extremely elongated
2. Unbranched
3. Cylindrical cells
Functioning
Large motor nerves “motor unit”
(Fasciculation)
Cardiac muscles
Histology Sarcomere
- Long cylindrical - mitochondria with closely packed cristae
- Branching fibers - glycogen granules
- Some striations - well developed sarcoplasmic reticulum
- 1 -2 central nuc. - T tubule system in Z line
- Intercalated discs
Junction between 2 cells
Smooth muscles
- Continuous contractions
- Contraction of whole muscle
- Spindle shaped cell
- Independence of neurological innervation
- Elongated spindle shape with tapered ends
- Central single nuc.
- No striations
- Invaginations of plasma membrane “calveolae”(not unique)
Contractile proteins
Actin (tropomyosin) & Myosin (only bind to actin) in Criss-cross
Nerve system
1. Somatic 2. Autonomic
Neurons
Structure
Cell body Processes Nucleus – large,
Nucleus Axons Prominent
Perikaryon Dendrites
(Cytoplasm) Nissl bodies - RER
(Darkly stained)
*Lack in axons
Types
Axons
Synapses
Structure
- Nerve fibers form fascicles
- Surrounding layers of supporting tissue
- Rich blood supply
- Fibers follows a zig zag, longitudinal course (for stretching of the nerve)
- Supporting cells – schwann cells
Ganglia
- Aggregations of neuronal cell bodies located outside the CNS
- Cell bodies – surrounding satellite cells ( structural & metabolic support )
- Capsulated by supporting tissue
Meninges
1. Dura mater – Dense fibroelastic layer, lined by flat cells
-Strongest layer
-Skull: - merges with the periosteum
Subdural space
2. Arachnoid mater – Cobweb like
- Pia + Arachnoid = Leptomeninges leptomeninges
(Both found together)
Subarachnoid space
3. Pia mater – Delicate, glia limitants
- formed of collagen, elastin, fibroblasts
8. Regarding nerves
a) In unmyelinated nerves conduction is salutatory.
b) Action potential is generated in the cell body.
c) Myelin sheath of an axon is formed by several Schwann cells.
d) Myelin is absent in Ranvier nodes.
e) In the CNS the myelin sheath is formed by oligodendrocytes.
9. T/F
a) Has mesaxons wrapping spirally around the?
b) Have the axons in the extracellular compartment within the Schwann cell.
c) Ranvier nodes conduct impulses in a continuous manner.
d) Most of the nuclei which are seen in the fascicle belong to the neuron.
e) Wavy bands of nuclei are a characteristic feature.
Cartilage
Cells
Perichondrium
- At the periphery of mature cartilage tissue
-Zone of condense tissue
-Collagen fibers & spindle shaped fibroblasts
Types
1. Hyaline Cartilage
2. Fibro Cartilage
3. Elastic Cartilage
1. Hyaline Cartilage
- Translucent, homogenous appearance
- Small aggregations of chondrocytes
2. Fibro Cartilage
-resistance to stretching
-collagen fibers in dense bundles
3. Elastic Cartilage
- Equal to hyaline cartilage
- Many branching elastin fibers
- gives flexibility
Formation
- Mesenchymal cell
- Differentiate into chondroblasts
- They divide & secrets ground substance & fibers
- Clusters of mature cells—chondrocytes
Nutrition
Most of cartilage devoid of blood vessels
Substance diffuse through ECM
In thick cartilage-- “cartilage canals” convey small vessels into cartilage mass
Bone
Cells
1. Osteoblasts 2.Osteocytes
-Synthesize osteoid - assist in nutrition of bone
-Mediate the mineralization - large, inactive osteoblasts
- Inside the large lacunae
Periosteum
- Condensed fibrous tissue
- Inner layer – contain osteoprogenitor cells & osteoblasts
Sites: - outer shed of the bone
*Diaphysis
Types
1. Woven bone
-immature bone—fetal skeleton
-- fracture sites
2. Lamellar bone
Regular parallel bands of collagen sheets
Formation
1. Intra membranous ossification membrane bone
Sites: - clavicle
Vault of skull
Mandible (most part)
Mesenchymal cells
Remolding of bone
Osteoclastic & osteoblastic activity
Repair of bone
13. Osteoclasts
b) Has mesenchymal origin.
c) Are within the howship’s lacunae.
d) Cytoplasm is basophilic.
e) Are multinuclear cells.
Regional differences
8. −cuboidal
Respiratory epithelium
bronchioles − Clara cells
− Goblet cells
Lymph capillaries are not found in alveolar wall. But present in walls of respiratory
bronchioles and above
Surface epithelium
Pleura
Lined by mesothelium – flattened cuboidal cells with surface microvilli
Outer parietal pleura
Inner visceral pleura – contains fibrous septa, lymph vessels, blood vessels and capillaries
Conducting System
Modified cardiac muscle fibres, subendocardial purkinje fibres (larger than normal
muscle fibres)
Has no T tubule system
Connect with each other by desmosomes, gap junctions rather than intercalated discs
Pericardium
Consists of outer fibrous pericardium and
inner serous pericardium
Fibrous pericardium is made of fibrous tissue
Serous pericardium is a thin double layered membrane lined by mesothelium
Outer layer of serous pericardium – parietal pericardium is fused with
the fibrous pericardium
Inner layer of serous pericardium – visceral pericardium (epicardium) is
fused to the heart
Mesothelial cells are flattened epithelial cells that secrete a fluid for
lubrication
Myocardium – Cardiac muscle
Endocardium
Line the cavities of the heart and
continuous with blood vessels
Consists of simple squamous epithelium
Sub epithelial layer (beneath the epithelium) consists of fibrous tissue and
elastic fibres to prevent endocardial damage during contraction
Heart valves
Lined by thin endothelium layer with a fibro-elastic tissue core (collagen and
elastin)
Avascular
A sinus is present around the valve to facilitate opening and closing of the valve
Central fibroelastic core – lamina fibrosa
Tunica intima
− Consists of endothelium and subendothelium
− Endothelium is a single layer of simple squamous epithelial cells lying on a
basement membrane
− Intercellular junctions connect the cells together
− Cytoplasm contains membrane bound organelles that store and secrete
substances important in blood clotting
− Sub endothelium consists of fibroblasts and myointimal cells
− Fibroblasts secrete collagen fibres
− Myointimal cells have a contractile function and responsible for lipid
accumulation with age
Tunica media
− Consists of smooth muscle, collagen and elastin
− Smooth muscles contain receptors for adrenal medullary hormones to
control the diameter of the vessels
− Elastic arteries have a high content of elastin fibres and low content of
smooth muscles. Elastin fibres are arranged as sheets with collagen in
between
− Muscular arteries have a high content of smooth muscles and elastin
fibres are arranged in two well defined sheets
1.Internal elastic lamina – between tunica intima and media
2.External elastic lamina – between tunica media and tunica adventitia
Tunica adventitia
− A fibrous connective tissue, consists of collagen and elastin
− Vasa vasorum are small arteries in the adventitia of large arteries (eg:-
aorta) that supply the thick wall. They penetrate outer half of tunica
media
Arterioles
Micro-circulation
Sinusoids
Arterioles
− Smooth muscles > elastin
− Major site of controlling peripheral resistance
Micro-circulation
− Composed of smallest blood vessels (small arterioles,
metarterioles, capillaries, venules, AV shunts)
− Capillaries contain only a tunica intima with a single layer of
flattened endothelial cells resting on a basement membrane
and pericytes
− Nuclei bulge in to the lumen
− Pericytes are flattened cells with a contractile function. They surround
the endothelial cells
− At origin of each capillary, Pre-capillary sphincter found
Capillaries
Metarterioles
− Larger diameter capillaries
− Discontinuous outer layer of smooth muscles
− Make direct communication on between arterioles & venules
Venous system
Venules
Post capillary venules size increases
Collecting venules tunica media acquire more smooth muscles
Muscular venules Usually thickest layer is adventitia
Veins
Lymphatic system
Wall structure is similar to veins
Contain valves
Endothelium – extremely thin cell cytoplasm
− Basement membrane is rudimentary or absent
− No pericytes
1.Mucosa epithelium
Lamina propria
Muscularis mucosa
2.Submucosa supportive tissue collagenous fibres
Blood vessels, lymphatics
3.Muscularis propria smooth muscle (Inner circular and outer longitudinal)
(oblique layer present innermost in stomach)
4.Serosa loose supportive tissue, lined by mesothelium
Meissner’s plexus- in submucosa
Myenteric plexus/ Auerbach’s plexus – between 2 muscle layers of muscularis propria
Fundus/body pylorus
Glands- straight tubular Glands- Branched coiled tubular
Occupies ¼ of thickness of gastric mucosa Occupies half the thickness of the mucosa
Small Simple columnar Lining cells of villi – Mucosa – contain folds called villi
intestine epithelium with 1.Enterocytes (simple Lamina propria forms the core of each
villi and crypts of columnar with microvilli) villus containing loose connective tissue,
Lieberkühn 2.Goblet cells lymphoid cells, lymphatics and capillaries
Crypts contain Paneth cells -
simple tubular Defensive function
glands Base of crypts
Neuroendocrine
cells
Stem cells – at the
crypt bases
Lymphocytes
Plasma cells –
secrete IgA
Plicae circularis -
Submucosa and mucosal folds
Colon and Simple columnar Goblet cells No villi but crypts present
rectum epithelium Straight tubular glands in mucosa(main
feature)
Crypts – goblet Absorptive Smaller aggregates of lymphocytes in
cells cells submucosa
Taeniae coli formed by longitudinal
muscle layer in muscularis propria
appendix Simple columnar Goblet cells Prominent lymphoid tissue in submucosa
with goblet cells Tall columnar cells No villi
Crypts present
Anal canal Simple columnar Above the pectinate line mucosa forms
above the longitudinal folds called anal columns
pectinate line Upper ¾ - circular muscle layer forms the
Stratified internal anal sphincter
squamous below Outer longitudinal muscle layer is thin
the pectinate Outer to this is the external anal
line sphincter made of skeletal muscles
Lower 8mm
resembles true
skin with sweat
and sebaceous
glands
Villi longest in duodenum, Shortest in ileum
Lymphoid – most important in the ileum (payer’s patches)
Goblet cells – number high distally
Plicae circularis – absent in proximal duodenum & distal ileum. More prominent in
jejunum & proximal ileum
2. Gastroduodenal junction –
No change in the type of epithelium
Pyloric sphincter – thickening of circular layer
3. Ileocecal junction -
No change in the type of epithelium
Contains a valve formed by thickening of muscularis propria
4. Anorectal junction –
No change in the type of epithelium
Hepatic acinus
Functional unit of liver
Ellipsoid mass of hepatocytes
Lies between 2 or more terminal
hepatic venules
Centered on a portal tract
Divided into 3 zones
Zone 1 – closer to portal tract, receive
more oxygenated blood
Zone 2 – intermediate in oxygen
supply
Zone 3 – receive less oxygen, more prone to ischaemic injury
Pancreas
• Exocrine component- secretory acini and duct system
• Endocrine component –islets of Langerhans
β-cells-insulin α-cells-glucagon δ-cells-somatostatin
• Acinar cells –> intercalated ducts –> intralobar ducts –> interlobular duct (small ducts- cuboidal, large
ducts - stratified cuboidal) pancreatic duct
• Tunica vaginalis
- Double layer of mesothelium (parietal and visceral)
- Mesothelial cells secrete serous fluid
- Covers the testis except posteriorly
- Collection of fluid within tunica vaginalis is called Hydrocele
• Tunica albuginea(capsule)
- Dense fibrous tissue with fibroblast and myofibroblast
- Thickened posteriorly to form the mediastinum testis
- Incomplete fibrous septa arise from the mediastinum testis and
divide the testis into lobules
• Deepest layer (Tunica vasculosa)
- Lines the inner surface of lobules
- Loose connective tissue
- Blood vessels
- Lymphatics
Seminiferous tubules
• Tubules within testicular lobules
• Tightly packed, highly convoluted
• Each lobule has 1-4 seminiferous tubules
• Production of spermatozoa
• Tubules lining cells(stratified)
-germ cells
-non germ cells: Sertoli cells (support and nourish
spermatozoa)
• Between tubules (interstitial space)
-Leydig cells
-Very vascular
• Seminiferous tubules converge upon the mediastinum testis which consist of plexus of channels
known as Rete testis
Rete Testis
• Surrounded by highly vascular collagenous supporting tissue containing myoid cells.
• The rete testis is lined by a single layer of cuboidal epithelial cells with surface microvilli and a single
cilium.
• Myoid cell contraction helps to mix the spermatozoa and move them towards the epididymis.
• The lining epithelium reabsorbs protein and potassium from the seminal fluid.
Epididymis
• The epididymis is a long extremely convoluted duct extending down the posterior aspect of the testis
to the lower pole where it becomes the ductus deferens.
• The epididymis consists of a head at the upper pole of the testis, a body lying along the posterior
margin and a tail at the lower pole of the testis.
• The major function of the epididymis is the accumulation, storage and maturation of spermatozoa in
the epididymis, the spermatozoa develop motility.
• The epididymis is a tube of smooth muscle lined by a pseudostratified epithelium with stereocilia.
• Smooth muscle wall changes from single to 3 layers distally
• Proximally, the smooth muscle exhibits slow rhythmic contractility which gently moves spermatozoa
towards the ductus deferens.
• Distally, the smooth muscle is richly innervated by the sympathetic nervous system which produces
intense contractions of the lower part of the epididymis during ejaculation.
• The epithelial lining of the epididymis exhibits a gradual transition from a tall pseudostratified
columnar form in the head, to a shorter pseudostratified form at the tail.
Ductus deferens
• The ductus (or vas) deferens, conducts spermatozoa from the epididymis to the ejaculatory ducts.
• It is a thick-walled muscular tube consisting of inner and outer longitudinal layers and a thick
intermediate circular layer.
• Like the distal part of the epididymis, the ductus deferens is innervated by the sympathetic nervous
system, producing strong peristaltic contractions to expel its contents into the urethra during
ejaculation.
• The ductus deferens is lined by a pseudostratified columnar epithelium.
• Epithelium and lamina propria are highly folded
• The dilated distal portion of each ductus deferens, known as the ampulla, receives a short duct
draining the seminal vesicle, thus forming the short ejaculatory duct; the ejaculatory ducts from each
side converge to join the urethra as it passes through the prostate gland
Seminal vesicle
• Each seminal vesicle is a complex glandular diverticulum of the associated ductus deferens.
• Between them the seminal vesicles secrete up to 85% of the total volume of seminal fluid,
most of the rest being secreted by the prostate gland.
• The epithelial lining is usually of a pseudostratified tall columnar type.
• The prominent muscular wall is arranged into inner circular and outer longitudinal layers
and is supplied by the sympathetic nervous system; during ejaculation, muscle contraction
forces secretions from the seminal vesicles into the urethra via the ampullae
• Irregular, honeycomb shaped lumen
Follicular Maturation
1. Primordial follicle
Contains the primary oocyte (large nucleus, small cytoplasm)
Surrounded by a single layer of flattened follicular cells
2. Primary follicle
Primary oocyte enlarges
Follicular cells proliferate to form cuboidal shaped granulosa cells (zona granulosa)
Zona pellucida – glycoprotein and proteoglycan rich acellular layer between granulosa
cells and primary oocyte
Surrounding stromal cells (fibroblasts) organize to form a cellular layer around zona
granulosa called theca folliculi
4. Graffian follicle
Initially contains the primary follicle
Just before ovulation, primary oocyte completes the 1 st meiotic division and forms the
secondary oocyte
Follicular antrum enlarges
Zona granulosa forms an even layer around the periphery of the follicle (cumulus
oophorus diminish)
Corona radiata – a thick cellular layer around zona granulosa, attach to ZG by thin bridges
of cells
During ovulation, secondary oocyte, zona pellucida, corona radiate are released from the
ovary
5. Corpus luteum
Contains granulosa and theca lutein cells
Granulosa cell are large polygonal cells with round nuclei and abundant cytoplasm, SER,
mitochondria, lipid droplets and lipofuscin (yellow colour)
Theca externa – dark staining
Theca interna – pale staining due to the presence of lipid droplets
Fallopian tube
Mucosa contains branched longitudinal folds
3 types of cells line the mucosa
- Ciliated tall (showing irregular cell margin)
- Non-ciliated secretory cells (prominent in ampulla)
- Intercalated cells
Non-ciliated cells secrete substances to take ova forward with the aid of cilia
2 layers of smooth muscles
Serosa – vascular, covered by mesothelium, cont. with the broad ligament
(1) Endometrium - Epithelium lining tall, columnar cells with microvilli or cilia
Form numerous simple tubular glands supported by endometrial stroma
Histological layers
1. Stratum compactum stratum functionalis – undergo cyclical changes
2. Stratum spongiosum functional layers are shed off during menstrual phase
3. Stratum basalis No shedding during menstrual cycle
-columnar cells (cilia or microvilli) Tall columnar cells Functional layers shed
-glands-initially simples tubular, straight, sparse Coiled tubular glands off due to the absence
But proliferation is started (saw tooth appearance) of implantation
Lined by tall columnar cells Tall columnar cells Stratum functionalis
undergo ischaemia due
to spasm of spiral
arteries
-gradually stroma become thicker, very cellular Stroma reaches to the
maximum thickness, highly
vascular
-Blood vessels less More blood vessels
When taking endometrial curettings/biopsies the first day of last menstrual cycle is very important
Uterine cervix
Endocervix –lined by simple columnar epithelium
Ectocervix – lined stratified squamous epithelium
Cervical canal
Lined by tall columnar mucous secreting cells
Leukocytes are more between junction of endocervix and ectocervix (external os)
Cervical cytology
Cervical smear /pap test
Vagina
(1) Epithelium – stratified squamous, non-keratinized
Superficial cells of epithelium form glycogen
anaerobic
Glycogen respiration lactic acid (inhibit growth of microorganisms)
Nephron
Structural and functional unit of kidney
Nephron = renal corpuscle + renal tubule (from Bowman’s capsule to collecting
ducts)
Renal corpuscle = Bowman’s capsule + glomerulus
PCT DCT
Lumen smaller Larger
Cell size Larger than DCT cells Smaller than PCT cells
Nuclei Less in cross section More in cross section
Brush border Present due to microvilli Absent
Juxtaglomerular apparatus
Specialization of glomerular afferent arteriole and DCT of the same nephron
Situated near the glomerular vascular pole
Function – regulation of blood pressure
Urinary bladder
• Bladder is histologically similar to the structure of lower 1/3rd of the Ureter
• So, muscle layers are arranged as inner longitudinal, outer circular and outermost
longitudinal. All together these smooth muscle layers are known as Detrusor muscle
• Epithelium is thrown in to folds in relaxed state
Urethra
Male urethra is lined by stratified or pseudo stratified columnar epithelium (Except
prostatic urethra which is lined by transitional epithelium)
External urethral meatus is lined by Stratified squamous epithelium (This become
continuous with epithelium of glans) refer
Epidermis
Layers cell types
Stratum basale Keratinocytes
Stratum spinosum Melanocytes
Stratum granulosum Langerhan cells
Stratum corneum Merkel cells
Stratum basale – single layer of cells
Cuboidal/low columnar cells
basement membrane- dermal epidermal junction
Epidermal cell renewal – mitotic figures
Stratum spinosum – prominent epidermal layer
Large cuboidal cells / polyhedral cells
Cells synthesis protein cytokeratin
Desmosomes are seen as spines
Desmosomal bridges used to diagnose epithelial tumours
Stratum granulosum – cytokeratin aggregate (tonofibrils) + keratohyalin granules
(involucrin) = keratin
Stratum corneum – by keratin
Damage to the basement membrane causes separation of the epidermis from the
dermis, followed by fluid accumulation in the space resulting in the formation of
blisters.
Breast
Modified apocrine sweat gland
Compound tubulo-acinar gland
Changes during pregnancy
1. Secretory acini – number increased
- Dilated
- Lining cells contain secretory vacuoles that later secrete colostrum
2. Intralobular tissue and intralobular adipose tissue – less
Breast carcinoma – confined to the breast lobule
Clinicals
Nodular hyperplasia - increased activity of thyroid tissue nodules
Grave’s disease – all follicles active at the same time
2. Hypothalamus 3. Pituitary gland (hypophysis) 4. Parathyroid gland
Nerve tissue - Anterior pituitary Usually 2 pairs
Neurosecretory cells Fenestrated capillaries – facilitate hormone passage Within thyroid capsule
Glial cells (supporting Cell types identified with immunohistochemical technique – Rich vascular network
cells) – somatotrophs, lactotrophs, thyrotrophs, gonadotrophs, -Principal cells/chief cells-
Blood vessels corticotrophs secrete PTH
Cell types identified with H and E stains -Oxyphil cells-degenerate
-chromophils (basophils, acidophils), chromophobes form of principle cells,
One cell type secretes a single hormone increase in number with age
Different cells are localized in different zones
Posterior pituitary
– Neurosecretory activity
– Dilated end of axons – herring bodies
Adrenal gland
Cortex – mesodermal in origin
- Secrete glucocorticoids (ex:-cortisol), mineralocorticoids (ex:-aldosterone),
sex steroids (ex:-testosterone)
Medulla – neural crest cells
- Secrete epinephrine, norepinephrine
Vasculature – subcapsular plexus short and long cortical arteries sinusoids
Venules central vein
Cortex – zona glomerulosa, zona fasciculata, zona reticularis
Pineal gland
Flattened, cone shaped structure
Degenerate after childhood
In adults, seen as a calcified structure in the midline in X-rays
Cells – pinealocytes, secrete melatonin and serotonin
Pineal sand – salts of Ca, Mg is a characteristic feature increasing with age
Endocrine pancreas
Islets of Langerhans – group of secretory cells surrounded by a capsule
- Scattered among exocrine tissue
- Surrounded by a network of fenestrated capillaries
- Largely found in the tail of pancreas
Identification Increased in
Neutrophil Nucleus with 3-5 lobes, granulated Bacterial infection
(decreased – viral infection, TB)
Eosinophil Nucleus with 2 lobes, reddish orange Chronic hypersensitivity – asthma,
staining with granules parasitic infections
Basophil Highly dense granules, deep blue or purple Immediate hypersensitivity – allergy
granules, small marginal cytoplasm Viral infection
Malignant disease
Monocyte Kidney shaped nucleus, non-granulated Bacterial infection (acute and chronic)
cytoplasm Malignant disease
Lymphocyte Large round nucleus, thin non-granulated Viral infection, chronic lymphocytic
cytoplasm leukaemia
(decreased: AIDS, lymphocytopenia)
Eosinophil
RBC
Platelets Neutrophil
Lymphocyte
Basophil
Monocyte
➢ Macrohaematocrit method
• Items needed – Wintrobe tube, Anticoagulant (1.5%
EDTA), Centrifuge
• Blood: EDTA ratio = 10:1
• Reading – Fraction or Percentage of the volume of
the red cell column out of the total blood volume
• Reading is expressed as a percentage. (%- no unit)
• when taking the reading buffy coat should be excluded
• Precautions
✓
Haematocrit should be determined ideally within 6 hours
of collection of blood.
✓
Blood sample should not be haemolysed as it will yield
falsely low results.
✓
Anticoagulant volume should not affect the total blood
volume.
✓
Air bubbles should not be included in the tube
Wintrobe tube
➢ Microhaematocrit method
• Items needed – capillary haematocrit tube (heparinised), micro haematocrit reader, micro
haematocrit centrifuge, anticoagulant Heparin
• Precautions
• When aligning the height of the plasma column, get the lower margin of the meniscus of the
plasma column.
• Exclude the buffy coat when aligning the height of the red blood cell column.
1.Newborn : 0 - 2 mm/hour
2. Children : 3 -13 mm/hour
3. Women
range for ages 18 to 50 years : 0 - 20 mm/hour
range for ages > 50 years : 0 - 30 mm/hour
Normal maximum = (Age in years+10)/2 mm/hour
4. Men
range for ages 18 to 50 years : 0 - 15 mm/hour
range for ages > 50 years : 0 - 20 mm/hour
Normal maximum = (Age in years)/2 mm/hour
• ESR increase with age, females > males, pregnancy (due to increase in fibrinogen concentration)
• Increased in – severe anaemia, tuberculosis, rheumatic fever, malignancies, osteomyelitis, Renal
diseases (e.g. end stage renal failure, nephrosis), Gastrointestinal diseases (e.g. Cholecystitis,
peritonitis, acute pancreatitis)
• Decreased in – polycythaemia, red blood cell abnormalities e.g. spherocytosis & sickle cell
anaemia, protein abnormalities, severe leucocytosis
• Heparin should not be used as an anticoagulant as it alters the zeta potential of RBCs.
• The tube should not be kept in direct sunlight or path of draughts, surface on which the stand is
kept should be flat, horizontal and should not vibrate.
• Advantages
✓ Inexpensive and easy to perform
• Disadvantages
✓ Fresh blood samples are required.
✓ Low sensitivity and specificity.
• Slide method;
❖ Clumping of RBC observed after adding antisera
❖ Anti A- Blue Anti B- Yellow Anti D – colourless
Centrifuge Centrifuge
Observe Observe
Tube method
Items needed – Haemocytometer (counting chamber), microscope, cover slip, mouthpiece, lancet,
cotton wool, surgical spirit
• For RBC counting – RBC pipette (red colour ball inside) is filled with blood and RBC counting fluid.
This fluid lyses WBC. (1:200 dilution)
• For WBC counting – WBC pipette is filled with blood and WBC counting fluid. (this fluid lyses RBCs).
(1:20 dilution)
RBC pipette
WBC pipette
• Bleeding time is the time taken to stop bleeding from small subcutaneous vessels which have
been severed by a standard lancet.
• Tests vascular response (vasoconstriction) and platelet response (platelet plug formation)
• Items needed – circular filter paper, stopwatch, standard sterile blood lancet
• Reading – I min + (no. of gaps x 30s)
• Normal range – 1 – 5 minutes
• Increased in
✓ Thrombocytopenia - reduction in platelet
count E.g. Dengue fever, bone marrow
malignancies
✓ Thrombasthenia - abnormality of platelet
function.
✓ Do not allow the blotting paper to press on the bleeding site as it may interfere with
bleeding.
Ring electrodes are placed on index finger which receives sensory fibres from median nerve
𝐷𝑖𝑠𝑡𝑎𝑛𝑐𝑒 𝑏𝑒𝑡𝑤𝑒𝑒𝑛 𝑝𝑟𝑜𝑥𝑖𝑚𝑎𝑙 𝑎𝑛𝑑 𝑑𝑖𝑠𝑡𝑎𝑙 𝑠𝑡𝑖𝑚𝑢𝑙𝑎𝑡𝑖𝑛𝑔 𝑒𝑙𝑒𝑐𝑡𝑟𝑜𝑑𝑒𝑠
Conduction velocity =
𝐷𝑖𝑓𝑓𝑒𝑟𝑒𝑛𝑐𝑒 𝑏𝑒𝑡𝑤𝑒𝑒𝑛 𝑝𝑟𝑜𝑥𝑖𝑚𝑎𝑙 𝑎𝑛𝑑 𝑑𝑖𝑠𝑡𝑎𝑙 𝑙𝑎𝑡𝑒𝑛𝑐𝑖𝑒𝑠
Electromyography
1. Electrocardiogram (ECG)
ECG waveforms
Pulse
Rate
Rhythm
Volume
Character
Radio-femoral delay coarctation of aorta
1. The patient should either be seated or lying comfortably. He should have rested for
at least 3 minutes prior to blood pressure measurement.
2. The sphygmomanometer is placed at the same level of the cuff on the patient’s arm
and the observer’s eye level.
3. The arm should be horizontal and at the heart level.
4. The center of the bladder should be positioned over the line of the artery.
5. Feel the patient’s brachial (or radial) pulse and inflate the cuff to a pressure above
which pulse can no longer be felt.
The point of disappearance of pulse represents the systolic pressure.
6. Place the stethoscope gently over the brachial artery.
7. Inflate the cuff further to raise the pressure to 30 mmHg above the systolic blood
pressure as estimated by palpation.
8. Deflate the cuff at 2-3mmHg per second, listening carefully to the appearance of
Korotkoff sounds.
Phase 1
Appearance of tapping sound
Indicates systolic pressure
Phase 2 and 3
Sounds get louder as more blood enters brachial artery
Phase 4
Sounds become muffled
JVP is the pressure exerted on internal jugular vein during cardiac cycle.
Assessed from visible wave form of the internal jugular vein.
Only seen, not felt.
JVP is an indirect measure of central venous pressure (CVP) which is the pressure
in the great veins at their entrance to the right atrium.
Important,
Volunteer lies on a bed with the head end raised to 45 0 angel.
Measure the vertical height between the highest level of internal jugular vein
pulsations and sternal angel. This value in cm H2O is JVP.
To obtain CVP, add 5cm to the measurement since right atrium lies 5cm below
the sternal angle.
Uses of PEFR
o Identifying obstructive airway disease, air way narrowing
o Monitor progression of asthma
o To adjust treatments
3. Spirometry
o Is a method of studying pulmonary ventilation by recording the movement of air
in and out of the lungs.
VC-Begins with full inspiration but the patient is asked to exhale fully but slowly.
FVC- Same except the patient has to exhale as fast as and hard as he/she can.
In healthy individuals, there is no/little difference in volume vise.
Voluntary hyperventilation
After hyperventilation
Period of apnoea shallow breathing Period of apnoea shallow
breathing
This happens periodically until PACO2 level becomes normal.
Items required:
1. Bicycle ergometer (To perform the isotonic exercise)
2. Hand dynamometer (To perform the isometric exercise)
3. Stop watch
4. Mercury thermometer
5. Measuring tape
6. Stethoscope
7. Sphygmomanometer
Hand dynamometer
Bicycle ergometer
Results in isometric exercise
Respiratory 14 20 15
rate(breaths/min)
1. Pulse rate: heart rate increases in both types of exercises from the beginning by decreasing
parasympathetic stimulation on SA node.
2. Blood pressure:
In isotonic exercises- systolic blood pressure increases as CO increases. But vasoactive
metabolites cause vasodilatation resulting decreased diastolic blood pressure.
After exercise BP may fall transiently (persistent vasodilation by metabolites while the CO
has decreased).
In Isometric exercises systolic and diastolic blood pressure sharply increased. Compression
of vessels leads to increased diastolic blood pressure.
4. Oral temperature: Total heat production of the body exceeds increased total body heat
dissipation. So, core temperature will increase in both exercises.
5. Calf circumference:
Fluid transudation to interstitial fluid increases. Despite of increased lymph
flow, calf circumference still increases in both types of exercises
Dilation of blood vessels.
20
30
40
50
Refractometer
Digital machine
Can display the osmolality of an unknown sample when calibrated by a known sample.
Urine osmolality can be varied from 50 mOsm/kg – 1400 mOsm/kg.
Urine analysis
1. Macroscopic examination
This includes assessment of
Quantity - volume or amount of the urine
Colour - normal urine ranges from colourless, pale yellow to amber
Appearance - normal urine is clear or slightly cloudy
A- Haemoglobinuria
B- Haematuria
C- Bilirubinuria
D- Concentrated urine
E- Diluted urine
F- Pyuria (pus in urine)
2. Microscopic examination
Take a urine sample a. Types of casts
Then centrifuge it. Hyaline, red cell, white cell, epithelial
Discard the fluid at the top cell casts
Examine the drops of fluid remaining b. Types of crystals
in the bottom under microscope Calcium oxalate, triple phosphate urate
Cells, crystals and casts are observed crystals
and reported as number observed c. Types of cells
per low power field (LPF) or high- RBCs, WBCs, epithelial cells
power field (HPF).
1. Examination of muscles
• Inspection
Inspect the muscles for
Wasting
Fasciculations
Abnormal movements
And Skin for scars
• Lower limb
Knee reflex (L3)
Ankle reflex (S1)
Plantar response
Planter response
4. Examination of gait
Observe for posture, base, length of strides and speed arm swing, symmetry, balance and any
abnormality
4. Facial nerve
• Inspect for facial asymmetry
• Motor examination
• Test for weaknesses in
Raising eyebrows and observe for loss of
wrinkling
Sensory areas which are checked
Closing eyes tightly
when examining the divisions of
Blowing cheeks out trigeminal nerve
Showing teeth
6. Accessory nerve
• Ask patient to shrug the shoulders against resistance (Trapezius)
• Ask patient to turn the head to the side against resistance (sternocleidomastoid)
7. Hypoglossal nerve
• Ask the patient to protrude the tongue
• Inspect for tongue atrophy, fasciculations or asymmetry in movement.
o Damage to lower motor neuron
Atrophy, fasciculations
Deviation of tongue to affected side o Damage to upper motor
neuron
Deviation of tongue away from the affected side
Vision
1. Visual acuity
a. Visual acuity is the shortest distance by which two lines can be separated
and still perceived as two lines.
1. Confrontation method
2. Perimetry
Perimetry is mapping the peripheral visual fields using a perimeter that flashes lights
randomly at various points in the visual field.
Important: During the test, bring the light to the front of patient’s eye from the side to
avoid discomfort.
1 Both direct and consensual reflexes Both direct and consensual light reflexes
are lost. are present.
3 Both direct and consensual reflexes Both direct and consensual light reflexes
are lost. are present.
• Patients are given colour plates and asked to identify the number/trace the line they see
within 3 seconds.
• Colour of the figure and colour of the background will look similar to a patient with a
• particular form of colour blindness, so that the patient cannot distinguish the figure
from the background.
• The type of colour deficiency can be diagnosed according to the chart used.
1. Accommodation
2. Convergence of visual axes
3. Pupillary constriction
2. Sensorineural deafness
Ex: i. Damage to hair cells, cochlear nerve or/and organ of Corti.
ii. Acoustic neuroma
iii. Hereditary defects
iv. Infections, Inflammations (mumps, meningitis)
v. Transverse facture of the petrous temporal bone
Hearing tests
Turbidity
2. Precipitate Monosaccharide
did not appear is absent
2. A tube – No Haemoglobin
colour change absent
B tube – No
colour change
(Control tube)
E) Bile Pigments