Solution Key The Language of Medicine 12th Edition (2023)

Table of Contents Instructions for Online Access Cover Image Title Page Dedication Preface WELCOME TO THE 12TH EDITION OF THE LANGUAGE OF MEDICINE NEW IN THE 12TH EDITION HOW TO USE THE BOOK ALSO AVAILABLE Acknowledgments Reviewers Chapter 1 Basic Word Structure Objectives in the study of medical language

Word Analysis Exercises Answers to Exercises Chapter 2 Terms Relating to the Whole Body Structural Organization of the Body Abdominopelvic Regions and Quadrants Divisions of the Back (Spine) Positional and Directional Terms Body Plan Exercises Answers to Exercises Chapter 3 Suffixes Introduction A Word Analysis Exercises Closer Looking Exercise Answers Chapter 4 Prefixes Introduction Looking Closer Exercises

Exercise Answers Chapter 5 Digestive System Introduction Anatomy and Physiology Pathology of the Digestive System Pathological Conditions Exercises Exercise Answers Chapter 6 Additional Suffixes and Terminology of the Digestive System Introduction Laboratory Tests and Clinical Procedures Exercises Exercise Answers Chapter 7 Urinary System Introduction Anatomy of Major Organs Physiology: How The Kidneys Produce Urine Urinalysis Pathology Terminology: Kidney, Bladder, and Associated Conditions Laboratory Tests and Clinical Procedures

Exercises Exercise Answers Chapter 8 Female reproductive system Introduction Organs of the female reproductive system Menstruation and pathology of pregnancy: Gynecological, breast, pregnancy and neonatal clinical tests and procedures Exercises Exercise Answers Chapter 9 Male reproductive system Introduction Anatomy Pathological conditions; Sexually Transmitted Infections Laboratory Tests and Clinical Procedures Exercises Answers to Exercises Chapter 10 Nervous System Introduction General Structure of the Nervous System

Neurons, nerves, and glial cells Brain Spinal cord and meninges Pathology Laboratory tests and clinical procedures Exercises Answers to exercises Chapter 11 Cardiovascular system Introduction Blood vessels and blood circulation Anatomy of the heart Physiology of the heart Pathology of blood pressure: The Heart and Blood Vessels Laboratory Tests and Clinical Procedures Exercises Answers to Exercises Chapter 12 Respiratory System Introduction Anatomy and Physiology of Respiratory Pathology

Clinical Procedures Exercises Answers to Exercises Chapter 13 Blood System Introduction Blood Composition and Formation Blood Types Pathological Coagulation Laboratory Tests and Clinical Procedures Exercises Answers to Exercises Chapter 14 Lymphatic and Immune Systems Introduction Lymphatic and Immune System Introduction Lymphatic System Immune System Pathological Conditions Laboratory tests and clinical procedures Exercises Answers to exercises

Chapter 15 Musculoskeletal System Introduction Pathology Bones: Bones Joints Pathology: Joints Muscles Pathology: Muscles Laboratory Tests and Clinical Procedures Exercises Answers to Exercises Chapter 16 Introduction to Skin Anatomy of the Skin Accessory Structures of the Skin Pathology Laboratory Tests and Clinical Procedures Exercises Answers to exercises Chapter 17 Sense Organs Introduction

Ocular refractive errors Pathology: The Eye Clinical Procedures: The Eye Ear Pathology: The Ear Clinical Procedures: The Ear Exercises Answers to Exercises Chapter 18 Endocrine System Introduction Thyroid gland Parathyroid glands Adrenal glands Pancreas Pituitary gland Ovaries Tests Pathology Laboratory tests Procedures clinicians

Exercises Exercise Answers Chapter 19 Cancer Medicine (Oncology) Introduction Tumor Characteristics Carcinogenesis Classification of Cancer Tumors Pathological Descriptions Classification and Staging Systems Cancer Treatment Laboratory Tests Clinical Procedures Exercises Exercise Answers Chapter 20 Radiology and Nuclear Medicine Introduction Radiology Nuclear Medicine Exercises Exercise Answers

Chapter 21 Pharmacology Introduction Drug names, standards, and references Drug administration Drug actions and interactions Drug toxicity Drug classes Exercises Exercise answers Chapter 22 Psychiatry Introduction Psychiatric clinical symptoms Psychiatric disorders Treatment modalities Exercises Exercise answers Mini dictionary A B C D

E F G H I J K L M N O P Q R S T U V W X Y Z

Glossary Appendix I Plurals Appendix II Abbreviations, Acronyms, Eponyms, and Symbols Abbreviations Acronyms Eponyms Symbols Appendix III Reference Values of Normal Hematology and Implications of Abnormal Results Appendix IV Medications Illustrations Credits Index Chabner makes medical terminology MEMORABLE... Students.. Instructors... Order Now!

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Copyright THE LANGUAGE OF MEDICINE, 12TH EDITION ISBN: 978-0-323-55147-2 Copyright © 2021, Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without the written permission of the publisher. Details on obtaining permissions, more information on publisher permission policies, and our agreements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found on our website: www. .elsevier.com/permissions. This book and individual contributions contained in it are copyrighted by the publisher (except as noted herein).

Disclaimer Physicians and researchers should always rely on their own experience and knowledge when evaluating and using any information, methods, compounds, or experiments described in this document. Due to rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages must be performed. To the fullest extent of the law, Elsevier, the authors, publishers or contributors assume no responsibility for any injury and/or damage to persons or property as a matter of product liability, negligence or otherwise, or for any use or operation of any method, product, instruction or idea contained in this material. Previous editions are copyrighted 2017, 2014, 2011, 2007, 2004, 2001, 1996, 1991, 1985, 1981, and 1976.

Library of Congress Control Number: 2020932476 Senior Content Strategist: Linda Woodard Senior Content Development Manager: Luke Held Publishing Services Manager: Julie Eddy Senior Project Manager: Abigail Bradberry Design Director: Amy Buxton Printed in Canada The last digit is the print number: 9 8 7 6 5 4 3 2 1

Dedication to Gus, Amari, Solomon, Bebe, Ben and Louisa You guys make it all worth it.

Preface

WELCOME TO THE 12TH EDITION OF THE LANGUAGE OF MEDICINE The continuing focus of this new edition is its cutting-edge relevance to real-life medical practice. Drawing on the latest state-of-the-art medical technology, procedures and treatments, The Language of Medicine brings medical terminology to life. Newly designed dynamic images and updated photography, plus compelling patient stories, further illustrate medical terminology in action. I am honored that this book continues to be the book that instructors return to year after year because their students say it works! As a student, you will find that The Language of Medicine speaks to you, regardless of your background or level of education. It is written in simple, non-technical language that creates an exceptionally accessible learning path. Because it is a blended textbook, you participate and interact on virtually every page, writing and reviewing terms, labeling diagrams, and answering questions. Terminology is explained so that you understand medical terms in their proper context, which is the structure and function of the human body in health and disease. Throughout the process of writing this text in its 12 editions, I have listened to hundreds of students and instructors and incorporated their thoughtful suggestions. Expert medical reviewers again helped me ensure that the terminology included reflects the latest clinical practice. The new information and illustrations are the result of the recommendations of all those who so generously provided feedback. My continuing goal in writing The Language of Medicine is to help you not only learn medical terminology, but also enjoy learning! You'll find medical terminology comes alive and stays with you when you use my interactive, logical, and easy-to-follow approach. No doubt, studying this language requires commitment and hard work, but the benefits are great. Knowledge of medical terminology will give you a good start in your career.

NEW IN THE 12TH EDITION The biggest advantage for both students and teachers is the new MINI-DICTIONARY at the end of the book. This is a comprehensive list of all medical terms in the text with easy-to-understand explanations. I thought I'd provide an immediate and convenient way to find definitions, view pronunciations, and check answers for all terminology sections. It will also be a useful reference not only during your course but also when you start your new medical career!

While the essential elements of The Language of Medicine remain relevant, the new 12th Edition is even more relevant to real-life medical situations. The 12th Edition includes helpful tips to point out important facts and set the record straight. There are also new first-hand stories about medical conditions and procedures. These personal accounts make medical terminology more understandable and relevant.

HOW TO USE THE BOOK The Language of Medicine facilitates learning. The book guides and coaches you step by step through the learning experience. Don't get overwhelmed! Approach learning systematically, step by step. I helped him study each chapter by organizing the information into small chunks. Icons are provided to help you navigate through sections of the text.

ALSO AVAILABLE Student Development Resources (free access included with purchase of this book) The student website that accompanies this new edition is packed with activities, games, additional information, and video clips to broaden your understanding and test your knowledge . In addition, on the website you can listen to the terms corresponding to the Pronunciation of terms section of each chapter (more than 3,000 terms in total). Access his resources at: http://evolve.elsevier.com/Chabner/language.

INSTANT MEDICAL LANGUAGE TRANSLATOR (sold separately) The Instant Medical Language Translator is an exceptionally useful resource for all healthcare professionals and students of medical terminology. It's a pocket medical terminology reference with convenient information at your fingertips!

INSTRUCTOR RESOURCE MANUAL The Language of Medicine Instructor Resource Manual (includes the instructor manual, ExamView test bank, PowerPoint presentations and a collection of images) is now available with even more new quizzes, teaching tips, crossword puzzles, medical reports and reference material. The Image Collection contains all the figures and photos from the 12th Edition. Instructor materials and an online test suite can be accessed at hp://evolve.elsevier.com/Chabner/language. The foundational features you rely on for learning and teaching medical terminology remain robust in this new edition. Those are:

• Simple, non-technical explanations of medical terms. • Workbook format with ample space to write answers. • Explanations of clinical procedures, laboratory tests, and abbreviations related to each body system. • Sections for pronunciation of terms with phonetic spelling and spaces to write the meanings of the terms. • Sections of Practical Applications with clinical cases, surgical and diagnostic tests, laboratory reports and radiographs. • Exercises that test your understanding of terminology as you move through the text step by step

step (answers are included). • Review sheets that collect terminology to help you study. • Comprehensive glossaries and appendices for reference in the classroom and at work. Every student and teacher who chooses The Language of Medicine becomes my partner in the exciting adventure of learning medical terms. Continuity is crucial. Please continue to contact me via email ([emailprotected]) with your suggestions and comments so that future printing and publishing can benefit. A website connected to The Language of Medicine and dedicated to helping students and teachers is located at hp://evolve.elsevier.com/Chabner/language. I hope you'll let me know what additional features you'd like to see on this site so we can make it an even more useful part of the learning process. You should know that I still feel the excitement and joy of teaching new students. I love being in a classroom and I feel privileged to continue writing this text. I hope that my enthusiasm and passion for medical language is transmitted to you through these pages. Work hard but have fun with The Language of Medicine!

DAVI ELLEN CHABNER

Acknowledgments Maureen Pfeifer has been my extraordinary and indispensable editorial collaborator for the past 22 years. Her phenomenal experience in all facets of communication, coordination, production, editing, updating and management is incredible. She has the unique ability to "make things happen" and "make things right". Personally and professionally, I am grateful for her vision and her unique capabilities. She is smart, calm, and optimistic about any issues that affect The Language of Medicine and her helpers. Above all, I rely on her loyalty and confidence that we are creating an eminently useful and valuable textbook and resource for students and instructors alike. Thank you, Maureen, for all you do for me, especially when you take things off my plate. Bruce A. Chabner, MD, and Elizabeth Chabner Thompson, MD, MPH, continue to be incredible resources to me for up-to-date and expert medical advice. Their contributions were fundamental in the revision and edition of all the chapters and glossaries. My devoted friend, Dan Longo, MD, never turned down my valuable medical advice and chapter editing. It was also a wonderful resource to help identify expert reviewers. Jim Perkins, Assistant Professor of Medical Illustration, Rochester Institute of Technology, has been associated with The Language of Medicine since its sixth edition. He worked with me to create layouts that are not only informative but essential in making terminology more understandable. I came to trust his unique talent for clarity, precision, and detail. I am grateful to the many medical reviewers listed on pages xv-xvi who provided essential advice and commentary on specific chapters. Their insights and experience make this 12th edition a reflection of what is current, accurate, and modern in medicine today.

The classroom instructors listed on pages xvi-xvii have reviewed the text extensively and carefully, and I have listened to their comments, which are incorporated into this new edition. Many other instructors contacted me personally via email with helpful suggestions. I am always happy to hear from students commenting on the book and asking important questions. I try to answer each of them as quickly and accurately as possible. Thanks to Shulamit Izen, Vashine Kamesan, Stephanie Kitchingham, Alfred Kyrollos, Rachel Recolcolin, Megan Peterson, Christina Sastre, Julia Sjoquist, Victoria Swanson, and Lan Wang. The personal stories throughout the text are firsthand personal accounts from people who deal with diseases and medical procedures. The writers of these stories are extraordinarily generous in sharing their views and reactions so that we all benefit. A very special thanks to: Stan Ber, Nancy J. Brandwein, Mary Braun, Bruce A. Chabner, Lenore Estrada, Sidra DeKoven Ezrahi, Elizabeth F. Fideler, Tanzie Johnson, Kevin Mahoney, Frank McGinnis, Brenda Melson, John Melson, John Murphy, Laura Claridge Oppenheimer, Carolyn Peter, Bob Rowe, Ruthellen Sheldon, Elizabeth Chabner Thompson, Cathy Ward, and Kemisha White. The excellent team at Elsevier Health Sciences continues to be vital to the success of The Language of Medicine. Luke Held, Content Development Manager, is always responsive, available, and efficient in managing many project details. Thanks to Linda Woodard, Sr. Content Strategist, for her expert management and ongoing support of my books. I am grateful to Annie Martin, Director of Book Production, Jeff Paerson, Manager of Book Production, and Julie Eddy, Manager of Publishing Services, for their outstanding production efforts. Abbie Bradberry, Book Production Specialist, has tirelessly and efficiently handled the day-to-day aspects of the production process. Thank you Abby! Kim Denando and Amy Buxton created and directed the design for this issue. I appreciate your expertise and responsiveness. I continue to be impressed by the talent of the entire marketing team, especially Julie Burche, Senior Director of Product

Portfolio Marketing and Samantha Page, Marketing Manager, Product Portfolio Marketing. They do a phenomenal job keeping The Language of Medicine in tune with the needs of both instructors and students. Thanks to Manju Thirumalaivasan, Senior Media Producer and Prakash Kannan, Media Team Leader, for their work on the electronics associated with this new edition. A very special thank you note to the amazing and dedicated sales team at Elsevier Health Sciences who are second to none. Led by Bryan Gripka, Vice President of Sales, this dedicated team works tirelessly to bring my books and learning system to market. You are the best!!! My family and friends continue to be my greatest comfort and support. The children, Noonie, Brandon and Marla, are always “in my corner”. The grandchildren, Bebe, Solomon, Ben, Gus, Louisa and Amari make me feel “on top of the world”. Juliana DoCarmo, by managing so many day-to-day responsibilities, she gives me the luxury of being able to work and focus. I am grateful to photography expert Bob Williams, who continues to provide expert imaging advice throughout the book. My husband, Bruce, has always encouraged my passion for teaching and writing, giving me the space and time to enjoy both. I count on his peace of mind and willingness to answer all medical and non-medical questions. Finally, our canine children, Ginger and Fred, continue to be the love of our lives, providing countless hours of excitement and fun.

Reviewers The following people reviewed the text and/or assistants: MEDICAL REVIEWERS Elizabeth Chabner Thompson MD, MPH CEO/Founder of Masthead Scarsdale, New York Bruce A. Chabner MD Clinical Director, Allen Distinguished Investigator Emeritus Professor of Medicine, Cancer Center Massachusetts General Hospital Harvard Medical School Boston, Massachusetts s Lisa Caulley MD, MPH Otolaryngology/Head and Neck Surgery The O'awa Hospital, Canada Michael J. Curtin MD Medical Director, St. Luke's Sports Medicine Orthopedic Surgery and Sports MedicineSt. Luke's Clinic Boise, Idaho Morris A. Fisher MD A late neurologist Edward Hines Jr. Veterans Hospital Hines, Illinois Loyola University Professor of Neurology Chicago Stritch School of Medicine Maywood, Illinois Carlos A. Jamis-Dow M.D.

Radiologist Su er Medical Group Sacramento, California Jay Loeﬄer MD Chief of Radiation Oncology Massachuse's General Hospital Cancer Center Herman and Joan Suit Professor Harvard Medical School Boston, Massachuse's Dan L. Longo MD Deputy Editor New England Journal of Medicine Professor of Medicine Harvard Medical School Boston, Massachuse's Neera R. Nathan MD, MSHS Massachuse's General Hospital Boston, Massachuse's Tomas G. Neilan MD, MPH División de Cardiología Departamento de Medicina Massachuse's General Hospital Boston, Massachuse's Aparna Parikh MD Massachuse's General Hospital Boston, MD Mihir Parikh de Massachusetts Beth Israel Medical Center Deaconess Boston, MD Cliff Rosen of Massachusetts Laboratorio Rosen Scarborough, Maine James L. Rosenzweig MD

Hebrew Rehabilitation Center for Endocrinology, Diabetes and Metabolism Roslindale, MA Henry E. Schniewind MD,

Boston, Massachusetts

Sydney Schoensee PT, DPT, FAAOMPT St. Luke's Rehabilitation McCall, Idaho Noëlle S. Sherber MD, FAAD Cofounder Dermatologist, Sherber+Rad Washington, DC Leigh H. Simmons MD Assistant Professor of Medicine Harvard Medical School Division of General Internal Medicine Massachuse s General Hospital Boston, Massachusetts s Daniel I. Simon MD President, University Hospitals Case Medical Center President, Harrington Heart & Vascular Institute Chief, Division of Cardiovascular Medicine University Hospitals Health System Herman K. Hellerstein President of Cardiovascular Investigation and Professor of Medicine Case Western Reserve University Escuela de Medicina Cleveland, Ohio Jill Smith MD Chief of Ophthalmology Newton-Wellesley Hospital Newton, Massachusetts Daniel Talmasov MD Harvard Longwood Psychiatry Boston, Massachusetts

Beatriz Thompson,

New Haven, Connecticut

Cornelia L. Trimble MD Professor Departments of Obstetrics and Gynecology, Oncology and Pathology The Johns Hopkins Medical Institutions Baltimore, Maryland INSTRUCTOR REVIEWERS Teresa S. Boyer MSN, APN-BC, PMHNP Associate Professor of Nursing Motlow College Lynchburg, Tennessee Cheryl Christopher RHIA Assistant Township of Manha an Community College New York, New York Mary Jane Durksen Medical Office Administrator Diploma Virtual Principal Instructor/Course Developer AOLC Ontario, Canada Shelba Durston MSN, RN, CCRN, SAFE Professor of Nursing San Joaquin Delta College Stockton, California Erin J. Gerald RN, BSN, MBA Norwalk Community College Norwalk, Connecticut Rosalie Griffith RN, MSN, MA.Ed Nursing Success Coordinator Chesapeake College Wye Mills, MD Shawn McGowan

Manager, AOLC Division of Health Ontario, Canada Angela J. Moore RN, MSN Ed. Assistant Director, Nurses Career Care Institute Lancaster, California José L. Mosqueda Lead Healthcare Instructor Erie Neighborhood House Chicago, Illinois Mary Prorok RN, MSN Instructor South Hills School of Business & Technology Altoona, Pennsylvania Danielle Robel MBA Professor, Life Sciences Health AAMA , Milwaukee Area Technical College Milwaukee Wisconsin Deb Stockberger MSN, RN Health Division Instructor North Iowa Area Community College Mason City, Iowa Donna J. Wilde MPA, RHIA Professor, Health Informatics and Information Management Shoreline Community College Sea le, Washington Charles K. Williston BA , MS, CPC Instructor Traviss Career Center Lakeland, Florida Lynda Wilson Master of the Art of Teaching, EMT-Paramedic

Professor of Medical Terminology Valencia College Orlando, Florida Mindy Wray MA, CMA (AAMA), RMA Program Director, Healthcare ECPI University Greensboro, North Carolina Carole Zeglin MSEd, BSMT, RMA Associate Professor/Director of Medical Laboratory Technology, Healthcare and Phlebotomy / Specimen Processing Programs Westmoreland County Community College Youngwood, Pennsylvania

CHAPTER 1

Basic Word Structure CHAPTER SECTIONS: Objectives in the Study of Medical Language 2 Word Analysis 3 Terminology 6 Practical Applications 16 Exercises 17 Answers to Exercises 24 Pronunciation of Terms 27 Review Sheet 29

CHAPTER OBJECTIVES • Identify basic objectives to guide your study of medical language. • Separate medical words into their component parts. • Learn the meanings of the basic combinations of forms, suffixes, and prefixes in medical language. • Use these combined forms, suffixes, and prefixes to build medical words.

Objectives when studying medical language There are three objectives to keep in mind when studying medical terminology:

• Analyze words by breaking them into component parts. Your goal is to learn word analysis tools that will make it easier to understand complex terminology. Don't just memorize the terms; think about breaking terms into their component parts: the building blocks of terminology. This book shows you how to separate complicated and simple terms into understandable word elements. Medical terms are a lot like puzzles in that they are built with small pieces that make each word unique, with one big difference: the pieces can be mixed and used in various combinations to make other words as well. As you become more familiar with word parts and learn what each one means, you will be able to recognize those word parts in entirely new combinations in other terms. • Relate medical terms with the structure and function of the human body. Memorizing terms, while essential for language retention, should not become the main goal of your study. The main purpose of this book is to explain the terms in the context of how the body functions in health and disease. Medical terms explained in their proper context will also be easier to remember. So the term hepatitis, which means inflammation (itis) of the liver (hepat), is better understood when you know where the liver is and how it works. No prior knowledge of biology, anatomy, or physiology is required for this study. The explanations in this book are simple and basic. • Be aware of spelling and pronunciation problems. Some medical terms are pronounced the same but spelled differently, which explains their different meanings. For example, the ilium and ileum have

identical pronunciations, but the first term, ilium, means a part of the hip bone, while the second term, ileum, refers to a part of the small intestine (Figure 1-1). Even when terms are spelled correctly, they can be misinterpreted due to incorrect pronunciation. For example, the urethra (u-RE-thrah) is the tube leading from the bladder to the outside of the body, while the ureter (U-reh-ter) is one of two tubes, each leading from a single kidney and inserting into the urinary bladder. Figure 1-2 illustrates the different anatomies of the urethra and ureters.

FIGURE 1-1 The terms ileum and ilium can be confusing because they are pronounced the same and refer to body parts located in the same general region of the body. TIP: The ileum, with "e", is part of the digestive tract, which has to do with eating.

FIGURE 1-2 Male urinary tract. The terms urethra and ureter can be confusing because they are both tubes of the urinary system, but the spelling and pronunciation are different. Note their locations: two ureters between the kidneys and the urinary bladder, and one urethra between the urinary bladder and the outside of the body. TIP: The ureter has two "e"s and the urethra has only one "e".

Word Analysis Studying medical terminology is a lot like learning a new language. At first, the words seem strange and complicated, even though they may represent commonly known terms and disorders. For example, cephalalgia means "headache" and an ophthalmologist is an "eye doctor." Your first task in learning the language of medicine is to understand how to break words down into their component parts. Logically, most terms, complex or simple, can be broken down into basic parts and then understood. For example, consider the following term, which is divided into three parts:

The root is the foundation of the word. All medical terms have one or more roots. For example, the root hemat means blood. The suffix is the ending of the word. All medical terms have a suffix. The suffix -logy means study process. The combined vowel, usually la, as in this term, links the root to the suffix or the root to another root. A combined vowel has no meaning of its own; Matches one part of the word to another. It is helpful to read the meaning of medical terms starting with the suffix and then going back to the beginning of the term. Thus, the term hematology means the study of blood. Here's another familiar medical term:

Electrocardiogram, reading from the suffix to the beginning of the term, means recording the electricity in the heart. Note that there are two vowels combined, both or, in this term. The first connects the two roots electr and cardi; the second connects it with the root cardi and the suffix gram. Try another term:

Gastritis, reading from the end of the term (suffix) to the beginning, means inflammation of the stomach. Note that the combined vowel, o, is missing from this term. This is because the suffix -itis begins with a vowel. The combined vowel is dropped before a suffix beginning with a vowel. It is preserved, however, between two roots, even if the second root begins with a vowel. Consider the following term:

The whole term means process of study of the stomach and intestines. Note that the combined vowel is held between gastr and enter, even though the second stem, enter, begins with a vowel. When a term contains two or more roots related to parts of the body, the anatomical position usually determines which root precedes the other. For example, the stomach receives food first, before the small intestine, so the word is formed as gastroenterology, not "enterogastrology."

In summary, remember three general rules: 1. READ the meaning of medical terms from the suffix to the beginning of the term and to the end. 2. DELETE the combined vowel (usually o) before a suffix beginning with a vowel: gastritis, not “gastroitis”. 3. KEEP the vowel combined between two roots: gastroenterología, not “gastrenterología”. In addition to the root, suffix, and vowel combination, two other word parts are commonly found in medical terms. These are the combination form and the prefix. The combination form is simply the root plus the combination vowel. For example, you are already familiar with the following combination forms and their meanings:

The combined forms are used with many different suffixes. Remembering the meaning of a combined form will help you understand unfamiliar medical terms. The prefix is a small part added to the beginning of a term. Not all medical terms contain prefixes, but the prefix can have a major influence on the meaning. Consider the following examples:

In summary, the important elements of medical terms are the following: 1. ROOT: base of the term 2. SUFFIX: word end 3. PREFIX: word beginning 4. COMBINING VOWEL: vowel (usually o) that joins the root with the suffix or the root to another root 5. FORM OF COMBINATION: combination of the root and the vowel combination

Terminology

In the examples above, you were presented with the combined forms gastr/o (stomach), hemat/o (blood), and cardio/o (heart). This section of the chapter presents a list of additional combination forms, suffixes, and prefixes, with examples of

medical words using these word parts. Similar lists are included for each chapter of the book. Write the meaning of the medical term in the space provided. Then check the correct pronunciation of each term with the Term Pronunciation List on pages 27 and 28. The Mini Dictionary, beginning on page 897, includes definitions for all terms in this book. Evolve's website for The Language of Medicine also contains audio pronunciations for each term. Use the! Most medical terms are derived from Greek and Latin roots. Greek, Roman, and Arab physicians developed medically useful concepts and associated vocabularies long before the 21st century. The Greek and Latin origins of the medical terms are presented for your interest on the Evolve website.

Chapter Study Guide 1. Use slashes to divide each term into its component parts (adeno/oma) and write its meaning (tumor of a gland) in the space provided. While most medical terms are easily broken down into parts and understood, others defy simple explanation. Information in italics under a medical term helps define and understand the term. You can check the meanings by using the MiniDictionary at the end of this book. 2. Complete the Exercises, pages 17 to 23, and check your answers on pages 24 to 26. 3. Practice your pronunciation of each term using the Term Pronunciation list, pages 27 and 28. The definitions of each term are in the Mini - Dictionary beginning on page 897. 4. Complete the Review Sheet, pages 29 and 30. Check your answers against the Word Parts Glossary, page 967. Then, test yourself by writing terms and meanings from the Review Sheet on a separate sheet of paper. 5. Make your own flash cards. Using the review sheet as a guide, create flashcards that you can take with you wherever you study! 6. Create your own book guides to easily access key concepts and frequently used sections, for example, the Word Part Glossary, which begins on page 967. 7. Review terms using the audio pronunciations Evolve finds on the website. Note that you are actively participating in the learning process, writing terms and their meanings, and repeatedly testing yourself. Here is your study mantra: READ, WRITE, RECITE and REVIEW. I guarantee success if you follow these simple steps. This is a proven method, it really works!

Combined forms Write the meaning of each medical term in the space provided. Remember, you'll find all the terms pronounced phonetically starting on page 27, and you can listen to the pronunciations on the Evolve website.

COMBINATION OF MEANINGS Gland aden/o

arthr/o bi/o

cancer

cardi/the cephalus/the brain/the cis/the

horse hair

cyst

cyt/o derm/o dermat/o electr/o encephal/o enter/o

erythr/o gastr/o

wise

TERMINOLOGY

SENSE

adenoma tumor of a gland____________________________________ The suffix -oma means tumor or mass. adenitis ________________________________________ The suffix -itis means inflammation. joint arthritis ________________________________________ biology of life ________________________________________ The suffix -logy is composed of the stem log (study) and the final suffix -y (process or condition). biopsy ____________________________________ The suffix -opsy means visualization process. Living tissue is removed from the body and viewed under a microscope. cancerous, carcinoma ____________________________________ cancer A carcinoma is a cancerous tumor. Carcinomas grow from epithelial cells (superficial or cutaneous) that cover the outside of the body and line the organs, cavities, and ducts inside the body (Figure 1-3A and B). heart cardiology ____________________________________ head head ____________________________________ (seh-FAL-ik) The suffix -ic means belonging to. A cephalic presentation describes a "head first" position for delivering a baby. brain brain ____________________________________ (most The suffix -al means belonging to. Figure 1-4 shows the brain and its parts of the brain) many functional areas. cut incision ________________________________________ The prefix en- means inside, and the suffix -ion means process. excision ____________________________________ The prefix ex means out. secrete (for endocrine glands ____________________________________ form and The prefix endo- means in; endocrine glands (eg, thyroid, pituitary, and release) adrenal glands) secrete hormones directly into (into) the bloodstream. Other glands, called exocrine glands, release their secretions (eg, saliva, sweat, tears, milk) through tubes (ducts) outside the body. urinary cystoscopy ________________________________________ bladder; a bag (sis-TOS-ko-pe) The suffix -scopy is a complex suffix that includes the root or a cyst (sac scop, meaning visual examination, and the final suffix -y, meaning process, containing fluid) cell cytology ________________________________________ See Figure 1-5 for examples of blood cells. ______________________________________ hypodermic skin dermatitis ______________________________________ The prefix hypo- means under or below. electrocardiogram of electricity __________________________________________ The suffix -gram means record. Abbreviated ECG (or sometimes EKG). Cerebral electroencephalogram __________________________________________ Abbreviated EEG. intestinal enteritis ____________________________________ (The small intestine is usually narrower but much longer than the small intestine (colon). See Figure 1-1 on page 2, which shows the small and large intestines. intestine) Red blood cells ________________________________________ The suffix -cyte means cell. Red blood cells carry oxygen in the blood. stomach gastrectomy __________________________________________ The suffix -ectomy means excision or removal. All or, more commonly, part of the stomach is removed. gastrotomy __________________________________________ The suffix -tomy is another complex suffix, containing the root tom, meaning to cut, and the final suffix -y, meaning process of. sugar hyperglycemia __________________________________________ The prefix hyper- means excessive, above or more than normal. The suffix emia means condition of the blood.

COMBINED FORM OF MEANING gnos/o knowledge

gynec/o hemat/o dobladillo/o

woman, female blood

hepat/o iatr/o

liver treatment, medical

bueno

branco

record/the nefr/the

kidney study

neuro/onc/o

nerve tumor (cancerous)

ophthalmic

ojo

osteo

very

camino

illness

ped/o

son

psychopath

mind

radio

X-rays

ren/o

should

rhino

nose

TERMINOLOGY

SENSE

diagnosis ______________________________________ The prefix day- means complete. The suffix -sis means state or condition of. A diagnosis is made after getting enough information about the patient's condition. Literally, it is a “state of complete knowledge”. prognosis ____________________________________________ The prefix pro- means before. Literally "before knowledge," a prognosis is a prediction about the outcome of a disease, but it is always given after the diagnosis has been made. gynecology __________________________________ hematology ______________________________________ hematoma _____________________________________ In this term, -oma means a mass or collection of blood, rather than a growth of cells (tumor). A hematoma forms when blood leaks from blood vessels and collects as a clot in a cavity or organ or under the skin. See Figure 1-6. hemoglobin ______________________________________ The suffix -globin means protein. Hemoglobin carries oxygen in red blood cells. ____________________________________ Iatrogenic hepatitis ______________________________________ The suffix -genic means to produce, to produce by, or to produce in. Iatrogenic conditions are adverse effects that result from treatment or intervention by a physician. leukocytes ____________________________________ This blood cell helps the body fight disease. dermatology __________________________________ nephritis __________________________________________ nephrology _____________________________________ neurology ______________________________________ oncology __________________________________________ oncologist __________________________________________ The suffix -ist means someone who specializes in a field of medicine (or other profession). ophthalmoscope __________________________________________ (from-THAL-mo-skope) The suffix -scope means an instrument for visual examination. TIP: Pronunciation helps! The first syllable is "off" and here the "f" sound is written "ph". osteitis __________________________________ osteoarthritis ______________________________________ This aging condition is actually a degeneration of the bones and joints, often accompanied by inflammation. pathology ______________________________________ pathologist ______________________________________ A pathologist microscopically examines biopsy specimens and examines cadavers to determine cause of death. pediatrician __________________________________ Note that ped/o is also in the term orthopedist. Orthopedists were once doctors who straightened (orth/o means straight) children's bones and corrected deformities. Today, orthopedists specialize in bone and muscle disorders in people of all ages. psychology ______________________________________ psychiatrist ______________________________________ radiology _____________________________________ Low-energy x-rays are used for diagnostic imaging. kidney ___________________________________ Ren/o (Latin) and nephr/o (Greek) both mean kidney. Ren/o is used with -al (Latin) to describe the kidney, while nephr/o is used with other suffixes such as -osis, -itis, and -ectomy (Greek) to describe abnormal conditions and surgical procedures. rhinitis ______________________________________

MATCH MEANING FORM sarc/o carne

sect

thrombus

you/her

TERMINOLOGY

SENSE

sarcoma __________________________________ This is a cancerous (malignant) tumor. A sarcoma (Figure 1-7) grows from “fleshy” connective tissue cells, such as muscle, bone, and fat, whereas a carcinoma (another type of cancerous tumor) grows from epithelial cells that line the outside or inside of the skin. inside the skin. of the body. of the organs of the body. to cut the resection ________________________________________ The prefix means to go back. A resection is a return in the sense of removal or removal (excision). A gastric resection is a gastrectomy, or excision of the stomach. clot, thrombocyte cloning _____________________________________ Also known as platelets, these cells help blood clot. A thrombus is the actual clot that forms, and thrombosis (-osis means condition) is the clot-forming condition. urinary tract, urologist __________________________________________ urine

FIGURE 1-3 A. Carcinoma of the skin. This is a basal cell carcinoma, the most common form of skin cancer. It usually occurs on sun-damaged skin. B. Esophageal carcinoma is a cancerous tumor of the esophagus (the tube that leads from the throat to the stomach).

FIGURE 1-4 The brain and the functions it controls. A cerebrovascular accident (CVA), or stroke, occurs when blood vessels (vasculo means blood vessel) are damaged in the brain, preventing blood from reaching functional areas of the brain. The cells, deprived of oxygen and nutrients, are damaged, leading to loss of movement or speech and other signs and symptoms of a stroke.

FIGURE 1-5 Blood cells. Look for red blood cells (erythrocytes), white blood cells (leukocytes), and clotting cells (thrombocytes or platelets).

FIGURE 1-6 A. Note the hematoma under the nail. B, Hematoma of broken ribs.

FIGURE 1-7 Muscle sarcoma of the thigh. (Courtesy of Dr. Sam Yoon, Sloan Kettering Hospital, New York.)

suffixes

The suffix -ac -al -algae

MEANING related to pain

-cytocell -ectomy excision, removal -emia blood condition

-genic

relating to the production, produced by or produced in

-protein depth -registro gram -ic, -ical belonging to a -ion -ist -itis -logia -oma

inflammation specialist process study process tumor, mass, swelling

-apart, sideways

visualization process

-osis

Condition, usually abnormal (slight increase in numbers when used with blood cells)

-patia

disease condition

-reach

instrument for visually examining

-copy

visual examination process

-sis -tomy

State; cutting condition process, incision process, condition

-y

TERMINOLOGY MEANING cardiac ____________________________________ neuralgia _______________________________________ arthralgia ________________________________________ neuralgia ________________________________________ erythrocytes ________________________________________ nephrectomy ____________________________________________ leukemia ________________________________________ Literally, this term means “a condition of the white blood cells (blood cells)”. It is actually a blood condition in which cancerous white blood cells proliferate (increase in number). Carcinogenic ____________________________________ Cigarette and smoke are carcinogenic. pathogen ____________________________________ Many viruses and bacteria are pathogenic organisms. Osteogenic sarcoma ____________________________________ It is a malignant tumor that occurs in the bone. hemoglobin ________________________________________ electroencephalogram ________________________________________ gastric ______________________________________ neurological ________________________________________ Log/o means study of. excision ________________________________________ ophthalmologist ____________________________________ cystitis ______________________________________ endocrinology ________________________________________ hepatoma ________________________________________ A hepatoma (hepatocellular carcinoma) is a malignant tumor of the liver. biopsy ________________________________________ Biopsy samples are obtained and viewed under a microscope. nephrosis ________________________________________ leukocytosis ________________________________________ This condition, a slight increase in normal white blood cells, occurs when white blood cells multiply to fight an infection. Do not confuse leukocytosis with leukemia, which is a cancerous (malignant) condition characterized by high levels of abnormal, immature white blood cells. ____________________________________________ encephalopathy (en-sef-ah-LOP-ah-the) adenopathy ________________________________________ (ah-deh-NOP-ah-the) Also known as lymphadenopathy, this condition refers to the lymph nodes (groups of stationary cells along the path of the lymphatic vessels) that become enlarged due to infection or during the spread of malignant (cancerous) tumors. endoscope ____________________________________ Endo- means inside. A cystoscope is a type of endoscope. A periscope is a non-medical term meaning an instrument for visually examining an area around (peri-) an obstacle. endoscopy ________________________________________ (en-DOS-ko-pe) Endoscopy is performed with an endoscope. A common endoscopic procedure is a colonoscopy (colon/o = colon or large intestine). prognosis ________________________________________ osteotomy ____________________________________ (os-te-OT-o-me) gastroenterology ________________________________________

prefixes

PREFIX MEANING a-, an- no, no, without

aut-, autodiaendoepiex-, exohiperhipo-

imperiproretrosubtrans

TERMINOLOGY MEANING anemia ________________________________________ Anemia is a decrease in the number of red blood cells or an abnormality of hemoglobin (a chemical) within the red blood cells. This results in a decrease in the supply of oxygen to the cells of the body. Anemic patients look so pale that early doctors thought they were literally "out of blood." self, self autopsy ____________________________________ This term literally means “self-visualization process”. So, an autopsy is the examination of a corpse with one's own eyes in order to determine the cause of death and the nature of the disease. complete, diagnosis ____________________________________ a The plural of diagnosis is diagnoses. inside endocrinologist __________________________________ above, in the epidermis _________________________________ epigastric __________________________________ This outermost layer of skin lies above the middle layer of skin known as the dermis. exterior, external exocrine __________________________________ of, external exocrine glands __________________________________ excessive, hyperthyroidism __________________________________ above, plus The suffix -ism means process or condition. than normal deficient, hypogastric _____________________________________ below, when hypo- is used with a body part, it means below. low, less hypoglycemia _____________________________________ than normal In this term, hypo- means poor. inside, in incision _____________________________________ around, pericardium _____________________________________ around The suffix -um means a structure. The pericardium is the membrane that surrounds the heart. before, prostate _____________________________________ forward This exocrine gland “sits” (-states) before or in front of the male urinary bladder (see Figure 1-2). It produces semen, which contains fluid and sperm. back, _____________________________________ back resection, this is an operation that “cuts” or removes tissue. The Latin resectio again means a cut or pruning. behind the retrocardiac ________________________________________________ below, below the subhepatic _____________________________________ on the other side, transhepatic _____________________________________ on the other side of the

complex suffixes

Many suffixes, such as -scopy, contain an embedded root word. Other examples are opsy (ops is a root) and -logy (log is a root).

Hyperglycemia and Diabetes

Hyperglycemia (high blood sugar) is often associated with diabetes. People with diabetes have high blood sugar levels because they lack insulin (in type 1 diabetes) or have ineffective insulin (in type 2 diabetes). Insulin is the hormone that is normally released by the pancreas (an endocrine gland near the stomach) to "escort" sugar from the bloodstream to the cells. The sugar (glucose) is then broken down in cells to release energy. When there is no insulin, sugar cannot enter the cells and accumulates in the bloodstream (hyperglycemia).

Sixty-five

Urologist and Nephrologist

A urologist is a surgeon who operates on the urinary tract and the organs of the male reproductive system. A nephrologist is an internal medicine (non-surgical) specialist who diagnoses and treats disorders of the kidneys. Both urologists and nephrologists are doctors.

Ophthalmologist, Optometrist, Optician

An ophthalmologist is a doctor who specializes in the diagnosis and treatment (both surgical and medical) of eye disorders. An optometrist is a health professional who examines (metr/o = measure) the eyes and prescribes corrective lenses and can treat eye conditions. An ophthalmologist straightens lenses and adjusts glasses, but does not examine the eyes, prescribe corrective lenses, or treat eye diseases.

What is Chronic Traumatic Encephalopathy?

Chronic traumatic encephalopathy (CTE) (pertaining to a long period of time) is a severe brain injury associated with high-impact head trauma (as can be found in football and boxing). The following autopsy images show a normal brain and a brain affected by CTE.

Plural

Terms ending in -is (diagnosis, prognosis) form their plural by dropping -is and adding -es. See Appendix I, page 989, for other rules on plural formation.

Understanding hyperthyroidism

In hyperthyroidism, an overactive thyroid gland (an endocrine gland in the neck) secretes a higher than normal amount of thyroxine (thyroid hormone, or T4). Because thyroxine causes cells to burn fuel and release energy, signs and symptoms of hyperthyroidism include increased energy level and nervousness, tachycardia (increased heart rate), weight loss, and exophthalmos (bulging eyes).

Practical applications

This section gives you the opportunity to use your ability to understand the medical terms in this chapter and to increase your knowledge of new terms. Be sure to check your answers with Answers to Practical Applications on page 27. There you will find helpful explanations.

Specialists Compare the abnormal condition in column I with the treating physician (specialist) in column II. Write the correct specialist letter in the space provided. COLUMN I: Abnormal conditions 1. myocardial infarction 2. ovarian cysts 3. bipolar (manic-depressive) disorder 4. adenocarcinoma of the breast 5. iron deficiency anemia 6. retinopathy 7. cerebrovascular accident (ictus) 8. renal failure 9 inflammatory bowel disease 10 prostate adenocarcinoma

_______ _______ _______ _______ _______ _______ _______ _______ _______ _______

COLUMN II: Physicians (Specialists) A. gastroenterologist B. hematologist C. nephrologist D. cardiologist E. oncologist F. gynecologist G. urologist H. ophthalmologist I. neurologist J. psychiatrist

Exercises The following exercises are designed to help you learn the terms presented in the chapter. Writing terms repeatedly is a good way to study this new language. You will find the answers to these exercises starting on page 24. This makes it easy to check your work. By marking each answer, you will not only reinforce your understanding of a term, but you will also gain additional information from the answer. Each exercise is designed not as a test, but as an opportunity for you to learn the material.

A Complete the following sentences. 1. Word beginnings are called _________________________________. 2. Word endings are called ___________________________________. 3. The foundation of a word is known as _____________________. 4. A letter that connects a suffix and a root, or connects two roots, in a term is _______________________. 5. The combination of a root and a combined vowel is known as a ___________________________. B Give the meanings of the following forms of combination. 1. cardio/o ________________________________________________________ 2. aden/o ______________________________________________________ 3. bi/o ______________________________________________________ 4. cerebr/o _________________________________________________ 5. cephal/o ________________________________________________ 6. arthr/o _____________________________________________________ 7. carcin/o _________________________________________________

8. cyst/o ________________________________________________________ 9. cit/o _______________________________________________________ 10. derm/o or dermat/o ___________________________________________ 11. encephal/o _______________________________________________ 12. elec/o _________________________________________________ C Give the meaning of the following suffixes. 1. -oma _____________________________________________________ 2. -al ______________________________________________________ _ 3. -itis ______________________________________________________ 4. -logy ________________________________________________________ 5. -scopy ________________________________________________________ 6. -ic __________________________________________________________ _ 7. -gram _____________________________________________________ 8. -opsy _____________________________________________________ D Using slashes, divide the following terms in parts and give the meaning of the whole term. 1. brain ____________________________________________________ 2. biopsy __________________________________________________________

3. adenitis _____________________________________________________ 4. cephalic _________________________________________________ 5. carcinoma ________________________________________________ 6. cystoscopy ________________________________________________ 7. electrocardiogram ____________________________________________ 8. cardiology ________________________________________________ 9. electroencephalogram ________________________________________________ 10. dermatitis _________________________________________________ 11. arthroscopy ________________________________________________ 12. cytology _________________________________________________ E Give the meaning of the following combined forms. 1. erythr/o ________________________________________________________ 2. enter/o _______________________________________________________ 3. gastr/o ________________________________________________________ 4. gnos/o ________________________________________________________ 5. hemat/o __________________________________________________________ 6. cis/o _____________________________________________________ 7. nephr/o ________________________________________________________

8. leuk/o __________________________________________________________ 9. iatr/o _____________________________________________________ 10. hepat/o _____________________________________________________ 11. neur/o ________________________________________________________ 12. gynec/o _____________________________________________________ F Complete the medical term, according to its meaning as indicated. 1. white blood cell: _________________________cyte 2. stomach inflammation: gastrointestinal_________________________ 3. belonging to be produced by treatment: _________________________genetic 4. renal study: _________________________ology 5. red blood cell: _________________________cyte 6. blood mass: _________________________oma 7. live tissue visualization process (using a microscope): bi___________ 8. nerve pain: neuro___________ 9. visual examination process of the eye: _________________________scopia 10. inflammation of the small intestine: _________________________ite G Select one of the combination forms below to correspond to the numbered terms in English. Write the correct combination form in the space provided. onc/the ophthalmic/the west/the road/the

psych/o radio/o rena/o rhin/o sarc/o sect/o thromb/o ur/o Terms in English 1. kidney ________________________________ 2. disease ________________________________ 3. eye ___________________________________ 4. cut _________________________________ 5. nose _____________________________________ 6. flesh __________________________________ 7. mind __________________________________ 8. urinary tract __________________________ 9. bone ___________________________________ 10. X-rays ________________________________ 11. cloning ________________________________ 12. tumor ________________________________ H Underline the suffix in each term and then give the meaning of the term. 1. ophthalmoscopy _____________________________________________________ __________ 2. ophthalmoscope _____________________________________________________ __________ 3. oncology _____________________________________________________ ________________

4. osteitis _____________________________________________________ __________________ 5. psychosis _____________________________________________________ ________________ 6. thrombocytes _____________________________________________________ _____________ 7. renal __________________________________________________________ ___________________ 8. nephrectomy __________________________________________________________ _____________ 9. osteotomy __________________________________________________________ _______________ _______________ 10. resection __________________________________________________________ _______________ 11. carcinogenic __________________________________________________________ ____________ 12.________________ suffix________________ sarcoma _____________________ in ________________ I Combine the suffix Column I with its meaning in Column II. Write the correct meaning in the space provided.

COLUMN I Suffix 1. -algia ________________________________ 2. -ion ________________________________ 3. -emia ________________________________ 4. -gram ________________________________ 5. -scope ________________________________ 6. -osis ________________________________ 7. -ectomy ________________________________ 8. -genesis ________________________________ 9. -pathia ________________________________ -tomy ______________________________ 11. -ite ______________________________ 12. -cyte ______________________________ 13. -globin ______________________________

COLUMN II Meaning condition, usually abnormal blood condition cellular disease condition healing process, incision inflammation instrument for visual examination of pain related to the production, produced by, or produced in the process protein recording excision, removal (resection)

J Select from the terms listed to complete the sentences below. arthralgia cancerous cystitis encephalopathy hematoma exocrine endocrine hepatoma (hepatocellular carcinoma) iatrogenic leukemia leukocytosis neuralgia 1. When Paul smoked cigarettes, he inhaled a __________ substance with each puff. 2. Sally's sore throat, fever, and chills caused her doctor to order a white blood cell count. The results, which indicated infection, showed a slight increase in normal cells, a condition called ______________________. 3. Mr. Smith increased, causing abdominal pain. Radiological examinations and biopsy of him revealed a malignant tumor or ______________________. 4. Mrs. Rose complained of pain in her hip, knee and shoulder joints every morning. She was told that she was in pain.

joints, or ______________________. 5. Dr. Black was trained to treat disorders of the pancreas, thyroid gland, adrenal glands, and pituitary gland. Therefore, he was an expert on the ______________________ glands. 6. Mrs. Walsh told the doctor that she had pain when she urinated. After examinations, the doctor's diagnosis was inflammation of the urinary bladder or ______________________. 7. Elizabeth's tennis swing hit David on the thigh, producing a big _________________. His skin looked bruised and the affected area was tender. 8. Mr. White's white blood cell count. Bell is 10 times bigger than normal. His blood work shows cancerous white blood cells. His diagnosis is ________________________. 9. Mr. Kay was resuscitated (revived from potential or apparent death) in the emergency department after suffering a heart attack. Unfortunately, she broke a rib from the doctor's chest compressions. This is an example of a _________________________ fracture. 10. After playing one season on a professional football team, Bill Smith decided to retire because of concerns about the dangers of concussions and head injuries, a condition called CTE, or Chronic Traumatic _________________________. K Give the meanings of the following prefixes. 1. day_______________________________________________________________ _ 2. pro___________________________________________________________ _ 3. aut-, auto________________________________________________ 4. a-, an_____________________________________________________

5. hyper________________________________________________________ 6. hypo__________________________________________________________ 7. epi___________________________________________________________ _ 8. endo___________________________________________________________ 9. retro__________________________________________________________ 10. trans_____________________________________________________________ 11. peri__________________________________________________________ 12. ex-, exo__________________________________________________________ 13. sub__________________________________________________________________________ 14. re__________________________________________________________ _ L Underline the prefix in the following terms and then give the meaning of the term complete. 1. diagnosis _____________________________________________________ _____________ 2. prognosis _____________________________________________________ _____________ 3. subhepatic _____________________________________________________ ____________ 4. pericardium __________________________________________________________

___________ 5. hyperglycemia _____________________________________________________ _____________ 6. hypodermic _____________________________________________________ ___________ 7. epigastric __________________________________________________________ _____________ 8. resection __________________________________________________________ ____________ 9. hypoglycemia __________________________________________________________ _________ 10. anemia _____________________________________________________ _____________ M Complete the following terms (describing the areas of medicine), according to their meaning as it Says . 1. study of the urinary tract: ________________________ logy 2. study of women and female diseases: ________________________ logy 3. study of blood: ________________________ logy 4. study of tumors: ________________________ logy 5. study of the kidneys: ________________________ logy 6. study of nerves: ________________________ logy ________________________ logy 7. treatment of children: ________________________ iatria 8. study of x-rays in diagnostic imaging: ________________________ logy 9. study of eyes: ________________________ logy 10. study of stomach and intestines: ________________________ ology

11. study of glands that secrete hormones: ________________________ ology 12. treatment of the mind: ________________________ iatry 13. study of disease: ________________________ ology 14. study of the heart: ________________________ ology N Give the meaning of the underlined part of the word and then define the term. 1. stroke ________________________________________________ 2. encephalitis _____________________________________________________ _____ 3. cystoscope _____________________________________________________ _____ 4. transhepatic __________________________________________________________ _____ 5. osteogenic sarcoma __________________________________________________________ _______ 6. hypogastric ________________________________________________________________________ ______ 7. endocrine glands ________________________________________________________________________ __ 8. nephrectomy __________________________________________________________ _____ 9.___________________ __________________________ __________________________________________ neuralgia

_______ OR Select one of the terms listed below to complete the sentences below. anemia biopsy diagnosis leukemia nephrologist oncogenic neuropathy oncologist osteoarthritis pathogenesis prognosis psychiatrist thrombocytes thrombosis urologist 1. Pamela Crick is 72 years old and suffers from a degenerative joint disease caused by the wear and tear of the tissue surrounding the joints. This disease, which literally means “inflammation of the bones and joints”, is __________________________. 2. The __________________________ specimen was removed during surgery and sent to a pathologist for examination under a microscope for proper diagnosis. 3. A/A ___________________________ performed surgery to remove Mr. Simón. 4. Ms. Rose has suffered from diabetes with hyperglycemia for many years. This condition can lead to long-term complications, such as the disease of the nerves called _____________________ diabetic.

5. A virus or bacterium causes disease and is therefore a _________________________ organism. 6. Jordan has a disease caused by abnormal hemoglobin in his red blood cells. Red blood cells change shape, collapsing to form sickle-shaped cells that can form clots and stop blood flow. Your condition is called _____________________ sickle cell anemia. 7. Dr. Max Shelby is a doctor who treats carcinomas and sarcomas. He is a __________. 8. Bill had trouble stopping the bleeding from a cut on his face while he was shaving. He knew his medication was causing him to have low platelets, or a low _________________________ count, and that was probably why his blood wasn't shutting off very well. 9. Dr. Susan Parker told Paul that her condition would improve with treatment in a few weeks. She said that her __________________________ is excellent and that she can expect a full recovery. 10. After fleeing the World Trade Center on September 11, 2001, Ms. Jones had many problems with her job, her husband, and her family relationships. She went to see a _________________, who prescribed medication to treat her depression. Q Circle the correct term to complete each sentence. 1. Mrs. Brody had a cough and fever. Her doctor told her to go to the department (pathology, radiology, hematology) for a chest X-ray. 2. After giving birth to her fourth child, Mrs. Thompson had trouble holding urine (a condition known as urinary incontinence). She made an appointment with a (gastroenterologist, pathologist, urologist) to evaluate her condition. 3. Dr. Monroe told a new mother that she had lost a lot of blood giving birth to her child. She had (anemia, leukocytosis, adenitis) and needed a blood transfusion immediately.

4. Mr. Preston had chest pain during his morning walks. He made an appointment to discuss his new symptom with a (nephrologist, neurologist, cardiologist). 5. After my skiing accident, Dr. Curtin suggested (cystoscopy, biopsy, arthroscopy) to visually examine my swollen and painful knee.

Answers to exercises A 1. prefixes 2. suffixes 3. root 4. combined vowel 5. combined form B 1. heart 2. gland 3. life 4. brain, most of the brain 5. head 6. joint 7. cancer , cancerous 8. urinary bladder 9. cell 10. skin 11. brain 12. electricity C 1. tumor, mass, swelling 2. belonging to 3. inflammation 4. study process 5. visual examination process

6. pertaining to 7. recording (image) 8. visualization process D 1. cerebr/al—pertaining to the brain, or most of the brain 2. biopsy—life visualization process (removal of living tissue and visualization under a microscope) 3. aden/itis—inflammation of a gland 4. cephalic—related to the head 5. carcin/oma—tumor that is cancerous (cancerous tumor) 6. cyst/oscopy—visualization process examination of the urinary bladder 7 . elect/o/cardi/o/gram—heart electricity record 8. cardio/o/logy—heart study process 9. electr/o/encephal/o/gram—brain electricity record 10. dermat /itis: inflammation of the skin 11. artr/o/scopia: process of visual examination of a joint 12. cit/o/logy: process of studying E cells 1. red 2. intestines (usually small intestine) 3. stomach 4 knowledge 5. blood 6. cut 7. kidney

8. target 9. medical treatment 10. liver 11. nerve 12. female, female F 1. leukocyte 2. gastritis 3. iatrogenic 4. nephrology 5. erythrocytes 6. hematoma 7. biopsy 8. neuralgia 9. ophthalmoscopy 10. enteritis G 1. ren/o 2. path/o 3. ophthalm/o 4. sect/o 5. rhin/o 6. sarc/o 7. psych/o 8. ur/o 9. oeste/o 10. radi/ He

11. thrombus 12. onc/o H 1. ophthalmoscopy—process of visual examination of the eye 2. ophthalmoscope—instrument for visual examination of the eye 3. oncology—study of tumors 4. osteitis—inflammation of the bone 5. psychosis—abnormal condition of the mind 6. thrombocytes: cloning cell (platelets) 7. renal: belonging to the kidney 8. nephrectomy: removal (excision or resection) of the kidney 9. osteotomy: incision of (the process of inserting into) a bone 10. resection: extirpative process (in the sense of “removing” or removing) 11. carcinogenic: related to the production of cancer 12. sarcoma: tumor of flesh tissue (cancerous tumor found in connective tissue such as bone, skin, fat and muscle ) I 1. pain 2. process 3. state of blood 4. recording (image) 5. instrument for visual examination 6. condition, usually abnormal 7. excision, excision (resection) 8. related to production , produced by or produced in 9. disease condition

10. healing process, incision 11. inflammation 12. cell 13. protein J 1. carcinogenic 2. leukocytosis 3. hepatoma (hepatocellular carcinoma) 4. arthralgia 5. endocrine 6. cystitis 7. hematoma 8. leukemia 9. iatrogenic 10 encephalopathy K 1. complete, up to 2. before 3. own, own 4. no, no, without 5. excessive, above, more than normal 6. deficient, below, less than normal 7. above, after 8. within 9 . behind 10. across, across 11. around

12. outside 13. under, under 14. behind L 1. diagnosis - full knowledge; a decision on the nature of the patient's condition after the appropriate tests have been carried out 2. prognosis - before knowledge; a prediction of the outcome of treatment given after diagnosis 3. subhepatic: relating below the liver. A vowel combined between the prefix and the stem is not required. 4. pericardium: the membrane that surrounds the heart 5. hyperglycemia: a condition of too much sugar in the blood 6. hypodermic: pertaining to the lower part of the skin 7. epigastric: pertaining to the upper part of the stomach 8. resection—process reverse (in the sense of elimination) 9. hypoglycemia—a condition of deficient (low) blood sugar 10. anemia—a condition of low numbers of erythrocytes (red blood cells) or deficient hemoglobin in these cells. Note that the root of this term is em, which is short for heme, which means blood. M 1. urology 2. gynecology 3. hematology 4. oncology 5. nephrology 6. neurology 7. pediatrics (the vowel combined o was omitted between ped and iatr)

8. radiology 9. ophthalmology 10. gastroenterology 11. endocrinology 12. psychiatry 13. pathology 14. cardiology N 1. brain (most of the brain). A stroke, or cerebrovascular accident, is damage to the brain's blood vessels, leading to the death of brain cells. 2. brain. Encephalitis is an inflammation of the brain. 3. urinary bladder. A cystoscope is an instrument used to visually examine the urinary bladder. The cystoscope is inserted into the urethra and urinary bladder. 4. through, through. Transhepatic means pertaining to or through the liver. 5. meat. Osteogenic sarcoma is a malignant (cancerous) tumor that begins in bone, considered a fleshy (connective) tissue in the body. 6. under, below, deficient. Hypogastric means pertaining to the lower part of the stomach. 7. inside. Endocrine glands secrete hormones within the body. Examples of these are the pituitary, thyroid, and adrenal glands. 8. excision or resection. Nephrectomy is the removal of a kidney. 9. out. The exocrine glands secrete chemicals to the outside of the body. Some examples are the sweat, lacrimal or tear-producing glands, the prostate, and the salivary glands. 10. pain. Neuralgia is nerve pain.

OR 1. osteoarthritis 2. biopsy 3. urologist (a nephrologist is a doctor who treats kidney disorders but does not operate on patients) 4. neuropathy 5. pathogenic 6. anemia 7. oncologist 8. thrombocytes 9. prognosis 10. psychiatrist ( a psychologist can treat mental patients, but he is not a doctor and cannot prescribe medication) P 1. radiology 2. urologist 3. anemia 4. cardiologist 5. arthroscopy Answers to Practical Applications 1. D A cardiologist is a specialist in internal medicine who takes ( scholarship ) training in the diagnosis and treatment of heart disease. 2. F A gynecologist specializes in surgery and internal medicine to diagnose and treat disorders of the female reproductive system. Ovarian cysts are sacs of fluid that form in the ovaries (female organs that produce eggs and hormones). 3. J A psychiatrist is an expert in the diagnosis and treatment of mental illness. In bipolar disorder (manic-depressive illness),

the mood changes periodically from excessive mania (excitability) to deep depression (sadness, despair and despondency). 4. E An oncologist is a specialist in internal medicine who is trained in the diagnosis and medical treatment (drugs) of cancer. 5.B A hematologist is a specialist in internal medicine who is trained in the diagnosis and treatment of blood disorders such as anemia and obstructive diseases. 6. H An ophthalmologist is trained in surgery and internal medicine to diagnose and treat disorders of the eye. The retina is a sensitive layer of light-receiving cells at the back of the eye. Retinopathy can occur as a secondary complication of chronic diabetes (from hyperglycemia). 7. I A neurologist is a specialist in internal medicine who is trained in the diagnosis and treatment of disorders of nervous tissue (brain, spinal cord, and nerves). A stroke causes damage to areas of the brain, resulting in loss of function. 8.C A nephrologist is an internal medicine specialist who is trained in the diagnosis and medical treatment of kidney disease. A nephrologist does not perform surgery on the urinary tract, but treats kidney disease with medication. 9. A gastroenterologist is an internal medicine specialist who is trained in the diagnosis and treatment of disorders of the gastrointestinal tract. Examples of inflammatory bowel disease are ulcerative colitis (inflammation of the large intestine) and Crohn's disease (inflammation of the last part of the small intestine). 10. G A urologist is a surgeon who operates on the organs of the urinary tract and the male reproductive system (such as the prostate). Urologists also prescribe medications for some conditions. Pronunciation of Terms

The terms you learned in this chapter are presented here with their pronunciations. CAPITAL letters indicate the stressed syllable. The meanings of all the terms are found in the Mini Dictionary starting on page 897. You can also listen to the pronunciation of each term on the Evolve website (h p://evolve.elsevier.com/Chabner/language/).

TÉRMINO adenitis adenoma adenopatía anemia artralgia artritis autopsia biología biopsia cancerígeno carcinoma cardiología cistitis cerebral cefálica cistoscopia citología dermatitis dermatología diagnóstico electrocardiograma electroencefalograma encefalopatía glándulas endocrinas endocrinólogo endocrinología endoscopio endoscopia enteritis epidermis escisión epigástrica eritrocitos glándulas exocrinas gastrectomía gástrica gastroenterología gastrotomía ginecólogo ginecología hematoma hemoglobina hepatoglucemia hipodermia hipertiroidismo hipogástrico hipoglucemia iatrogenic incision leukemia leukocytes leukocytosis nephrectomy nephritis nephrology nephrosis

PRONUNCIATION ah-deh-NI-tis ah-deh-NO-mah ah-deh-NOP-ah-the ah-NE-me-ah ar-THRAL-jah ar-THRI-tis AW-top-se bi-OL- o-je BI-op-se kar-sih-no-JEN-ik kar-sih-NO-mah KAR-de-ak kar-de-OL-o-je see-FAL-ik see-RE-bral sis- TI-tis sis-TOS-this-is-a si-TOL-o-he la-mah-TI-tis la-mah-TOL-o-he dia-ag-NO-sis eh-lek-tru-KAR-de- o-gram eh-lik-tro-en-SEF-ah-lo-gram en-sef-ah-LOP-ah-o EN-do-krin glanz en-do-krin-OL-o-gist en-do- krin-OL-o-je EN-do-scope en-DOS-co-pe en-teh-RI-tis ep-ih-DER-mis ep-ih-GAS-trick eh-RITH-ro-site ek-SIZH -un EK-so-creen view gas-TREK-to-me GAS-trick gas-thin-en-teh-ROL-o-je gas-TROT-o-me gi-neh-COLD-o-jist gi-neh -KOL-o-je he-mah-TOL-o-je he-mah-TO-mah HE-mo-glo-bin hep-ah-TI-tis hep-ah-TO-mah hi-per-gli-SE -me-ah hi-per-THI-royd-izm hi-po-DER com hi-po-GAS-trick hi-po-gli-SE-me-ah i-ah-tro-JEN-ik in-SIZH - un lu-KE-me-ah LU-ko-site lu-ko-si-TO-sis neh-FREK-to-me neh-FRI-tis neh-FROL-o-je neh-FRO-sis

TERM neurological neuralgia neuralgia neurology oncologist oncology ophthalmologist ophthalmoscope osteitis osteoarthritis osteogenic sarcoma osteotomy pathologist pathogenic pathology pediatric pericardium prognosis prostate psychiatrist psychology radiology renal resection retrocardiac rhinitis sarcoma subhepatic thrombocytes transhepatic urologist

PRONUNCIATION NU-ral nu-RAL-jah nu-ro-LOJ-ik nu-ROL-o-je ong-COLD-o-jist ong-COLD-o-ge of-thal-MOL-o-jist of-THAL- mo-scope os-te-I-tis os-te-o-ar-THRI-tis os-te-o-JEN-ic sar-KO-mah os-te-OT-o-me road-o-JEN- ik road-OL-o-jist road-OL-o-je pe-of-AH-trick peh-rih-KAR-of-um prog-NO-sis PROS-tight gland see-KI-ah-sad see-COL -o-je ra-de-OL-o-je RE-nal re-SEK-shun reh-tro-KAR-de-ac ri-NI-tis sar-KO-mah sub-heh-PAT-ik THROM-bo -site tranz-heh-PAT u-ROLE-o-gist

revision sheet

This review sheet and the ones that follow each chapter are complete lists of the verbal elements contained in the chapter. They are designed to bring terminology together and reinforce your learning by giving you the opportunity to write the meanings of each word part in the spaces provided and test yourself. Check your answers with the information in the chapter or in the Glossary (Parts of Medical Words—English) at the end of the book. It's a good idea to bookmark the Glossary so you can find it easily.

match shapes

COMBINED FORM aden/o arthr/o bi/o carcin/o cardi/o cephal/o cerebr/o cis/o crin/o cyste/o cyt/o derm/o, dermat/o electr/o encephal/o enter/ o erythr/o gastr/o glyc/o gnos/o gynec/o hem/o, hemat/o hepat/o iatr/o leuk/o log/o nephr/o neur/o onc/o ophthalm/o oste/o camino/o ped/o psych/o radio/o ren/o rhin/o sarc/o sect/o thromb/o ur/o

SENSE _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________ _____________________

suffixes

SUFFIX -ac -al -algia -cyte -ectomy -emia -genic -globin -gram -ic, -ical -ion -ist -itis -logy -oma -opsy -osis -pathy -scope -scopy -sis -tomy -y

Prefixes PREFIX a-, anaut-, autodiaendoepiex-, exohiperhypoinperiproretrosubtrans-

Suffixes Meanings related to

There are many suffixes that mean "belong to." In this chapter, he learned -ac, -al, -ic, and -ical. For a more complete list, see the Glossary (English for parts of the medical word), page 967.

EPISODE 2

Terms Relating to the Whole Body CHAPTER SECTIONS: Structural Organization of the Body 32 Abdominopelvic Regions and Quadrants 46 Divisions of the Back (Spine) 48 Positional and Directional Terms 50 Planes of the Body 52 Terminology 53 Practical Applications 57 Exercises 58 Answers to Exercises 63 Term Pronunciations 65 Review Sheet 67

CHAPTER OBJECTIVES • Define terms that apply to the structural organization of the body. • Identify body cavities and recognize the organs contained within those cavities. • Locate and identify the anatomical and clinical divisions of the abdomen. • Locate and name the anatomical divisions of the back. • Become familiar with the terms that describe the positions, directions, and planes of the body. • Identify the meanings of new word elements and use them to understand medical terms.

Structural Organization of the Body This chapter provides guidance for the body as a whole (cells, tissues, organs, and systems) along with terminology that describes positions and directions within the body. We start with the smallest living unit, the cell, and move on to understanding the complex systems of the body. To understand how organs function in both health and disease, it is important to assess the functioning of their individual cell units.

Cells The cell is the fundamental unit of all living things (animals or plants). Cells are everywhere in the human body: every tissue, every organ is made up of these individual units.

Similarities in Cells All cells are similar because they contain a gel-like substance made up of water, protein, sugar, acids, fats, and various minerals. Various parts of a cell, described below, are depicted in Figure 2-1 as they might appear when photographed under an electron microscope. Label the structures in Figure 2-1. Throughout the book, numbers or letters in brackets indicate that the preceding bold term should be used in labeling.

FIGURE 2-1 Main parts of a cell. Ribosomes (RI-bo-sohmz) are small granules that help the cell make proteins.

The cell membrane [1] not only surrounds and protects the cell, but also regulates what goes in and out of the cell. The kernel [2] controls the operations of the cell. It directs cell division and determines cell structure and function. Chromosomes [3] are rod-shaped structures within the nucleus. All cells in the human body, except the sex cells, the egg cell, and the sperm (short for sperm), contain 23 pairs of chromosomes. Each sperm and each egg has only 23 unpaired chromosomes. After an egg and a sperm unite to form the embryo, each cell of the embryo has 46 chromosomes (23 pairs) (Figure 2-2).

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FIGURE 2-2 Egg and sperm cells, each with 23 chromosomes.

Chromosomes contain regions called genes. There are several thousand genes, in an ordered sequence, on each chromosome. Each gene contains a chemical called DNA (deoxyribonucleic acid). DNA regulates the activities of the cell according to its sequence (arrangement in genes) on each chromosome. The DNA sequence resembles a series of coded recipes. This code, when passed from the nucleus to the rest of the cell, directs the activities of the cell, such as cell division and protein synthesis. A karyotype is a photograph of an individual's chromosomes, arranged by size, shape, and number (Figure 2-3). The karyotype can determine if the chromosomes are normal. For example, an obstetrician may recommend amniocentesis (puncture of the sac surrounding the fetus to remove fluid and cells) for a pregnant woman so that the baby's karyotype can be examined.

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FIGURE 2-3 Karyotype of a normal male. Twenty-three pairs of chromosomes are shown. Pair 23 is the XY pair present in normal males. In normal women, the 23rd pair is XX. For this karyotype, the chromosomes have been treated with chemicals so that bands of light and dark areas are visible.

If a baby is born with a chromosome abnormality, serious problems can occur. In Down syndrome, the karyotype shows 47 chromosomes instead of the normal number of 46 (Figure 2-4). The extra chromosome 21 results in the development of a child with Down syndrome (also called trisomy 21 syndrome). Its incidence is approximately 1 in 750 live births, but as the mother's age increases, the presence of the chromosomal abnormality increases.

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FIGURE 2-4 A, Karyotype of a patient with Down syndrome who has trisomy 21. There is one additional copy of chromosome 21 in addition to the usual pair, making three (tri-) in total. B, Photograph of a child with the typical facial appearance of Down syndrome. Characteristics include a small, somewhat flat nose and upturned eyes. Other characteristics of patients with Down syndrome are mental disability and heart defects.

Continue to identify Figure 2-1. The cytoplasm [4] (cyt/o = cell, -plasma = formation) includes all material outside the nucleus and surrounded by the cell membrane. It does the work of the cell (for example, in a muscle cell, it does the contraction; in a nerve cell, it transmits impulses). The cytoplasm contains a specialized apparatus to meet the chemical needs of the cell. Mitochondria[a] are small sausage-shaped bodies that provide the main source of energy for the cell. They use nutrients and oxygen to release energy stored in food. During the chemical process called catabolism, complex foods like sugar and fat are broken down (catameans) into simpler substances, and energy is released by the mitochondria. Therefore, catabolism provides the energy for the cells to do the work of the body. The endoplasmic reticulum [b] is a network (reticle) of channels within the cell. These channels are cellular tunnel systems that produce proteins for the cell. Adjacent to the endoplasmic reticulum are ribosomes, which build long chains of proteins. Anabolism, which occurs in the endoplasmic reticulum, is the process of building (ana- means building) large proteins from small protein fragments called amino acids. Examples of proteins important for cell growth are hormones and enzymes. Together, these two processes, anabolism and catabolism, make up the metabolism of the cell. Metabolism, then, is the totality of chemical processes that occur in a cell. If a person has a "fast metabolism," foods like sugar and fat are consumed very quickly and energy is released.

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If a person has a "slow metabolism", then food burns slowly, and fat accumulates in the cells.

Study Section 1

Practice spelling each term and learn its meaning. anabolism

The process of building large proteins from small protein fragments called amino acids. Ana- means up, bol means throw and -ism is a process. catabolism Process by which complex nutrients are broken down into simpler substances and energy is released. Cata- means down, bol means throw, and -ism is a process. cell Structure that surrounds and protects the cell. It determines what enters and what membrane leaves the cell. chromosomes Rod-shaped structures in the nucleus that contain regions of DNA called genes. There are 46 chromosomes (23 pairs) in each cell, except for eggs and sperm, which contain only 23 individual unpaired chromosomes. cytoplasm All material that is outside the nucleus and still contained within the cell membrane. Chemical DNA found within each chromosome. Organized as a sequence of coded recipes, it directs the activities of the cell. endoplasmic Network of channels within the cytoplasm of the cell. Here, the large proteins are crosses made up of smaller pieces of protein. genes Regions of DNA within each chromosome. karyotype Image (sorting) of the chromosomes in the nucleus of a cell. Chromosomes are arranged in numerical order to determine their number and structure. Metabolism Total chemical processes in a cell. It includes catabolism and anabolism. Meta- means change, bol means release, and -ism means process. mitochondria Rod-shaped structures in the cytoplasm that provide the main source of energy ("miniature powerhouses") for the cell. Catabolism is the process that takes place in the mitochondria. (From the Greek mythos means thread and chondrion means granule). TIP: Think "mighty" mitochondria! Nucleus Control center of the cell. Contains chromosomes and directs the activities of the cell.

anabolic steroids

These drugs are similar to androgens (male hormones) in their effects on the body. Proteins accumulate inside cells.

Metabolism and the Thyroid Gland

The thyroid gland secretes thyroid hormone (thyroxine or T4), which stimulates metabolism in cells. Increased hormone levels accelerate

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metabolism (increased energy and weight loss) and decreased hormone levels slow metabolism (slowness and weight gain).

Differences in Cells Although we have just seen how cells contain similar structures, as they develop in the embryo, cells change to form many different types. Cells are different or specialized throughout the body to carry out their individual functions. For example, a muscle cell is long and thin and contains fibers that help it contract and relax; an epithelial cell (a skin cell and lining) can be square and flat to provide protection; a nerve cell can be long and have many fibrous extensions that help it in its job of carrying impulses; a fat cell contains large empty spaces for fat storage. These are just a few of the many types of cells in the body. Figure 2-5 illustrates the different sizes and shapes of muscle, epithelial, nerve, and fat cells. The term that describes this change in cells as they mature and specialize is differentiation.

FIGURE 2-5 Cell types. A muscle cell; B, epithelial cell; C, nerve cell; and D, fat cell.

Differentiation

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It is still a scientific mystery why cells with the same DNA change or specialize into different cell types in the developing embryo. The factors are believed to influence genes (DNA), leading to cell differentiation. If we can figure out what causes them to differentiate as they mature, we may be closer to understanding what happens to cells when they revert to a more primitive, unspecialized form, such as cancer cells.

Tissues A tissue is a group of similar cells that work together to do a specific job. A histologist (hist/o = tissue) is a scientist who specializes in the study of tissues. Several different types of tissue are recognized. Tissues of the same type can be located in various regions of the body. Figure 2-6 illustrates four types of fabrics.

FIGURE 2-6 Types of fabrics. A, epithelial. B, Muscle. C, Connective tissue (fat). D, Nerve.

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Epithelial Tissue Epithelial tissue, located throughout the body, forms the lining of internal organs and the outer surface of the skin that covers the body. It also lines the exocrine and endocrine glands and is responsible for the secretions that the glands produce. The term epithelial originally referred to the tissue (epi-) of the nipple (thel/o). Now describe all the tissue that covers the outside of the body and lines the inner surface of the internal organs.

Muscle Tissue Voluntary muscle is found in the arms and legs and in parts of the body where movement is under conscious control. Involuntary muscle, found in the heart and digestive system, as well as other organs, allows movement that is not under conscious control. Cardiac muscle is a specialized type of muscle found only in the heart. Contractions of this type of muscle can be seen as a beating heart on an ultrasound of a 6-week fetus.

Connective Tissue Some examples are adipose (fat) tissue, cartilage (fibrous, elastic tissue attached to bone), bone, and blood.

Nervous Tissue Nervous tissue conducts impulses throughout the body.

Organs Different types of tissue combine to form an organ. For example, an organ such as the stomach is made up of muscle tissue, nervous tissue, and glandular epithelial tissue. The medical term for internal organs is viscera (singular: viscera). Examples of abdominal viscera (organs located in the abdomen) are the liver, stomach, intestines, pancreas, spleen, and gallbladder.

Systems Systems are groups of organs that work together to perform complex functions. For example, the mouth, esophagus, stomach, and small and large intestines are organs that do the job of the digestive system to digest food and absorb it into the bloodstream. Figure 2-7 discusses the difference between cells, tissues, organs, and systems.

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FIGURE 2-7 Cells, tissues, organs, and systems.

The body systems with their individual organs are listed below. Learn to spell and identify the organs in bold. digestive system

ORGANS Mouth, pharynx (throat), esophagus (tube from throat to stomach), stomach, intestines (small and large), liver, gallbladder, pancreas Urinary o Kidneys, ureters (tubes from kidneys to bladder), bladder urinary excretory, urethra (from bladder to outside of body) Respiratory Nose, pharynx, larynx (voice box), trachea (windpipe), bronchi, lungs (where gas exchange occurs) Female Reproductive: ovaries, tubes Fallopian gland, uterus (belly), vagina, mammary glands Male: Testicles and associated fallopian tubes, urethra, penis, prostate gland Endocrine Thyroid gland (in the neck), pituitary gland (in the base of the brain), sex glands (ovaries and testicles), adrenal glands, pancreas (islets of Langerhans), parathyroid glands Nervous Brain, spinal cord, nerves and nerve bundles Circulatory Heart, blood vessels (arteries, veins and capillaries), vessels and lymph nodes icos, spleen, thymus Skeletal muscle Muscles, bones and joints ts Skin and sharp bones Skin, hair, nails, sweat glands and sebaceous (oil) glands; eye, ear, nose, organs and tongue

Study Section 2

Practice spelling each term and learn its meaning.

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adipose cartilage tissue

Collection of fat cells.

Flexible connective tissue often hurts in the bones of the joints. Cartilage is part of the outer ear and nose. Rings of cartilage surround the trachea. skin epithelial cells that cover the exterior of the body and line the internal surfaces of cellular organs. Histologist Specialist in the study of tissues. larynx voice box; located above the trachea. (TIP: Think of the word laryngitis, which means inflammation of the COURTS) larynx and loss of voice! throat pharynx. The pharynx serves as the common passageway for food (from the mouth of the FAH to the esophagus) and air (from the nose to the trachea). TIP: Note that "y" comes before "n" in both the pharynx and larynx. pituitary gland Endocrine gland at the base of the brain. gland TIP: Be careful when spelling pituitary; contains 2 i. thyroid Endocrine gland that surrounds the trachea in the neck. trachea gland Trachea (tube leading from the throat and larynx to the bronchi). ureter One of two tubes, each leading from a single kidney to the urinary bladder. HINT: Spelling Hint: The ureter has two e's and there are two ureters. urethra Tube from the urinary bladder to the outside of the body. HINT: Spelling hint: The urethra has an e, and there is only one urethra. uterus uterus; the organ that contains the embryo/fetus as it develops. viscera Internal organs in the main cavities of the body, mainly in the abdomen.

Body Cavities A body cavity is a space within the body that contains internal organs (viscera). Check out Figure 2-8 as you learn the names of body cavities. Some of the important organs contained in these cavities are also listed.

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FIGURE 2-8 Body cavities. The ventral (anterior) cavities are at the front of the body (blue). The dorsal (posterior) cavities are on the back (red).

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ORGANS OF THE CAVITIES Cranial [1] Brain, pituitary gland. Thoracic Lungs, heart, esophagus, trachea, bronchi, thymus, aorta (large artery [2]). The thoracic cavity is divided into two smaller cavities (Figure 2-9): a. Pleural cavity - space around each lung. The pleura is a double membrane that surrounds and protects the lungs. If the pleura is inflamed (as in pleurisy or pleurisy), the pleural cavity can fill with fluid. This is called a pleural effusion. B. Mediastinum: centrally located space outside and between the lungs. It contains the heart, aorta, trachea, esophagus, thymus gland, bronchi, and many lymph nodes. Continue to identify Figure 2-8. Abdominal The peritoneum is the double-fold membrane that surrounds the abdominal cavity [3] (Figure 2-10). It is pain from the abdominal organs to the abdominal muscles and involves each organ to hold it in place. The kidneys are two bean-shaped organs located behind the abdominal cavity (retroperitoneal area) on either side of the spine (see Figures 2-10 and 2-12). The abdominal cavity also contains the stomach, small and large intestines, spleen, pancreas, liver, and gallbladder. The diaphragm (a muscular wall) divides the abdominal and thoracic cavities (see Figure 2-8). Pelvic [4] Portions of the small and large intestines, rectum, urinary bladder, urethra, and ureters; uterus and vagina in women. Spinal [5] Nerves of the spinal cord.

FIGURE 2-9 Thoracic cavity.

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FIGURE 2-10 Abdominal (peritoneal) cavity (lateral view and in light blue). Look at the peritoneum, which is a membrane that surrounds the organs in the abdominal cavity. If there is a disease of the abdominal organs, fluid can accumulate in the peritoneal cavity. This fluid is called ascites. The retroperitoneal area is behind the peritoneum. The kidneys are in the retroperitoneal area.

The cranial and spinal cavities are the dorsal body cavities (dors/o = back) due to their location in the posterior or posterior part of the body. The thoracic, abdominal, and pelvic cavities are ventral cavities (ventr/o = belly) of the body because they are in the front (anterior) part of the body (see Figure 2-8). While the thoracic and abdominal cavities are separated by a muscular wall called the diaphragm, the abdominal and pelvic cavities are not separate and are together referred to as the abdominopelvic cavity. Figures 2-11 and 2-12 show the abdominal and thoracic viscera in anterior (ventral) and posterior (dorsal) views.

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FIGURE 2-11 Organs of the abdominopelvic and thoracic cavities, anterior view.

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FIGURE 2-12 Organs of the abdominopelvic and thoracic cavities, posterior view.

Study Section 3

Practice spelling each term and learn its meaning.

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abdominal The space below the chest that contains organs such as the liver, stomach, gallbladder cavity, and intestines; also called the abdomen or peritoneal cavity. Cranial cavity The space in the head that contains the brain and is surrounded by the skull. Cranial means pertaining to the skull. Diaphragm Muscle that separates the abdominal and thoracic cavities. The diaphragm moves up and down and helps with breathing. dorsal Relating to the back. Mediastinum (posterior) The space located in the center outside and between the lungs. pelvic cavity The space below the abdomen that contains portions of the intestines, rectum, urinary bladder, and reproductive organs. Pelvic means pertaining to the pelvis, formed by the hip bones that surround the pelvic cavity. peritoneum The folded membrane that surrounds the abdominal cavity. The peritoneum connects the abdominal viscera to the muscles and functions as a protective membrane (containing blood vessels and nerves) around the organs. pleura The folded membrane that surrounds each lung. Pleural means pertaining to the pleura. TIP: Don't confuse pleural with plural, which means more than one! pleural Space between the pleural layers. Cavity Spinal cavity The space within the vertebral column (vertebral column) that contains the spinal cord. See Figure 2-13. Thoracic space in the chest that contains the heart, lungs, bronchi, trachea, esophageal cavity, and other organs. ventral Relative to the front. (former)

FIGURE 2-13 Spinal cavity. A disc is a cushion of cartilage that acts as a cushion between each spine.

Peritoneum and other membranes

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Many vital organs are covered and protected by membranes. The peritoneum surrounds the abdominal viscera (liver, small and large intestine, stomach) and the pleura covers the lungs. You can visualize the way the organs are surrounded by a double membrane by imagining your fist pushing deep into a soft balloon. The balloon is then folded in two layers over the fist, in the same way that the pleura surrounds the lungs and the peritoneum surrounds the abdominal organs. The double wrap around the organs provides protection and cushioning, as well as a place for a firm grip on the muscles. In the case of inflammation or disease of organs or membranes, fluid can accumulate in the space between the membranes that surround the organs. This accumulation of fluid in the pleural cavity is called a pleural effusion. A collection of fluid in the peritoneal cavity is called ascites.

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Abdominopelvic Regions and Quadrant Regions Doctors divide the abdominopelvic area into nine regions. Label these regions in Figure 2-14.

FIGURE 2-14 Abdominopelvic regions. These regions can be used clinically to locate internal organs.

Right hypochondriac region [1]: upper right region below (hypo-) rib cartilage (chondr/o) that extends over the abdomen Left hypochondriac region [2]: upper left region below the rib cartilage Epigastric region [ 3]: region above the stomach Right lumbar region [4]: right mid region near the waist Left lumbar region [5]: left mid region near the waist Umbilical region [6]: navel or umbilicus region Inguinal region right [7] : lower right region near the groin (inguin/o = groin), which is the area where the legs meet the torso

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of the body. This region is also known as the right iliac region because it is close to the ilium (the top of the hip bone). Left inguinal region [8]: Lower left region near the groin. Also called the left iliac region. Hypogastric region [9]: Lower middle region below the umbilical region.

Quadrants The abdominopelvic area can be divided into four quadrants by two imaginary lines, one horizontal and one vertical, that intersect in the midsection of the body. Figure 2-15 shows the four abdominopelvic quadrants; add the appropriate abbreviation on the line below each label in the diagram.

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FIGURE 2-15 Abdominopelvic quadrants. Write the abbreviation for each quadrant on the line provided.

Right Upper Quadrant (RUQ): Contains the liver (right lobe), gallbladder, part of the pancreas, parts of the small and large intestines. Left Upper Quadrant (LUQ): contains the liver (left lobe), stomach, spleen, part of the pancreas, parts of the small and large intestines Right Lower Quadrant (RLQ): contains parts of the small and large intestines, ovary right, right fallopian tube, appendix, right ureter Left lower quadrant (LLQ): contains parts of the small and large intestines, left ovary, left fallopian tube, left ureter

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Divisions of the back (vertebral column) The vertebral column is made up of a series of bones that extend from the neck to the coccyx. Each bone is a vertebra (plural: vertebrae). Label the rear splits in Figure 2-16A as you study the following:

FIGURE 2-16 A. Anatomical divisions of the back (vertebral column). A disc is a small cushion of cartilage between each spinal column. B, MRI (magnetic resonance imaging) of a herniated disc at the L4-L5 level of the spine.

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DIVISION OF THE ACRONIC LOCATION BACK Cervical [1] C Neck region. There are seven cervical vertebrae (C1 to C7). Thoracic [2] T Region of the thorax. There are 12 thoracic vertebrae (T1 to T12). Each bone is attached to a rib. Lumbar [3] L Loin (waist) or flank region (between the ribs and the hip bone). There are five lumbar vertebrae (L1 to L5). Sacrum [4] S Five bones (S1 to S5) fuse to form a single bone, the sacrum. Coccyx [5] The coccyx (coccyx) is a small bone made up of four fused parts.

Do not confuse the vertebral column (spines or vertebrae) with the spinal cord (nerves that surround the spine). The vertebral column is the bone tissue, while the spinal cord is the nervous tissue. The spaces between vertebrae (intervertebral spaces) are identified according to the two vertebrae between which they lie; for example, the L5-S1 space is between the fifth lumbar vertebra and the first sacral vertebra; T2-3 is between the second and third thoracic vertebrae. Within the space and between the vertebrae is a small pad called a disc. The disc, made up of water and cartilage, is a shock absorber. Occasionally, a disc can slip out of place (herniate) and press on a nerve (see Figure 2-16B). This "slippery disc" can cause pain in an area of the body affected by the nerve.

Study Section 4

Practice spelling each term and learn its meaning.

Abdominopelvic regions hypochondriac epigastric lumbar umbilical inguinal hypogastric

Upper right and left regions below the ribs. Upper middle region above the stomach. Right and left midregions near the waist. Central region near the navel. Right and left lower regions near the groin. Also called iliac regions. Lower middle region below the umbilical region.

Abdominopelvic quadrants RUQ LUQ RLQ LLQ

Upper right quadrant. Upper left quadrant. Lower right quadrant. Lower left quadrant.

rear splits

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cervical thoracic lumbar sacrum coccygeal

Neck region (C1 to C7). Thoracic region (T1 to T12). Loin (waist) region (L1 to L5). Sacral region (S1 to S5). Tailbone (coccyx) region.

Related terms vertebrae vertebrae vertebral column disc spinal cord

Single spine. TIP: There are two e's on the Backbones vertebrae. (VER-teh-bray) Bone tissue surrounding the spinal cavity. Nervous tissue within the spinal cavity. Cartilage cushion between the vertebrae.

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Positional and Directional Terms Check Figure 2-17 to identify the following positional and directional terms.

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FIGURE 2-17 Positional and directional terms. Note that the standing figure is in an anatomical position, with the palms of the hands turned outward and the little (fifth) finger in a medial position (closer to the center of the body). The thumb is lateral.

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LOCATION Anterior (ventral) [1] Posterior (dorsal) [2] Deep [3]

RELATION The anterior part of the body. Example: The forehead is on the anterior (ventral) side of the body. Back of the body. Example: The back of the head is posterior (dorsal) to the face. away from the surface. Example: The stab wound penetrated deep into the abdomen. On the surface. Example: Superficial veins can be visualized through the skin.

Superficial [4] Proximal [5] Near the point of attachment on the trunk or near the beginning of a structure. Example: The proximal end of the thighbone (femur) attaches to the hip socket. Distal [6] Far from the point of attachment to the trunk or far from the beginning of a structure. Example: At its distal end, the femur is attached to the knee. Down [7] Under another structure. Example: The feet are in the lower part of the body. They are below the knees. Superior [8] On another structure. Example: The head is above the neck. Cephalic (relating to the head) also means above another structure. Medial [9] Pertaining to the middle, or closer to the medial plane of the body. Example: When in anatomical position (palms facing out), the fifth finger (little finger) is medial. Side [10] Relative to the side. Example: When in the anatomical position (palms out), the thumb is to the side. Supine [11] Lying face up. Example: The patient is in the supine position during an abdominal exam and, in women, during a pelvic (gynecologic) exam. See Figure 2-21 on page 62. Face Down [12] Lying face down. Example: The spines are examined with the patient in the prone position. A patient is lying face down in the prone position.

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Planes of the body A plane is an imaginary flat surface. Check Figure 2-18 to identify the following planes of the body:

FIGURE 2-18 Planes of the body. The figure is in anatomical position. Note the views of the body represented by each plane.

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PLANO Plano frontal (coronal) [1] Plano sagial (lateral) [2] Plano transversal (axial) [3]

LOCATION Vertical plane that divides the body or structure into anterior and posterior portions. A common chest X-ray is a PA view (posteroanterior - back to front view), which is in the frontal (coronal) plane. See Figure 2-18. Longitudinal vertical plane that divides the body or structure into right and left sides. The median sagial plane divides the body into right and left halves. A lateral (side-to-side) chest radiograph is taken in the sagial plane. Horizontal (transverse) plane that crosses the body parallel to the ground. This transverse plane divides the body or structure into upper and lower portions. A computed tomography (CT) scan is one of a series of X-ray images taken in the transverse (axial or transverse) plane.

Study Section 5

Practice spelling each term and learn its meaning. anterior (ventral) distal deep frontal (coronal) inferior plane lateral medial posterior (dorsal) prone proximal sagittal (lateral) plane

Front surface of the body. away from the surface. Away from the point of attachment to the trunk or away from the beginning of a structure. Vertical plane that divides the body or structure into anterior and posterior portions. Under another structure; Pertaining to the lower part of the body. relative to the side Pertaining to or near the medial plane of the body. Posterior surface of the body.

Lie on your stomach (face down, palms down). Near the point of attachment on the trunk or near the beginning of a structure. Longitudinal longitudinal plane that divides the body or structure into right and left sides. From the Latin sagi a, meaning arrow. When an arrow is shot from a bow, it enters the body in the sagial plane, dividing from right to left. The median sagial plane divides the body into right and left halves. superficial On the surface. top On another structure; referring to the head. (cephalic) supine Lying on your back (face up, palms up). TIP: The supine position is the horizontal transverse (transverse) plane of the spine, which divides the body into upper and lower (axial) portions. airplane

Terminology

Break each term into its component parts and write their meaning in the space provided.

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match shapes

FIGURE 2-19 The cervix is the lower portion or cervix of the uterus.

FIGURE 2-20

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MATCH MEANING TERMINOLOGY MEANING SHAPE abdomin/or abdominal abdomen The abdomen is the region below the chest that contains the internal organs (such as the liver, intestines, stomach, and gallbladder). adip/or adipose fat The suffix -ose means belonging to or full of. Another form of combination that means fat is lip/o. Lipids are fats. anter/o front anterior The suffix -ior means pertaining to. cervix (of the cervical corpus or of The cervix is the cervix. See Figure 2-19. the uterus) cartilage chondroma chondroma (type of connective tissue. This is a benign tumor. chondrosarcoma) This is a malignant tumor. The root sarc indicates that the malignant tumor arises from a type of meat or connective tissue. Colored Chromium Chromosomes These nuclear structures absorb color from the dyes used to color the cell. The suffix -somes means bodies. Literally, this term means "colored bodies", because this is how it appeared to researchers who first saw them under a microscope. coccyx/or tailbone coccygeus (coccyx) crani/or craniotomy cyt/or cell cytoplasm The suffix -plasma means formation. distant, distant distal pains dorsal body inguinal/groin tissue histology il/or ilium ilium (upper See Figure 2-20 for an image of the ilium. of the hip bone) inguinal nucleus karyotype/the karyotype The suffix - type means classification or image. posterior/lateral lateral loin/lower back medial lumbosacral/medial core/pelvic core/pelvic pelvis The pelvis includes all the bones that surround the pelvic cavity (Figure 2-20). pharynx/pharynx pharynx (throat) The pharynx (FAH-heads) is the common passageway for food from the mouth and air from the nose. posterior/the back, posterior proximal posterior/the proximal sacrum/the nearest sacrum sacrum

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MATCH MEANING TERMINOLOGY MEANING SHAPE sarc/o flesh sarcoma spin/o spine, spine thel/o, theli/o teat epithelial cell This cell, originally identified in the skin of the teats, is found on external (outside) body surfaces nipple) body) and internally (lining of cavities and organs). thorax/thorax thoracotomy trachea/trachea, trachea trachea umbilicus/navel, umbilical umbilicus ventro/belly ventral lateral body vertebra/vertebra(s), vertebral column(s) viscera/organs internal visceral

Prefixes PREFIX MEANING TERMINOLOGY MEANING anup anabolism In this cellular process, proteins are built from simpler substances (amino acids). Catadown Catabolism Complex nutrients are broken down into simpler substances and energy is released. epi above epinephrine The suffix -ine means a substance. Epinephrine is a hormone secreted by the adrenal glands, located above (epi-) the kidneys (nephr/o). It is used as a treatment (as with an EpiPen®) for severe allergic reactions. Opens the airways and increases the heart rate in medical emergencies. lower hypochondriac region The Greeks thought that the organs (liver and spleen) in the hypochondriac region of the abdomen were the origin of imaginary diseases - hence the term hypochondriac, a person with unusual anxiety about their health and with symptoms not attributable to any process of disease. intervertebral inter between A disc is an intervertebral structure. intravenous intravenous The abbreviation for intravenous is IV. metachange metabolism Literally, to launch (bol/o) a (meta-) change, that is, the chemical changes (processes) that occur in a cell.

suffixes

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The following are some new suffixes introduced in this chapter. See the Glossary (parts of medical words—English) at the end of the book for additional suffixes that mean "pertaining to." SUFFIX -eal -iac -ior -ism -ose -plasm -somes -type

MEANING relative to process, condition relative to, formation-filled bodies image, classification

Cervical

The term cervical can have two different meanings depending on where it is used. In a gynecologic report, cervical means the lower portion or cervix (cervix). In a radiology report of the spine about the cervical vertebrae, cervical refers to the neck of the body.

Comparison of the female and male pelvis The female pelvis is wider and more massive than the male one. The female pelvic opening is larger, rounded, and oval, while the male pelvic opening is deep, narrow, and funnel- or heart-shaped. Thus, the female pelvis can accommodate the fetus during pregnancy and its passage downward through the pelvic cavity at birth.

Epinephrine and Adrenaline

These are the SAME hormone! Two different names for the same substance secreted by the adrenal glands (above the kidneys).

Practical applications

Be sure to check your answers with Answers for Practical Applications on page 64.

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X-rays Circle the correct answers in the following sentences related to each chest x-ray.

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FIGURE A

1. This is a view (coronal, sagittal, axial). The heart is located (anterior, posterior, dorsal) to the vertebrae.

FIGURA B

2. This is a view (coronal, sagittal, axial). It is one/one image (CT, traditional radiography).

Figure C

3. This is a view (coronal, sagittal, axial). It is one/an image (lateral, transversal, anterior/posterior).

surgical procedures

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Associate the surgical procedure in Column I with the indication to perform it in Column II. Note: You are not looking for the exact meaning of each surgical procedure, but rather why it would be performed. COLUMN I Procedures 1. Craniotomy 2. Thoracotomy 3. Discectomy 4. Mediastinoscopy 5. Tracheostomy 6. Laryngectomy 7. Arthroscopy 8. Laparoscopy (peritoneoscopy) *Lymph †A

_______ _______ _______ _______ _______ _______ _______ _______

COLUMN II Indications A. Emergency effort to remove foreign material from the trachea B. Inspection and repair of torn cartilage in the knee C. Removal of a diseased or injured part of the brain D. Inspection of lymph nodes* in the region between the lungs E. Removal of a squamous cell carcinoma† in the larynx F. Open-heart surgery or removal of lung tissue G. Inspection of abdominal organs (lapar/or means abdomen) and removal of diseased tissue H. Relief of symptoms of a bulging intervertebral disc

Nodes are collections of tissue that contain white blood cells called lymphocytes.

Squamous cell is a type of epithelial cell.

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Exercises Remember to check your answers carefully with the Answers to the exercises, page 63.

A The terms listed are parts of a cell. Match each term with its correct meaning. cell membrane chromosomes cytoplasm DNA endoplasmic reticulum genes mitochondria nucleus 1. cell material located outside the nucleus and still enclosed by the cell membrane _____________________________________________ __________________________________________ 2. regions of DNA within each chromosome _____________________________________________ __ 3. small sausage-shaped structures that are the main source of energy for the cell __________________________________________________ ________________________________________________ 4. network of channels within the cytoplasm; the site of protein synthesis _________________________ 5. structure that surrounds and protects the cell __________________________________________ 6. control center of the cell, which contains the chromosomes ______________________________________

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7. chemical found inside each chromosome ______________________________________________ __ 8. rod-shaped structures in the nucleus that contain regions called genes _________________________ B Use medical terms or numbers to complete the following sentences. 1. A picture of the chromosomes in the nucleus of a cell is a ________________________________. 2. The number of chromosomes in a normal male muscle cell is ________________________. 3. The number of chromosomes in a female's egg is _____________________________________. 4. The process of protein formation in a cell is _____________________________________________. 5. Complex nutrients are broken down into similar substances and energy is released __________________________________________ _____________________________________. 6. The total number of chemical processes in a cell is _____________________________________________. 7. A scientist who studies tissues is a _____________________________________________ ____. 8. The medical term for internal organs is _____________________________________________ ___. C Match the body parts or tissues listed with their correct descriptions below. adipose tissue

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cartilage epithelial tissue larynx pharynx pituitary gland pleura thyroid gland trachea ureter urethra uterus 1. larynx ____________________________________________ __________________________ 2. membrane around the lungs _____________________________________________ ________ 3. throat ____________________________________________ __________________________________________ 4. duct leading from the kidney to the urinary bladder ________________________________________________________ 5. accumulation of fat cells _____________________________________________ ___________________ 6. endocrine organ located at the base of the brain ___________________________________________ 7. trachea __________________________________________ __________________________

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8. Flexible connective tissue sore to the bone in the joints _____________________________________ 9. Skin cells that cover the outside of the body and line the internal organs ________________________________ 10. Endocrine gland that surrounds the trachea in the neck ________________________________________ 11. Uterus ________________________________________________ ________________________________ 12. Tube leading from the urinary bladder to the outside of the body ___________________________ D Name the five cavities of the body. 1. cavity surrounded by the skull ____________________________________________ ___________ 2. cavity in the chest surrounded by the ribs ___________________________________________ _ 3. cavity under the chest that contains the stomach, liver, and gallbladder ________________________ 4. cavity surrounded by the hip bones _____________________________________________ _______ 5. cavity surrounded by the bones of the back _____________________________________________ E Please select one of the following options to define the listed terms. space around each lung space between the muscles of the lungs that separates the abdominal and thoracic cavities

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membrane that surrounds the abdominal organs area below the navel (as well as below the stomach) area above the stomach area of the navel areas near the groin nerve tissue within the spinal cavity bone tissue that surrounds the cartilage of the spinal cavity between two adjacent vertebrae 1 .hypogastric region ______________________________________________ ____________________ 2. mediastinum __________________________________________ _________________________ 3. spinal cord _____________________________________________ ___________________________ 4. diaphragm ____________________________________________ ___________________________ 5. intervertebral disc _____________________________________________ ____________________ 6. pleural cavity _____________________________________________ _________________________ 7. vertebral column _____________________________________________ ________________________________

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8. Inguinal Regions ____________________________________________ ______________________ 9. Peritoneum __________________________________________ __________________________ 10. Umbilical Region ____________________________________________ ______________________ 11. Epigastric Region ____________________________________________ ______________________ F Name the five divisions of the back. 1. neck region ________________________________________________ _____________________ 2. chest region __________________________________________ _______________________ 3. waist region ________________________________________________ _____________________ 4. sacral region _____________________________________________ ___________________ 5. coccyx region ____________________________________________ __________________ G Give the meaning of the following abbreviations.

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1. LLQ __________________________________________ _________________________________ 2. L5–S1 __________________________________________ ________________________________ 3. RUQ _____________________________________________ ________________________________ 4. C3–C4 ____________________________________________ ________________________________ 5. RLQ ____________________________________________ ________________________________ H Give the opposites of the following terms. 1. deep ______________________________ 2. proximal ________________________ 3. supine ______________________________ 4. medial ______________________________ 5. dorsal _________________________ 6. superior _________________________ I Select one of the following medical terms to complete the sentences below. front distal (coronal) inferior lateral medial sagittal

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upper proximal (cephalic) vertebra transverse (axial) vertebrae 1. The kidney is located next to or ___________________ of the spinal cord. 2. The ___________ end of the thigh bone (femur) attaches to the kneecap (patella). 3. The ___________ plane divides the body into anterior and posterior parts. 4. Each vertebral column is a _____________________________________________ ______________. 5. Several vertebral columns are _____________________________________________ ______________. 6. The diaphragm is __________________________ to the organs of the thoracic cavity. 7. The __________________________ plane divides the body into right and left halves. 8. The ______________________ end of the upper arm bone (humerus) is in the shoulder. 9. The ________________________ plane divides the body into upper and lower parts. 10. The pharynx is located _____________________________________________ to the esophagus. J Give meanings to each of the following.

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1. Craniotomy __________________________________________________ __________________________________ 2. Cervical __________________________________________ ___________________________________ 3. Chondroma _____________________________________________ ___________________________ 4. Chondrosarcoma _____________________________________________ _____________________________ 5. Nucleic _____________________________________________ ___________________________ 6. Epinephrine _____________________________________________ __________________________ 7. Intravenous _____________________________________________ __________________________ 8. Pharyngeal _____________________________________________ __________________________________ 9. Laryngitis _________________________________________________ __________________________________ _ the following settings. Be careful with the spelling! 1. space below the thorax that contains the liver, stomach, gallbladder, and intestines _____________________

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2. Flexible connective tissue attached to bones at joints _____________________________________ 3. Rod-like structures in the cell nucleus, containing regions of DNA _____________________ 4. Muscle separating the abdominal and thoracic cavities ____________________________________ 5. Larynx _____________________________________________ ___________________________ 6. Flat vertical dividing the body into right and left sides __________________________________ 7. pertaining to the neck __________________________________________ _________________ 8. cartilage tumor (benign) _____________________________________________ ____________ 9. cellular control center; directs the activities of the cell ________________________________________________ 10. belonging to the trachea __________________________________________ _____________ L Complete each term according to the given meaning. 1. pertaining to internal organs: __________________________ al 2. tumor of fleshy tissue (malignant): __________________________ oma

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3. belonging to the thorax: __________________________ ic 4. image of chromosomes in the nucleus of the cell: type __________________________ 5. sausage-shaped cell structures in which catabolism occurs: myth ___________________ 6. space between the lungs: middle __________________________ 7. endocrine gland at the base of the brain: __________________________ aria gland 8. belonging to skin (surface) cells: epi __________________________ 9. belonging to far from the beginning of a structure: __________________________ to 10. on the surface of the body: super __________________________ M Circle the correct term to complete each sentence. 1. Dr. Curnen said the wound (groin, upper, superficial) barely scratched the surface. 2. Since the liver and spleen are on opposite sides of the body, the liver is in (RUQ, LUQ, LLQ) of the abdominopelvic cavity and the spleen is in (RUQ, LUQ, RLQ). 3. When a gynecologist performs a pelvic exam, the patient lies on her back in the lithotomy position (ventral, dorsal, medial) (Figure 2-21).

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FIGURE 2-21 Dorsal lithotomy position. Lithotomy means incision to remove a stone (lith/o = stone). This supine position is used for pelvic (gynecologic) exams and to remove stones from the urinary tract.

4. Sally complained of pain in the region around her belly button. The physician described the pain as (periumbilical, epigastric, hypogastric). 5. After sampling the fluid surrounding her 16-week fetus and reviewing the chromosome image, the doctor explained to Ms. Jones that the fetus had trisomy 21. The diagnosis was made by testing for an abnormality (sample urine, x-ray, karyotype). 6. The cavity (spinal, sagial, abdominal) contains digestive organs. 7. The emergency department physician suspected appendicitis when Brandon was admitted with severe pain (LLQ, RLQ, RUQ). 8. Susan hiccuped after briefly eating spicy Indian food. Her doctor explained that hiccups were involuntary contractions or spasms of the (navel, diaphragm, mediastinum) that resulted in uncontrolled breathing of air. 9. Maria's coughing and sneezing were the result of an allergy to pet dander that affected her system (respiratory, cardiovascular, urinary).

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10. While ice skating, Natalie fell on her butt. She had persistent pain (cervical, thoracic, coccygeal) for a few weeks, but she had no broken bones on X-ray examination.

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Answers to exercises A 1. cytoplasm 2. genes 3. mitochondria 4. endoplasmic reticulum 5. cell membrane 6. nucleus 7. DNA 8. B chromosomes 1. karyotype 2. 46 (23 pairs) 3. 23 4. anabolism 5. catabolism 6. metabolism 7. histology 8. viscera C 1. larynx 2. pleura

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3. pharynx 4. ureter 5. adipose tissue 6. pituitary gland 7. trachea 8. cartilage 9. epithelial tissue 10. thyroid gland 11. uterus 12. urethra R 1. cranial 2. thoracic 3. abdominal 4. pelvic 5. spinal E 1. area below the navel 2. space between the lungs 3. nerve tissue within the spinal cavity 4. muscle that separates the abdominal and thoracic cavities 5. cushion of cartilage between two adjacent vertebrae

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6. space around each lung 7. bone tissue around the spinal cavity 8. areas near the groin 9. membrane around the abdominal organs 10. navel area 11. area over the stomach F 1. cervical 2. thoracic 3 lower back 4. sacrum 5. coccygeal G 1. left lower quadrant (of the abdominopelvic cavity) 2. between the fifth lumbar vertebra and the first sacral vertebra (common site of herniated disc) 3. right upper quadrant (of the abdominopelvic cavity) 4 . between the third and fourth cervical vertebrae 5. right lower quadrant (of the abdominopelvic cavity) H 1. superficial 2. distal 3. prone

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4. lateral 5. ventral (anterior) 6. inferior I 1. lateral 2. distal 3. frontal (coronal) 4. vertebra 5. vertebrae 6. inferior 7. median 8. proximal 9. transverse (axial) 10. superior ( cephalic) J 1. craniotomy: incision of the skull 2. cervical: related to the cervix or cervix 3. chondroma: cartilage tumor (benign or non-cancerous tumor) 4. chondrosarcoma: cartilage flesh tumor (malignant tumor ), cancerous) 5 .nucleic—related to the nucleus

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6. epinephrine: a substance (hormone) secreted by the adrenal glands (epi- = top; nephr- = kidney) 7. intravenous: belonging inside a vein 8. pharyngeal: belonging to the pharynx (throat) 9. laryngitis — throat inflammation larynx (voice box) K 1. abdomen or abdominal cavity 2. cartilage 3. chromosomes 4. diaphragm 5. larynx 6. sagittal—note spelling with double t 7. cervical 8. chondroma 9. nucleus 10 .tracheal L 1 .visceral 2. sarcoma 3. thoracic 4. karyotype 5. mitochondria—memory tip: catabolism and mitochondria, cat and mouse!

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6. mediastinum 7. pituitary 8. epithelial 9. distal 10. superficial M 1. superficial 2. RUQ; LUQ 3. dorsal; often called dorsolithotomy position 4. periumbilical 5. karyotype 6. abdominal 7. RLQ 8. diaphragm 9. respiratory 10. coccygeal Answers to practical applications X-ray views

1. sagittal, anterior 2. axial, CT 3. coronal, anterior/posterior Surgical procedures

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1.C A trephine is a type of circular saw used for craniotomy. 2. F 3. H Endoscopic discectomy is performed through a small incision in the back, lateral to the spine. All or part of the disk is removed. 4. D A small incision is made above the sternum and an endoscope is inserted to inspect the lymph nodes around the trachea. 5. A 6. E 7. B 8. G A small incision is made near the navel and a laparoscope is inserted. Laparoscopy, or minimally invasive surgery, is used to examine organs and perform many surgical operations, such as removing the gallbladder or appendix or inserting the fallopian tubes. Laparoscopy is also called peritoneoscopy. Pronunciation of Terms

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TERM abdomen abdominal cavity adipose anabolism adipose catabolism anterior cartilage cell membrane chondroma cervical chondrosarcoma cephalic coccygeal chromosome coccyx cranial cavity craniotomy cytoplasm disc diaphragm deep endoplasmic reticulum distal endoplasmic reticulum dorsal epigastric region epinephrine epithelial cells frontal plane genes histology hypochondriacal regions hypogastric region inferior inguinal regions iliac intervertebrae carium intravenous laryngitis lateral larynx lumbar regions lumbar spine lumbosacral mediastinum metabolism mitochondria nucleic nucleus pelvic cavity peritoneum

PRONUNCIATION AB-do-men ab-DOM-ih-nal KAV-ih-te AH-dih-pohs ah-NAB-o-liz-im an-TE-re-or KAR-tih-lij kah-TAB-o- cellular liz-im MEM-brain seh-FAL-ik SER-vih-cool con-DRO-mah con-dro-sar-KO-mah KRO-mo-sohm kok-sih-JE-al KOK-six KRA-ne- al KAV-ih-te kra-ne-OT-o-me SI-to-plaz-im deep DI-ah-do disco DIS-tal DOR-sal in-do-PLAZ with reh-TIK-u-lum ep - ih-GAS-trick RE-jen ep-ih-NEF-rin ep-ih-THE-le-al sels FRUN-number playn jeenz his-TOL-o-je hi-po-KON-dre-ak RE-jens hola -po-GAS-trick RE-jen IL-e-ak in-FE-re-or IN-gwih-nal RE-jens in-ter-ver-TE-bral in-trah-VE-nus KAIR-e-o- type lah-rin-JI-tis LAH-rinques LAT-er-al LUM-barra RE-jens LUM-barra spinhal lum-bo-SA-kral ME-de-al me-de-ah-STI-num meh-TAB - o-lism mi-to-KON-dre-ah nu-CLA-ik NU-cle-us PEL-vik KAV-ih-te per-eh-to-NE-um

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TERM pharynx pharynx pituitary gland pleura pleural cavity prone posterior sacral proximal sagittal plane sarcoma spinal cavity vertebral column spinal cord supine superior thoracic cavity thoracotomy thyroid gland trachea transverse tracheal plane umbilical region ureter urethra uterus ventral vertebrae visceral vertebrae visceral vertebrae

PRONOUNCATION fah-ren-JE-al FAH-pistas pih-TU-ih-ter-e glândula PLUR-ah PLUR-al KAV-ih-te pos-TE-re-ou prohn PROKS-ih-mal SA-kral SA- krum SAJ-ih-tal playn sar-KO-mah SPI-nal KAV-ih-te SPI-nal KOL-um SPI-nal cord super-per-FIH-shul su-PE-re-or su-PINE thor-AH -sik KAV-ih-te thor-ah-KOT-o-me THI-royd gland TRA-ke-ah TRA-ke-al tranz-VERS playn um-BIL-ih-kal RE-jen U-reh-ter u -RE-thrah U-ter-us VEN-tral VER-they-brah VER-they-bray ver-TE-bral VIS-er-ah VIS-er-al

revision sheet

Write the meaning of each form of combination, prefix or suffix in the space provided and see for yourself. Check your answers with the information in the chapter or in the Glossary (Parts of Medical Words—English) at the end of the book.

match shapes

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COMBINED FORM abdomin/o adipo/o antero/o cervic/o chondr/o chrom/o coccyg/o crani/o cyt/o dist/o dors/o hist/o ili/o inguin/o kary/o posterior laryng/ lumbar/middle/nuclear/pelvic/pharyngeal/posterior/proximal/sacral/sarcus/gyrus/posterior/la,theli/thoracic/tracheal/umbilical/ventral/la vertebra/the viscera/the

Prefixes PREFIX anacataepihypointtermeta-

SENSE ___________________ ___________________ ___________________ ___________________ ___________________ ___________________

suffixes

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SUFFIX -al -eal -ectomy -iac -ior -ism -oma -osa -plasma -somes -tomy -type

Label the regions and quadrants (use abbreviations) of the abdominopelvic cavity. Check your answers in the chapter, pages 46 and 47.

Name the divisions of the vertebral column. Check your answers on page 48. neck region (C1 to C7) ___________________________________________________________ ____________ thorax region (T1 to T12) _____________________________________________________________ _________ lumbar (spine) region (L1 to L5) __________________________________________________________ _ sacral region (S1 to S5) ________________________________________________________________________ ___ region coccyx __________________________________________________________ __________________

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Name the planes of the head as shown below. Check your answers on page 52.

Vertical plane that divides the body into anterior and posterior portions ____________________________________________________________ _____________ Horizontal plane that divides the body into superior and inferior portions Check your answers on pages 50-51. front of body __________________________________________________________________ _________________

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back of body ________________________________________________________________ __________________ away from body surface ___________________________________________________________ _ on body surface _______________________________________________________________ ________ away from point of attachment to trunk or away from beginning of a structure ________________________________________________________ ______________________________ near point of attachment to trunk trunk or near beginning of a structure ___________________________________________________________________ ______________________________ under another structure ___________________________________________________________ _______________ above another structure _____________________________________________________________ ____________ belonging to the side _____________________________________________________________ _____________ belonging to the middle ________________________ _____________________________ _____ ___ _____________ lying face down ___________________________________________________________ ________________ lying face up __________________________________________________________ _______________ Give the meaning of the following terms that belong to the cell. Check your answers in Study Section 1, page 35. chromosomes __________________________________________________________ ______________

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mitochondria __________________________________________________________ _________________ nucleus ___________________________________________________________ ______________________ DNA ___________________________________________________________ _____________________ endoplasmic reticulum _____________________________________________________________ ______ cell membrane ____________________________________________________________________________ ____ catabolism _____________________________________________________________ ___________________ anabolism _____________________________________________________________ _________________________ metabolism _____________________________________________________________ _____________________ Give the term that fits the given meaning. Check your answers in Study Section 3, page 45. Membrane that surrounds the lungs ________________________________________________________________ Membrane that surrounds the abdominal viscera _____________________________________________________ Muscular wall that separates the thoracic and abdominal cavities _____________________________________ Space between the lungs, which contains the heart, trachea, aorta ________________________________________ Vertebral column _______________________________________________________________ _______________ Pad of cartilage between each column and the next _______________________________________________ FYI: These are the common abnormalities of the spine.

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CHAPTER 3

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Suffixes CHAPTER SECTIONS: Introduction 72 Combining Forms 72 Suffixes and Terminology 74 A Closer Look 82 Practical Applications 88 Exercises 88 Answers to Exercises 96 Pronunciation of Terms 98 Review Sheet 100

CHAPTER OBJECTIVES • Define new suffixes and review those introduced in previous chapters. • Get practice analyzing words using these suffixes with combined forms to build and understand terms. • Identify the functions of the different types of blood cells in the body.

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Introduction In this chapter you will find many of the most common suffixes in medical language. As you progress through the book, these suffixes will appear frequently. An additional group of suffixes is presented in Chapter 6. This chapter presents additional combination forms for use in forming words with suffixes. Your mastery of this material and your analysis of the words in the Suffixes and Terminology section will increase your vocabulary of medical language.

match shapes

Use the following list of combined forms when writing the meanings of the terms beginning on page 74.

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COMBINED FORM abdominal/o acr/o acu/o aden/o adip/o amni/o angi/o arteri/o arthr/o axilla/o bi/o blephar/o bronch/o carcin/o cardio/o chem/o chondr / the chron / the cervix / the cyst / the encephalon / the erythrocyte / the heme / the liver / the hydric / the inguinal / the bait / the lapar / the larynx / the leuco / the lymphatic / the mammary / the mast / el morph/el muc/the my/the myel/the necr/the nephr/the neur/the neutr/the nucleus/the ophthalm/opi/the oste/the ot/the path/the

MEANING abdomen extremities, above, sharp point, severe, sudden fat gland amnion (sac that surrounds the embryo in the uterus) vessel artery articulation axilla life eyelid bronchi (two tubes, one right and one left, branching from the trachea ( large intestine) urinary bladder brain red blood liver water groin retaining fluid abdomen, abdominal wall larynx white lymph Clear fluid that bathes tissue spaces and is contained in lymphatic vessels and lymph nodes throughout the body breast form of breast, mucus form, spinal cord muscle; bone marrow Context of use indicates intended meaning death (of cells or whole body) kidney nerve neutrophil (a white blood cell) nucleus eye opium bone ear disease

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COMBINED FORM peritone/el phage/la phleb/el plas/the pleur/the pneumon/the pulmon/the radi/the rect/the ren/the rhin/the sarc/the splen/the staphyl/the strept/the thorac/ the thrombus/tonsil/trachea/venous

MEANING peritoneum for eating, swallowing vein formation, development pleura (membrane that surrounds the lungs and adjacent to the chest wall) lungs lungs x-rays rectum kidney

Encephal/o, Cerebr/o, Cephal/o, Crani/o and Psych/o Do not confuse the meanings of these combined forms! Encephal/o = brain Cerebr/o = brain (largest part of the brain) Cephal/o = head Crane/o = skull Psych/o = mind

Larynx and other parts of the body ending in x coccyx = coccyx larynx = larynx pharynx = throat phalanx = finger or toe

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To make shape matches for body parts ending in x, replace g with x: coccyx/o laryng/o pharynx/o phalanx/o

Suffixes and Terminology Noun Suffixes Following the meaning of each suffix, the terminology illustrates the use of that suffix. Remember the basic rule of thumb for building a medical term: use a combined vowel, such as o, to connect the root to the suffix. However, drop the combined vowel if the suffix begins with a vowel, for example, gastr/itis, not "gastr/o/itis". Beginning on page 82, more details on specific terms are provided. This section, called A Closer Look, will give you a fuller understanding of the terminology.

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SUFFIX -algia

MEANING pain

-a

hernia (see A Closer Look: Hernia, page 82) puncture to remove fluid

- percent

-cocos (singular) -cocos (plural)

berry-shaped bacteria (plural: bacteria)

-quickly

cell

-pumpkin

insect

-ectomia

excision, extirpation, resection blood state

-emia

-genesis

condition to produce

TERMINOLOGY MEANING arthralgia ________________________________________ otalgia _____________________________________ neuralgia _____________________________________ myalgia ______________________________________ Fibromyalgia is a common chronic disorder involving widespread pain in muscles and fibrous tissues around joints. rectocele _____________________________________ cystocele __________________________________________

thoracentesis __________________________________________ Note that this term is abbreviated thoracentesis. amniocentesis ______________________________________ The amnion is the sac (membrane) that surrounds the embryo (fetus after the eighth week) in the womb. The fluid collects in the amnion and can be taken for analysis between 12 and 18 weeks of pregnancy. See Figure 3-1. abdominocentesis ____________________________________ This procedure is more commonly known as abdominal paracentesis (para- means on the side or near). A tube is placed through an incision in the abdomen, and fluid is withdrawn from the peritoneal cavity (next to the abdominal organs). strep __________________________________________ staphylococci __________________________________________ (stah-fih-lo-KOK-si) Microbiologists often refer to bacteria grouped together as “staphylococci”. See A Closer Look: Streptococci, Staphylococci, and Other Bacteria, page 83. Red Blood Cells _________________________________________________ See A Closer Look: Blood Cells, page 84. White Blood Cells __________________________________________ Thrombocytes ____________________________________________ Pleurodynia ________________________________________ Pain in the muscles of the chest wall that gets worse when breathing laryngectomy ________________________________________ mastectomy ______________________________________ anemia ______________________________________ ischemia ________________________________________ Literally, withholding (isch/o) blood (-emia) from a part or tissue of the body. Due to a decrease in blood supply (blood clot in a vessel or narrowing and closing of a vessel), the tissue becomes ischemic and can even die if oxygen deprived for a long time. TIP: You may be familiar with a TIA (transient ischemic attack), which is a "mini-stroke" that occurs when blood backs up from tissue in the brain. carcinogenesis ________________________________________ pathogenesis _____________________________________ angiogenesis _____________________________________

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SUFFIX -grama -grafico -grafía -itis

-logy -lysis

-malacia -megalia

- ter

-apart, sideways

-osis

-patia

MEANING record

TERMINOLOGY MEANING electroencephalogram ______________________________________ mammography _____________________________________ electroencephalogram recording instrument __________________________________________ electroencephalographic recording process __________________________________________ angiography __________________________________________ inflammatory bronchitis ________________________________________ myelitis _____________________________________________ Honey means spinal cord in this term. tonsillitis ______________________________________ Tonsils (note the single letter spelling, while the combined form has a double letter) are lymphatic tissues in the back of the throat. See Figure 3-2. Thrombophlebitis __________________________________________ Also called phlebitis. ophthalmology study __________________________________________ morphology ______________________________________ degradation, hemolysis _____________________________________ destruction, normal degradation of red blood cells. Excessive destruction of separated red blood cells can lead to a type of anemia called hemolytic anemia. softening of osteomalacia ______________________________________ chondromalacia ______________________________________ enlargement of acromegaly ____________________________________________ See A Closer Look: Acromegaly, page 86. splenomegaly ________________________________________ tumor, mass, fibroma ________________________________________ collection of A benign tumor. fluid myosarcoma __________________________________________ A malignant tumor. Muscle is a type of fleshy tissue (sarcum). multiple myeloma __________________________________________ Honey/o means bone marrow in this term. This malignant tumor occurs in bone marrow tissue throughout the body. hematoma ______________________________________ to see biopsy _____________________________________ necropsy _______________________________________ This term is used in veterinary medicine. An autopsy is a necropsy performed on humans. condition, necrosis ___________________________________ usually abnormal hydronephrosis _____________________________________________ leukocytosis _____________________________________________ disease cardiomyopathy condition ________________________________________ primary disease of heart muscle in the absence of a known underlying etiology (cause).

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SUFFIX -cent

-phobia

-plasia

- plastics

-ptosis -rhea -esclerosis -scope -scopy

- it is

-ostomy

deficiency of MEANING

TERMINOLOGY MEANING erythropenia ________________________________________ neutropenia __________________________________________ Neutr/o in this term indicates neutrophil (a type of white blood cell). thrombocytopenia ____________________________________ fear acrophobia __________________________________________ Fear of heights. Acr/o means extremities, in the sense of extreme or distant points. TIP: Think of acrobats performing tightrope acts. agoraphobia __________________________________________ Agora means market. It is an anxiety disorder marked by the fear of leaving the house alone, being in open or closed places, or using public transport. development, achondroplasia formation, growth _____________________________________ This is an inherited disorder or may be the result of a mutation (alteration) in a specific gene. The bones of the arms and legs do not grow to normal size due to a defect in the formation of cartilage and bone. The result is dwarfism, characterized by short limbs but a normal-sized head and trunk and normal intelligence. See Figure 3-3. surgical angioplasty __________________________________________ repair An interventional cardiologist opens a narrowed blood vessel (artery) using a balloon that is inflated after being inserted into the vessel. Stents, or tipped tubes, are then placed to keep the artery open. drooping, blepharoptosis _________________________________ drooping, doctors use only ptosis (TO-sis) to indicate drooping or prolapse of the upper eyelids or sinuses. See Figure 3-4. runny nose ________________________________ discharge hardening arteriosclerosis _________________________________ In atherosclerosis (a form of arteriosclerosis), fatty deposits (air/or means fatty material) build up in an artery. _________________________________ laparoscope instrument for visual examination laparoscopy procedure _________________________________ visual See Figure 3-5B below and A Closer View: Laparoscopy Examination page 86. (with an endoscope) control, metastasis ________________________________ stop Meta- means beyond. A metastasis is the spread of a malignant tumor beyond its original site to a secondary organ or site. hemostasis _________________________________ Blood flow is interrupted naturally by an obstruction or artificially by compressing or suturing a wound. A hemostat is a surgical clamp used in operating rooms to stop the flow of blood. colostomy opening _________________________________ tracheostomy shape _________________________________ mouth (stoma)

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SUFFIX -therapy

-for mine

-trophy

MEANING treatment

TERMINOLOGY MEANING hydrotherapy _________________________________ chemotherapy _________________________________ radiation therapy _________________________________ High-energy radiation is used to treat, not diagnose, disease. incision, laparotomy _________________________________ cu ing into Also known as "lap," this procedure is the creation of a large incision into the peritoneal cavity, often done exploratory. Do not confuse laparotomy with laparoscopy. See Figure 3-5. phlebotomy _________________________________ tracheostomy _________________________________ See A Closer Look: Tracheostomy, page 87. development, hypertrophy _________________________________ nutrition (hi-PER-tro-fe) Cells increase in size, not number. Weightlifters' muscles often become hypertrophied. atrophy _________________________________ Cells decrease in size. Muscles atrophy when immobilized in a cast and not in use.

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FIGURE 3-1 Amniocentesis. Under ultrasound guidance (images based on high-frequency sound waves), the doctor inserts a needle through the uterine wall and through the amnion into the amniotic cavity. Amniotic fluid, which contains fetal cells, is removed and cultured (cultured) for microscopic analysis. A karyotype is performed to study the chromosomes. The fluid is examined for chemicals that indicate fetal defects.

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FIGURE 3-2 Tonsillitis. This shows strep throat with intense erythema (redness) of the tonsils (see arrows) and a creamy yellow exudate (pus containing white blood cells and bacteria). Normally, the tonsils contain lymphocytes that fight bacteria. When they become infected and inflamed, a tonsillectomy may be required.

FIGURE 3-3 Achondroplasia. A child with achondroplasia. His abnormalities include short stature with normal trunk length, short limbs and fingers, bowed legs, a prominent forehead, and a depressed nasal bridge. (Courtesy of A.E. Chudley, MD, Section of Genetics and Metabolism, Department of Pediatrics and Child Health, Children's Hospital, Winnipeg, Manitoba, Canada.)

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FIGURE 3-4 Ptosis of the upper eyelid (blepharoptosis). This condition may be congenital (appear at birth), may occur with aging, or may be associated with cerebrovascular accident (stroke), cranial nerve damage, and other neurological disorders. The eyelid droops due to muscle weakness.

FIGURE 3-5 A. Laparotomy. This large incision was closed with surgical staples. B. Laparoscopy. The abdomen is examined by making small incisions and using a laparoscope. This procedure is often used to examine and remove organs such as the appendix and gallbladder.

The following are suffixes for shorter nouns that are usually attached to word roots.

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MEANING OF SUFFIX -er the one who -ia

-ist -oid -ole -ule -um, ium -us -y

TERMINOLOGY MEANING radiologist _________________________________ A technologist who assists in the creation of diagnostic X-ray images. condition leukemia _________________________________ This is a group of cancers that begins in the bone marrow and results in a large number of abnormal, immature white blood cells. pneumonia _________________________________ specialist nephrologist _________________________________ opioid-like _________________________________ adenoid-derived _________________________________ See A Closer Look: Adenoids, page 87. small arteriole _________________________________ See Figure 3-6. small venule ________________________________ See Figure 3-6. structure, pericardium _________________________________ tissue This membrane surrounds the heart. structure, mucus _________________________________ substance esophagus ________________________________ That- means inside or within. condition, process of nephropathy _________________________________ (neh-FROP-ah-the)

FIGURE 3-6 Relationship of blood vessels. An artery carries oxygen-rich blood from the heart to the organs of the body. In organs, the artery narrows to form arterioles (small arteries) that branch into capillaries (the smallest blood vessels). Through the thin walls of the capillaries, oxygen leaves the blood and enters the cells. Therefore, capillaries that branch into venules (small veins) carry blood with low oxygen content. The venules lead to a vein that carries oxygen-poor blood to the heart.

Adjective Suffixes No simple rule will explain which suffix meaning "belonging to" is used with a particular combination form. Focus on identifying the suffix on each term; Then write the meaning of the term. For a list of suffixes meaning "belong to," see the Word Part Glossary beginning on page 967.

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SUFFIX MEANING -ac, -iac belonging to -al belonging to

-is it so

belonging to

-real -genic

relating to production, produced by or in -ic, -ical belonging to

-ose -huevos -tic

TERMINOLOGY MEANING cardiac _________________________________ peritoneal _________________________________ inguinal _________________________________ myocardial _________________________________ A myocardial infarction (MI) is a heart attack. A heart attack is an area of dead tissue (necrosis) resulting from ischemia (lack of blood supply to that tissue). pleural _________________________________ tonsillar _________________________________ pulmonary _________________________________ axillary _________________________________ Axillary lymph nodes are found in the armpit and are important in breast cancer. laryngeal _________________________________ cancerous _________________________________ osteogenic _________________________________ An osteogenic sarcoma is a malignant tumor that occurs in the bone.

chronic _________________________________ Acute is the opposite of chronic. Describes a disease of rapid onset, with severe symptoms and short duration. _________________________________ pathological pertaining to, _________________________________ fatty pertaining to the mucous membrane _________________________________ Mucous membranes (an adjective) produce the sticky secretion called mucus (a noun). related to _________________________________ necrotic

plural formation

Words ending in -us generally form their plural by removing -us and adding -i. Other examples of the formation of the plural -us are the following: nucleus → nuclei bronchi → bronchi thrombus → thrombi See Appendix I at the end of the book for additional information on plural formation.

Anemia

Although anemia literally means "without blood," it is actually a condition characterized by a reduction in the number of red blood cells, or the amount of hemoglobin in the blood. Examples of types of anemia are:

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• iron deficiency anemia (iron is needed to make hemoglobin) • sickle cell anemia (red blood cells take an abnormal sickle shape and clog blood vessels) • aplastic anemia (red blood cells, white blood cells, and platelets do not are formed in the bone marrow)

splenomegaly

The spleen is an organ in the left upper quadrant (LUQ) of the abdomen (below the diaphragm and next to the stomach). Composed of lymphatic tissue and blood vessels, it removes dying red blood cells and contains disease-fighting white blood cells. Splenomegaly occurs with the development of high blood pressure in the hepatic veins and hemolytic blood disorders (anemias involving excessive destruction or lysis of red blood cells). If the spleen is removed (splenectomy), other organs perform their functions.

Common Surgical Repair Procedures

Popular procedures include:

abdominoplasty—abdominal mammoplasty—breast blepharoplasty—tummy tuck—nose

opioids

An opioid is a drug derived from the opium poppy plant. Opioids, also known as narcotics (narc/o means stupor or sleep), include heroin, fentanyl, oxycodone (OxyContin), hydrocodone (Vicodin), codeine, and morphine. These drugs act on brain receptors to relieve pain. Misuse of opioids increases the risk of addiction, overdose, and death. A medicine called buprenorphine treats addiction to opioids. By reducing both acute and chronic pain, it minimizes withdrawal symptoms. Narcan (naloxone) is a medication to combat the life-threatening effects of opioid overdose.

Axillary lymph nodes and breast cancer

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Breast cancer cells often spread to the lymph nodes in the armpit. When this occurs, the tumor found in the underarm lymph nodes is a metastasis of breast cancer. The first lymph node to which the cancer is most likely to spread is called the sentinel axillary lymph node. It is removed during a mastectomy or lumpectomy and biopsied to determine if the cancer has spread beyond the breast (metastasis).

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A Closer Look Hernia A hernia is the protrusion of an organ or the muscular wall of an organ through the cavity that normally contains it. A hiatal hernia occurs when the stomach bulges into the mediastinum through the esophageal opening in the diaphragm (Figure 3-7). An inguinal hernia occurs when part of the intestine bulges into the groin area and commonly into the scrotum in men. A cystocele occurs when part of the urinary bladder herniates through the vaginal wall as a result of weakness of the pelvic muscles (Fig. 3-8). A rectocele is the protrusion of a portion of the rectum into the vagina (Figure 3-8). An omphalocele (omphal/o = umbilicus, umbilicus) is a herniation of the intestines through a weakness in the abdominal wall around the belly button that occurs in babies at birth. See Figure 3-9.

FIGURE 3-7 Hiatal hernia. The consequences of a hiatal hernia include the reflux of stomach contents and acid into the esophagus, resulting in esophagitis. This inflammation causes chest pain, commonly mistaken for a heart attack and known as "heartburn."

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FIGURE 3-8 Hernias: cystocele and rectocele. Arrows indicate areas of herniation. In a cystocele, a portion of the urinary bladder herniates posteriorly into the vagina. In a rectocele, a portion of the rectum herniates anteriorly into the vagina.

FIGURE 3-9 Omphalocele. This baby was born with a large omphalocele containing intra-abdominal viscera. His parents were advised to wait and have surgery when his abdominal muscles grew large enough to close the hernia. Surgery was performed at 7.5 months to permanently repair the hernia.

Streptococci, Staph and Other Bacteria Streptococcus, a berry-shaped bacterium, grows in twisted chains. One group of strep causes conditions such as "sore throats," tonsillitis, rheumatic fever, and certain kidney diseases, while another group causes infections of the teeth, sinuses (cavities) of the nose and face, and heart valves. . Staph, another berry-shaped bacteria, grows in small groups like grapes. Staphylococcal lesions can be external (skin abscesses, boils, styes) or internal (bone and kidney abscesses). An abscess is a collection of pus, white blood cells, and protein that is present at the site of infection. MRSA (methicillin-resistant Staphylococcus aureus) is a

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a serious staph condition that is difficult to treat with antibiotics. An infection can become resistant to antibiotics when the MRSA bacteria develop the ability to resist or defeat drugs designed to kill it. Examples of diplococci (berry-shaped bacteria arranged in pairs; dipl/o = two) are pneumococci (pneum/o = lungs) and gonococci (gon/o = seed). Pneumococci cause bacterial pneumonia, and gonococci invade the reproductive organs, causing gonorrhea (a sexually transmitted infection). Figure 3-10 illustrates the different growth patterns of streptococci, staphylococci, and diplococci.

FIGURE 3-10 Types of bacterial cocci. Note the berry or rounded shape of each bacterium. Streptococci and staphylococci are gram-positive bacteria, which means they retain the light purple color of the stain used in the Gram method (named after Hans C.J. Gram, Danish physician, 1853-1938). Gram-negative bacteria (such as diplococci) have the pink color of the counterstain (safranin) used in the Gram method.

Another group of bacteria is not round in shape, but rod-shaped. An example is the bacterium Clostridium difcile. C. difcile infection, which causes inflammation of the colon and severe diarrhea, is common in patients taking antibiotics for long periods of time. This is because C. difcile bacteria can become resistant to these antibiotics. To restore normal bacteria in the digestive tract, a fecal transplant (bacteriotherapy) may be needed. This is the transfer of stool containing normal bacteria from a healthy donor into the colon of a patient with chronic C. difcile infection.

Blood Cells Refer to Figure 3-11 as you read the following to see the differences between the three different types of blood cells.

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FIGURE 3-11 Types of blood cells. TIP: Here's an easy way to remember the names of the five white blood cells: Never (neutrophil) Leave (lymphocyte) Monkeys (monocytes) Eat (eosinophil) Bananas (basophil)

Erythrocytes, or red blood cells, are the first type. These cells are made in the bone marrow (soft tissue in the center of certain bones). They carry oxygen from the lungs through the blood to every cell in the body. Cells in the body use oxygen to burn food and release energy (catabolism). Hemoglobin (globin = protein), an important protein in red blood cells, carries oxygen through the bloodstream.

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LEUKOCYTES, or white blood cells, are the second type. There are five different types of leukocytes: three granulocytes or polymorphonuclear cells and two mononuclear cells.

• Granulocytes contain granules that stain dark in their cytoplasm and have a multilobed nucleus. They are formed in the bone marrow. There are three types: 1. Eosinophils (the granules stain red [eosin/o = pink] with acid staining) are increased in number in allergic conditions such as asthma. About 3% of leukocytes are eosinophils. 2. Basophils (granules stain blue with basic staining [bas/o = basic]). The function of basophils is unclear, but the number of these cells increases in the healing phase of inflammation. Less than 1% of leukocytes are basophils. 3. Neutrophils (granules stain pale purple with neutral staining) are the most important and numerous disease-fighting cells. About 50% to 60% of all white blood cells are neutrophils. They are phagocytes (fag/o = eat, swallow), which engulf and digest circulating "Pac-Men" bacteria. Neutrophils are called "poly" or polymorphonuclear leukocytes (poly = many, morph = shape), due to their multilobed nucleus. • Mononuclear cells have a large nucleus (mononuclear) and only a few granules in their cytoplasm. They are produced in the bone marrow, as well as in the lymph nodes and spleen. There are two types of mononuclear leukocytes (see Figure 311):

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4. Lymphocytes (lymphatic cells) fight disease by producing antibodies, thus destroying foreign cells. They can also directly attack foreign cells and destroy them. Two types of lymphocytes are T cells and B cells. About 32% of white blood cells are lymphocytes. In AIDS (acquired immunodeficiency syndrome), patients have a severe depletion of T lymphocytes (T cells). 5. Monocytes (containing a very large nucleus [mon/o = a]) engulf and destroy cell debris after neutrophils have attacked foreign cells. Monocytes leave the bloodstream and enter tissues (such as the lung and liver) to become macrophages, which are large phagocytes. Monocytes make up about 4% of all leukocytes. See Table 3-1 to review the five types of white blood cells. Each type fights infection in a specific way. This is similar to the five branches of the military (Navy, Army, Air Force, Marine Corps, and Coast Guard), each of which is equipped with specialized skills and procedures. TABLE 3-1 FIVE TYPES OF LEUKOCYTES (white blood cells)

THROMBOCYTES or PLATELETS (cloning cells) are the third type of blood cell. They are actually small fragments of cells formed in the bone marrow and necessary for blood clotting.

Acromegaly Acromegaly is an endocrine disorder. It occurs when the pituitary gland, located at the base of the brain, produces an excessive amount of growth hormone after puberty ends. Excess growth hormone usually results from a benign tumor of the pituitary gland. A person with acromegaly usually has a normal height because the

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p g y y p y g Long bones stop growing after puberty, but the bones and soft tissues of the hands, feet, and face grow abnormally (Figure 3-12). Abraham Lincoln was believed to have features of acromegaly. See Chapter 18, Endocrine System, page 699. Gigantism is the result of overproduction of pituitary growth hormone beginning in childhood.

FIGURE 3-12 Acromegaly. Note the changes in facial features (enlarged nose and jaw) and the enlarged hands of my grandmother, Bessie Brandwein.

Laparoscopy Laparoscopy (a form of minimally invasive surgery) is the visual examination of the abdominal cavity using a laparoscope. A surgeon inserts the laparoscope, a lighted, telescopic instrument, through an incision in the abdomen near the belly button. Gas (carbon dioxide) is then infused into the peritoneal cavity to separate and prevent injury to the abdominal structures during surgery. Surgeons use laparoscopy to examine the abdominal viscera for evidence of disease (biopsy) or for procedures such as removal of the appendix, gallbladder, adrenal gland, spleen, or ovary; colonic resection; and hernia repair. In tubal ligation, the laparoscope contains an instrument to cut and collapse the fallopian tubes, preventing sperm from reaching the eggs leaving the ovary (Figure 3-13).

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FIGURE 3-13 Laparoscopy for tubal ligation (breaking the continuity of the fallopian tubes) as a means of preventing future pregnancies. The vaginal speculum keeps the vaginal cavity open. A uterine cannula is a tube that is placed into the uterus for manipulation during the procedure. Forceps, placed through the laparoscope, grasp or move the tissue.

Tracheostomy A tracheostomy is an incision in the windpipe, usually made to open it under a blockage. A tracheostomy may be performed to remove a foreign body or to obtain a biopsy sample (Figure 3-14A).

FIGURE 3-14 A, Tracheostomy. B, Tracheostomy.

A tracheostomy is an opening in the windpipe through which an internal tube is inserted. The tube is necessary to allow air to flow.

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the lungs or to help clear secretions (mucus) from the bronchi. When performing a temporary tracheostomy, great care is taken to insert the tracheostomy tube below the larynx so that the vocal cords are not damaged (Figure 3-14B).

Adenoids Adenoids are small masses of lymphatic tissue in the part of the pharynx (throat) near the nose and nostrils. The literal meaning, "gland-like," is appropriate because they are not endocrine or exocrine glands. Enlargement of the adenoids can cause blockage of the airway from the nose to the pharynx, and an adenoidectomy may be recommended. The tonsils are also lymphatic tissue, and their location, like that of the adenoids, is indicated in Figure 3-15.

FIGURE 3-15 Adenoids and tonsils. Adenoids and tonsils are lymphatic tissue in the pharynx (throat).

Practical application procedures and their definitions Choose the correct diagnostic or treatment procedure for each of the numbered definitions. Answers are on page 97. amniocentesis

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angiography angioplasty colostomy laparoscopy laparotomy mastectomy paracentesis (abdominocentesis) thoracentesis tonsillectomy 1. removal of abdominal fluid (ascites) from the peritoneal space ________________________________ 2. large abdominal incision to remove an ovarian adenocarcinoma _________________________________ 3. removal of the breast ________________________________________________________________________ 4. a method used to determine the karyotype of a fetus ________________________________ 5. surgical procedure to remove pharyngeal lymphatic tissue _________________________________ 6. surgical procedure to open blocked coronary arteries _________________________________ 7. method of removing fluid from the chest (pleural effusion) ________________________________ 8. procedure to drain waste from the body after bowel resection _________________________________ 9. X-ray procedure used to examine the s blood vessels before surgery _____________ ___________________ 10. Minimally invasive bud within the abdomen _________________________________

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Exercises Remember to check your answers carefully with the Answers to the exercises on pages 96 and 97.

A Give the meaning of the following suffixes. 1. -cele __________________________________________________ ____ 2. -emia ___________________________________________ ____ 3. -coco _________________________________________________ ____ 4. -gram ________________________________________________ ____ 5. -cyto _____________________________________________ ____ 6. -algae _____________________________________________ ____ 7. -ectomy _____________________________________________ ____ 8. -centesis _____________________________________________ ____ -genesis _______________________________________ ____

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10. -graph _________________________________________ ____ 11. -itis ___________________________________________ ____ 12. -graphy _____________________________________________ ____ B Using the combined forms listed and your knowledge of suffixes, construct medical terms for the definitions below. amni/the angi/the arthr/the bronchus/the carcinogen/the cyst/the isch/the larynx/the mast/the my/the myel/the rhin/the staphyl/the strept/the thorac/the 1. hernia of the urinary bladder _____________________________________________

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2. muscle pain ________________________________________________ 3. cancer-producing process _____________________________________________ 4. inflammation of the spinal cord __________________________________________________ 5. berry-shaped bacteria in twisted strings _____________________________________________ 6. surgical puncture to remove fluid from the chest ___________________________________________ 7. removal of the breast ________________________________________________________ 8 . inflammation of the tubes leading from the trachea to the lungs __________________________________________________ 9. to retain blood cells __________________________________________________ 10. recording process (x-ray) of blood vessels ______________________________________________ 11. visual examination of joints _____________________________________________ 12. bunches of berries- bacteria in the form ________________________________________________ 13. resection of the larynx _____________________________________________ 14. surgery surgical procedure to remove fluid from the sac surrounding the fetus _____________________________________________ 15. nasal discharge ____________________________________________

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C Match the terms listed, which describe blood cells, with the following meanings. basophils eosinophils erythrocytes lymphocytes monocytes neutrophils thrombocytes 1. white blood cells granulocytes (granules stain purple) that destroy foreign cells by engulfing and digesting them; also called polymorphonuclear leukocyte ________________________ 2. mononuclear white blood cell that destroys foreign cells by producing antibodies ________________________________________________ ________________ 3. cloning cell; also called platelets __________________________________________ 4. white blood cells with reddish granules and increased numbers in allergic reactions ________________________________________________ __________________ 5. red blood cells ____________________________________________ 6. mononuclear white blood cells that engulf and digest cellular debris; contains a large nucleus ________________________________________________ ____________________

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7. white blood cells granulocytes that increase during the healing phase of inflammation ________________________________________________ _____________________ D State the meaning of the following suffixes. 1. -logy __________________________ 2. -lysis __________________________ 3. -pathy __________________________ 4. -penia ___________________________ 5. -malacia __________________________ 6. -ose __________________________ 7. -phobia ________________________ 8. -megaly ____________________________ 9. -oma ____________________________ 10. -opsia ____________________________ 11. -plasia __________________________ 12. -plasty __________________________ 13. -sclerosis __________________________ 14. -stasis ___________________________ AND Using the combined forms below and your knowledge of suffixes, construct medical terms for the following definitions. acr/o arteri/o bi/o blephar/o cardio/o chondr/o

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hem/o hydr/o morph/o my/o myel/o phleb/o rhin/o sarc/o splen/o 1. enlargement of the spleen ____________________________________ 2. study of the shape (of cells) ________________________________________ 3. softening of the cartilage ____________________________________ 4 abnormal water (fluid) condition in the kidney ___________________________________________ 5. disease condition of the heart muscle ____________________________________ 6. hardening of the arteries ________________________________________ 7. tumor (benign) of muscle ________________________________________ 8. superficial tumor (malignant) of muscle ________________________________________ 9 .surgical repair of the nose ____________________________________ 10. bone marrow tumor _________________________________________

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11. fear of heights ____________________________________ 12. observation of living tissue under a microscope _________________________________________ 13. interruption of blood flow (by mechanical or natural means) ____________________________________ 14. inflammation of the eyelid ____________________________________ 15. incision of a vein ________________________________________ F Give the plural formations of the following terms: 1. bacterium ____________________ 2. metastasis _______________________ 3. vertebra _____________________________ 4. streptococcus _________________________ 5. nucleus _________________________ 6. prognosis ________________________ G Match the following terms with their meanings. achondroplasia acromegaly atrophy chemotherapy colostomy hydrotherapy hypertrophy laparoscope laparoscopy

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metastasis necrosis osteomalacia 1. drug treatment _____________________________________________ _ 2. dead state (of cells) __________________________________________________ _ 3. softening of bone _____________________________________________ _ 4. opening of the large intestine to the outside of the body _____________________________________________ _ 5. no development; cell shrinkage _____________________________________________ _ 6. out of control; spread of a cancerous tumor to another organ ______________________________________________ _ 7. instrument for visual examination of the abdomen __________________________________________________ _ 8. enlarged limbs; an endocrine disorder that causes the pituitary gland to produce excess growth hormone after puberty

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9. condition of improper cartilage formation in the embryo leading to short bones and dwarfism __________________________________________________ _ 10. visualization process of the peritoneal (abdominal) cavity _____________________________________________ _ 11. water treatment ________________________________________________________ _ 12. excessive cell development (increase in size cell) individual cells ) _____________________________________________ _ H Give the meaning of the following suffixes. 1. -ia ____________________ 2. -trophy _______________________ 3. -stasis _______________________ 4. -ostomy _____________________________ 5. -tomy _________________________ 6. -ole _________________________ 7. -um ____________________ 8. -ule ____________________ 9. -y ______________________________ 10. -oid _________________________ 11. -genesis ____________________ 12. -ptosis _______________________

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Using the lists of combined forms and suffixes below, construct medical terms for the following definitions. FORMS OF COMBINATION arteri/pleur/laparo/pneumon/mamm/radio/nephr/ven/o

SUFFIXES -dinia -ectomy -gram -ia

-ole -patia -plasty -scopia

-therapy -tomy -ule

1. incision of the abdomen _____________________________________________ _ 2. visual examination process of the abdomen __________________________________________________ _ 3. a small artery __________________________________________________ _ 4. condition of the lungs _____________________________________________ _ 5. X-ray treatment ______________________________________________ _ 6. recording (X-ray film) of the breast _____________________________________________ _ 7. pain in the chest wall and in the membranes surrounding the lungs __________________________________________________ _ 8. a small vein _____________________________________________

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_ 9. kidney disease condition _____________________________________________ _ 10. surgical repair of the breast __________________________________________________ _ J Underline the suffix in the following terms and give the meaning of the complete term. 1. laryngeal _____________________________________________ _ 2. inguinal __________________________________________________ _ 3. chronic __________________________________________________ _ 4. pulmonary _____________________________________________ _ 5. adipose ________________________________________________________ _ 6. peritoneal _____________________________________________ _ 7. axillary _____________________________________________ _

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8. necrotic ___________________________________________________ _ 9. opioid __________________________________________________ _ 10. mucous membranes __________________________________________________ _ 11. agoraphobia _________________________________________ _ 12. esophagus ________________________________________________________ _ K Select from the terms related to blood and blood vessels to complete the sentences below. anemia angioplasty arterioles hematoma hemolysis hemostasis ischemia leukemia leukocytosis multiple myeloma myocardium neutropenia

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venular thrombocytopenia 1. Billy has been diagnosed with an excessively high number of cancerous white blood cells or _________________. His doctor prescribed chemotherapy and expected an excellent prognosis. 2. Mr. Clark showed that he had severe atherosclerosis in one of the arteries that supply blood to his heart. His doctor has recommended that ________________ would be helpful in opening the blocked artery by passing a catheter (tube) through the artery and opening a balloon at the end of the catheter to widen the artery. 3. Due to the impact of multiple footfalls, long-distance runners may develop a breakdown of red blood cells called _____________________. This condition, which leads to excessive loss of blood cells, is known as runner's _____________________. 4. The doctors refused to operate on Joe because of his low platelet count, a condition called ______________________. 5. The blockage of an artery leading to Mr. Stein led to the retention of blood flow to the nervous tissue of his brain. This condition, called _____________________, can lead to tissue necrosis and stroke. 6. The small arteries, or __________________________, were ruptured under Mrs. Bein when a stone hit her on the head. She soon developed a mass of blood, a/an

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__________________________, under the skin in that region of the head. 7. Sarah Jones had a staph infection, which caused an increase in her white blood cell count, known as ________________________. She was treated with antibiotics and her blood count returned to normal. 8. Inside the body, the bone marrow (soft tissue inside the bones) is the “factory” for making blood cells. Mr. Sco developed ________________________, a malignant condition of the bone marrow cells in the hip, arm, and thigh bones. 9. During operations, surgeons use clamps to close blood vessels and prevent blood loss. This way they maintain _________________ and avoid blood transfusions. 10. The small vessels that carry blood to the heart from the capillaries and tissues are ___________________________________. 11. Chemotherapy causes the destruction of rapidly dividing cancer cells, as well as rapidly dividing normal white blood cells. This deficiency of white blood cells is a side effect of chemotherapy called ___________________________________. 12. A heart attack ________________________ is the medical term for a heart attack. L Complete the medical term for the following definitions.

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DEFINITION 1. membrane surrounding the heart 2. hardening of the arteries 3. enlarged liver 4. new opening of the windpipe to the outside of the body 5. swollen tonsils 6. surgical puncture to remove fluid from the abdomen 7. muscle pain 8. Pertaining to the membranes surrounding the lungs 9. Study of the eye 10. Berry-shaped (spheroidal) bacteria in clusters 11. Runaway (spread of a cancerous tumor) 12. Pertaining to the larynx

MEDICAL TERM peri ______________________ artery ______________________ liver ______________________ trachea ______________________ ____________________ abdominal itis ______________________ mi ______________________ _____________________ al ___________________ lodge _________________ cocci meta ______________________ ____________________ eal

M Select the meanings in Column II to match the suffixes in Column I. Write each meaning in the space provided. COLUMN I Suffixes: Conditions 1. -algia or -dynia ___________________________________ 2. -cele ___________________________________ 3. -megaly ___________________________________ 4. -oma ___________________________________ 5. -penia ___________________________________ 6. -phobia ___________________________________ 7. -plasia ___________________________________ 8. -emia ___________________________________ 9. -itis ___________________________________ 10. -trophy ___________________________________ 11. -stasis ___________________________________ 12. -sclerosis ___________________________________ 13. -lysis ___________________________________ 14. -ptosis ___________________________________ 15. -malacia __________________________________

COLUMN II It means control of the state of the blood; stop the destruction of disability; break development; drop in nutrition; falling down; prolapse increase fear formation hardening hernia inflammation pain softening tumor; pasta

N Select the meanings in Column II to match the suffixes in Column I. Write each meaning in the space provided.

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COLUMN I Suffixes: Procedures 1. -centesis ___________________________________ 2. -opsia ___________________________________ 3. -ectomy ___________________________________ 4. -tomy ___________________________________ 5. -stomy ___________________________________ 6. -therapy __________________________________ 7. -plasty ___________________________________ 8. -scopy ___________________________________ 9. -endoscope ___________________________________ 10. -graphs ___________________________________ 11. -gram ___________________________________ 12. -graph ________________________________

COLUMN II Meanings excision incision instrument to record instrument to visually examine new opening process of visual examination record puncture to extract fluid surgical repair to visualize treatment

OR Circle the correct term to complete the following sentences. 1. Mrs Daley, who has nine children, visited her GP because she was having trouble urinating. After examining her, the doctor found that her bladder was protruding into her vagina and said that she had (rectocele, cystocele, hiatal hernia). 2. Susan coughed constantly for a week. Her doctor told her that her chest X-ray showed evidence of pneumonia. Her sputum (material expelled from the bronchi) contained bacteria (ischemic, pleuritic, pneumococcal). 3. Mr. Manion went to her family doctor because he couldn't stop her upper left eyelid from drooping. Her doctor told her that she suffered from a neurological condition called Horner's syndrome, characterized by (necrosis, hydronephrosis, ptosis) of the eyelid. 4. Jill broke her left arm in a fall while riding a mountain bike. After 6 weeks in a cast to treat the fracture, her left arm was noticeably smaller and weaker than her right arm: her muscles had atrophied,

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g p hypertrophied, metastasized). His doctor recommended physical therapy to strengthen the affected arm. 5. Ms. Brody was diagnosed with breast cancer. The first phase of her treatment included one (nephrectomy, mastectomy, lung resection) to remove the breast and tumor. After surgery, her doctors recommended (chemotherapy, radiation therapy, hydrotherapy) the use of drugs such as doxorubicin (Adriamycin) and paclitaxel (Taxol). 6. At 29, Kevin's facial features have grown coarser and his hands and tongue have grown. After a head CT scan, doctors diagnosed the cause of these changes as (hyperglycemia, hyperthyroidism, acromegaly), a slowly progressive endocrine condition that affects the pituitary gland. 7. Every winter, during "cold and flu season", Daisy developed (chondromalacia, bronchitis, cardiomyopathy). Her doctor prescribed antibiotics and respiratory therapy to help her recover. 8. After undergoing (arthroscopy, laparotomy, radiation therapy) on his knee, Alan noticed swelling and inflammation near the small incisions. Dr. Nicholas assured her that this was a common side effect of the procedure that would resolve on its own. 9. Under the microscope, Dr. Vance was able to see clusters of grape-like bacteria called (eosinophils, strep, staphylococci). she did the

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diagnosis of (staphylococcaemia, eosinophilia, streptococemia), and antibiotic therapy was started. 10. David liked to lift weights, but he recently noticed a lump in his right groin area. He visited his physician, who made a diagnosis of (hiatal hernia, rectocele, inguinal hernia) and recommended surgical repair.

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Answers to exercises A 1. hernia 2. blood condition 3. berry-shaped bacteria 4. recording 5. cell 6. pain 7. extraction, excision, resection 8. puncture to extract fluid 9. production process, training 10. recording instrument 11. inflammation 12. recording process B 1. cystocele 2. myalgia ("myodynia" is not used) 3. carcinogenesis 4. myelitis 5. streptococci (bacteria is a plural term) 6. thoracentesis or thoracentesis 7. mastectomy

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8. bronchitis 9. ischemia 10. angiography 11. arthroscopy 12. staphylococci 13. laryngectomy 14. amniocentesis 15. rhinorrhea C 1. neutrophils 2. lymphocytes 3. thrombocytes 4. eosinophils 5. erythrocytes 6. monocytes 7. basophils D 1. process of study 2. collapse, separation, destruction 3. disease process 4. deficiency, less than normal 5. softening 6. condition, abnormal condition

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7. fear of 8. increase 9. tumor, mass 10. visualization process 11. formation condition, growth 12. surgical repair 13. hardening, harden 14. stop, control E 1. splenomegaly 2. morphology 3. chondromalacia 4. hydronephrosis 5. cardiomyopathy 6. arteriosclerosis 7. myoma 8. myosarcoma 9. rhinoplasty 10. myeloma (called multiple myeloma) 11. acrophobia 12. biopsy 13. hemostasis 14. blepharitis

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15. phlebotomy F 1. bacteria 2. metastasis 3. vertebrae 4. streptococci 5. nuclei 6. prognosis G 1. chemotherapy 2. necrosis 3. osteomalacia 4. colostomy 5. atrophy 6. metastasis 7. laparoscope 8. acromegaly 9. achondroplasia 10. laparoscopy 11. hydrotherapy 12. H hypertrophy

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1. condition 2. development, nutrition 3. stop, control 4. new opening 5. incision, cut into 6. small, small 7. structure 8. small, small 9. condition, process 10. similar 11. belonging to produce, produced by or in 12. fall, fall, prolapse I 1. laparotomy 2. laparoscopy 3. arteriole 4. pneumonia (this condition is actually pneumonitis) 5. radiation therapy 6. mammography 7. pleurodynia 8. venule 9. nephropathy 10 . mammoplasty

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J 1. laryngeal: related to the larynx 2. inguinal: related to the groin 3. chronic: related to time (over a long period of time); the opposite of chronic is acute 4. pulmonary: belonging to the lung 5. adipose: belonging to (or filled with) fat 6. peritoneal: belonging to the peritoneum (membrane that surrounds the abdominal organs) 7. axillary: belonging to the armpit, below arm 8. necrotic – related to death 9. opioid – substance derived from opium 10. mucous – related to mucus 11. agoraphobia – fear of open spaces and being alone outside the home (agora means market) 12. esophagus – tube leaking from throat to stomach K 1. leukemia 2. angioplasty 3. hemolysis; anemia 4. thrombocytopenia 5. ischemia 6. arterioles; bruise

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7. leukocytosis 8. multiple myeloma 9. hemostasis 10. venules 11. neutropenia 12. myocardium L 1. pericardium 2. arteriosclerosis 3. hepatomegaly 4. tracheostomy 5. tonsillitis 6. abdominocentesis (this procedure is also known as paracentesis) 7. myalgia 8. pleural 9. ophthalmology 10. staphylococcus 11. metastasis 12. laryngeal M 1. pain 2. hernia

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3. enlargement 4. tumor; mass 5. deficiency 6. fear 7. formation 8. blood condition 9. inflammation 10. development; power 11. control; stop 12. hardening 13. destruction; collapse 14. fall; falling down; prolapse 15. softening N 1. puncture to remove fluid 2. to visualize 3. excision 4. incision 5. re-opening 6. treatment 7. surgical repair 8. visual examination process 9. visual examination instrument

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10. registration process 11. registration 12. instrument for registration of O 1. cystocele 2. pneumococcus 3. ptosis 4. atrophied 5. mastectomy; chemotherapy 6. acromegaly 7. bronchitis 8. arthroscopy 9. staphylococci; staphylococcaemia 10. inguinal hernia Answers for Practical Applications 1. paracentesis (abdominocentesis) 2. laparotomy 3. mastectomy 4. amniocentesis 5. tonsillectomy 6. angioplasty 7. thoracentesis 8. colostomy

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9. angiography 10. laparoscopy Terms pronunciation

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TERM abdominocentesis achondroplasia acromegaly acrophobia acute adenoids adipose agoraphobia amniocentesis anemia angiogenesis angiography angioplasty arteriole arteriosclerosis arthralgia atrophy axillary basophil biopsy blepharoptosis bronchitis carcinogenesis carcinogenic cardiac cardiomyopathy chemotherapy chondromalacia chronic colostomy cystocele electrocephalograph electroencephalogram electroencephalography eosinophil erythrocyte erythropenia esophagus hematoma hemolysis hemostasis hydronephrosis hydrotherapy hypertrophy inguinal ischemia laparoscope laparoscopy laparotomy laringectomia laringea leucemia

PRONUNCIATION ab-dom-in-o-sen-TE-sis a-kon-dro-PLAY-ze-ah ak-ro-MEG-ah-le ak-ro-FO-be-ah uh-KYOOT AH-deh- noydz AH-dih-pohz ah-gor-ah-FO-be-ah am-ne-o-sen-TE-sis ah-NE-me-ah an-je-o-JEN-ih-sis an-je- OG-rah-fe AN-je-o-plas-te ar-TE-re-ole ar-te-re-o-skleh-RO-sis ar-THRAL-jah AT-ro-fe AK-sil-ar- e BA-so-fil BI-up-see bleh-fah-rop-TO-sis brong-KI-tis kar-sih-no-JEN-eh-sis kar-sih-no-JEN-ik KAR-de-ak kar-de-o-mi-OP-ah-the ke-mo-THER-ah-pe kon-dro-mah-LA-shah KRON-ik ko-LOS-to-me SIS-to-seel eh-lek- accredit-them-to-SEF-lo-grapho eh-how-to-credit-em-to-SEF-lo-gram eh-how-to-accredit-em-to-SEF-LOG-rah-fe e-o-SIH-no-file eh-RITH-ro-site eh-rith-ro-PE-ne-a eh-SOF-ah-gus he-mah-TO-mah he-MOL-ih-sis he-mo-STA-sis hi-dro- neh-FRO-sis hi-dro-THER-ah-the hi-PER-tro-fe IN-gwih-nal is-KE-me-ah LAP-ah-ro-scope lap-ah-ROS-ko-the lap -ah-ROT-o-me lah-rin-JE-al lah-rin-JEK-to-me lu-KE-me-ah

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TERM leukocytes leukocytosis lymphocytes mammography mastectomy metastasis monocytes morphology mucous membrane myalgia myelitis myeloma myoma myosarcoma myocardium necrosis necrotic necrosis nephrology nephropathy neuralgia neutropenia neutrophils ophthalmology opioids osteomalacia osteomalacia otalgia paracentesis pathological pathogenesis pericardium peritoneal phlebotomy thrombocytosis pleurombocytosis pleurombocytopenia pleurombocytosis pleurombocytosis

PRONUNCIATION LU-ko-site lu-ko-si-TO-sis LIM-fo-site MAM-o-gram mas-TEK-to-me meh-TAS-tah-sis MON-o-site mor-FOL-o- je MU-cus MEM-brayn MU-cus mi-AL-jah mi-eh-LI-tis mi-eh-LO-mah mi-O-mah mi-o-KAR-de-al mi-o-sar-KO -mah NEH-cuerpo-se e-KRO-sis e-KROT-ik e-FROL-o-jist e-FROP-ah-the nu-RAL-jah nu-tro-PE-ne-ah NU-tro-fil of-thal-MOL-o-je O-pe-oyd os-te-o-JEN-ik os-te-o-mah-LA-shah o-TAL-jah par-ah-sen-TE-sis path- o-JEN-eh-sis path-o-LOJ-ik peh-rih-KAR-de-um peh-rih-to-NE-al fieh-BOT-o-me PLAY-let PLUR-al plur-o-DIN -e-ah nu-MO-ne-ah pol-e-morpho-o-NU-kle-ar LU-co-sitio TO-sis PUL-mo-nar-e ra-de-OG-rah-fer ra- de-o-THER-ah-pe REK-to-seel ri-no-RE-ah spleh-no-MEG-ah-le staf-ih-lo-KOK-si strep-to-KOK-sis thor-ah- cen-TE-sis THROM-loss-site throm-loss-site-o-PE-ne-at

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TERM thrombophlebitis tonsillitis tonsillar tracheostomy tracheostomy venule

PRONÚNCIA throm-bo-fleh-BI-tis TON-sih-lar ton-sih-LI-tis tra-ke-OS-to-me tra-ke-OT-o-me VEN-ule

revision sheet

Write the meanings of each part of the word in the space provided and test yourself. Check your answers with the information in the chapter or in the Glossary (Parts of Medical Words—English) at the end of this book.

nominal suffixes

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SUFIJO -algia -cele -centesis -coccus (-cocci) -cyte -dynia -ectomy -emia -er -genesis -gram -graph -graphy -ia -ist -itis -logy -lysis -malacia -megalia -ole -oma - opsy -osis -patia -penia -phobia -plasia -plastia -ptosis -reino -sclerosis -scopia -etapa -stoma -terapia -tomia -tropheo -ule -um, -ium -us -y

SENSE ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________

adjective suffixes

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SUFIXO -ac, -iac -al -ar -ary -eal -ic -ic, -ical -oid -ose -ous -tic

match shapes

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COMBINED FORM abdominal/o acr/o acu/o aden/o adip/o amni/o angi/o arteri/o arthr/o axilla/o bi/o blephar/o bronch/o carcin/o cardio/o chem/o chondr / the chron / the cervix / the cyst / the encephalon / the erythrocyte / the heme / the liver / the hydric / the inguinal / the bait / the lapar / the larynx / the leuco / the lymphatic / the mammary / the mast / el morph/el muc/el my/the myel/the necr/the nephr/the neur/the neutr/the nucleus/the ophthalm/opi/the oste/the ot/the path/the peritoneum/the phag/the fleb / or pla/o pleuro/o

SENSE ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ _ ___ _ _______________ ____________________ ____________________ ____________________ ____________________

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COMBINED FORM neumon/the pulmon/the radius/the rectum/the ren/the rhin/the sarc/the splen/the staphyl/the strept/the thorac/the thromb/the amygdala/the trache/the ven/the

Give the medical term for the following blood cells. red blood cells ____________________________________________ white blood cells _________________________________________________ white blood cells ___________________________________________ Name five different types of white blood cells (the first card is dealt). e ________________________________________ b ________________________________________ n ______________________________________ l ______________________________________ m ______________________________________

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CHAPTER 4

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Prefixes CHAPTER SECTIONS: Introduction 104 Combining Forms and Suffixes 104 Prefixes and Terminology 105 A Closer Look 114 Practical Applications 119 Exercises 120 Answers to Exercises 125 Pronunciation of Terms 126 Review Sheet 128

CHAPTER OBJECTIVES • Define the basic prefixes used in medical language. • Analyze medical terms that combine prefixes and other word elements. • Learn about Rh condition as an example of an antigen-antibody reaction.

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Introduction This chapter on prefixes, like the previous chapter on suffixes, provides practice in word analysis and provides a foundation for studying the terminology of the following body systems. The list of combinations of forms, suffixes, and meanings helps you analyze the terminology in the rest of the chapter. To support a broader understanding, A Closer Look, beginning on page 114, contains more detailed explanations of new terms.

Combining shapes and suffixes Combining shapes COMBINING FORM carpa/o cis/o costo/o cutane/o dactyl/o duct/o ﬂex/o furc/o gloss/o glyc/o immun/o morph/o mort/o nat/i norm/o ox/o pub/o seps/o somn/o son/o tens/o the/o thel/o, theli/o thyr/o top/o tox/o trache/o urethr/o

MEANING the bones of the wrist cut the skin of the ribs the fingers of the hands, the toes of the feet lead, carry, bend, branch, tongue, sugar, shape, protection, shape, death, birth, rule, order, oxygen , pubis (pubic bone); anterior part of the pelvic or iliac bone infection sleep sound force, stretch, stretch, put, put the nipple thyroid gland; shield (the shape of the thyroid gland resembled [-oid] a shield to those who named it) place, position, location poison trachea, trachea urethra

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Suffixes These suffixes are used in this chapter in combination with prefixes. Some are complex suffixes that contain roots. For example, the suffix pnea contains a root pne, meaning respiration, and a final suffix -a, meaning condition. SUFFIX -crine -drome -fusion -gen -lapse -lysis -meter -mission -or -oxia -partum -phoria -physis -plasia -plasma -pnea -ptom -ptosis -rrhea -stasis -trophy

MEANING union of secret execution; pour substance that causes slipping, falling, falling, sinking, destruction, measured separation send someone to oxygenate birth, delivery, carry; feeling (mood) growth development, formation, structure of growth or formation respiration event, occurrence fall, fall, flow prolapse, interruption of discharge, control of development, nutrition

Prefixes and Terminology

Write the meaning of the medical term in the space provided. Remember, the Evolve website provides the definition and audio pronunciation of each term.

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PREFIX MEANING TERMINOLOGY MEANING a-, an- no, no, apnea _____________________________________________ without anoxia _____________________________________________ away from abnormal ___________________________________________ abductor ________________________________________________________ Muscle that moves a limb away from the body. TIP: Notice that in abductor, b has his back to a. adductor to adductor ____________________________________________ Muscle that pulls a limb toward the body. TIP: Notice that in the adductor, the d faces the a. adrenal glands _____________ These glands are actually located on top of each kidney. See Figure 4-1. anaup, plus anabolism ___________________________________________ test ____________________________________ Urinalysis (urina/o + [an]/test) is a laboratory test of urine that aids in the diagnosis of many medical conditions. In this term, lysis means separation. anteantes, ante cibum ____________________________________ ahead The word cibum means food. The notation a.c., seen in recipes, means before meals. Can you guess which p.c. means after (post) meals. anteflexion ____________________________________ antepartum ____________________________________ antibiotic _________________________________________ Antibiotics destroy or inhibit the growth of microorganisms, such as bacteria. Penicillin was the first antibiotic discovered and was widely used in the 1940s. Since then, many penicillin-like antibiotics have been discovered that have shown valuable activity against penicillin-resistant organisms. antibody _____________________________________________ A protein produced against an antigen (foreign body). antigen _____________________________________________ In this term, anti- is short for antibody. An antigen (bacteria or virus) is a substance that stimulates the production of (-gene) an antibody. See A Closer Look: Antigens and Antibodies, page 114. antisepsis __________________________________________ An antiseptic substance (-sis changes to -tic to form an adjective) fights infection. Sepsis is a serious bacterial infection of the blood. antitoxin ____________________________________ This is an antibody, usually from an animal (such as a horse), that works against a toxin. An example is tetanus antitoxin administered against tetanus, an acute bacterial infection of the nervous system. autoimmune disease proper ________________________________ bifurcation bifurcation _________________________________________ Normal division into two branches, as the trachea bifurcates to form the bronchi. The root furc means branching. bilateral bradycardia ________________________________________ slow bradycardia _________________________________________ Usually pulse less than 60; a slow heart rate. Tachycardia (tachycardia means fast) is a pulse of more than 100 beats per minute. catabolism catabolism ____________________________________

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PREFIX MEANING TERMINOLOGY MEANING concom, congenital anomaly together See A Closer Look: Congenital Anomaly, page 116. connective __________________________________________ The root necto means to bind or bind. Connective tissue supports and connects other tissues and parts of the body. Bone, cartilage, and fibrous tissue are connective tissues. contra- against, contraindication _____________________________________ opposite Contra- means against in this term. contralateral ________________________________________ Contra means opposite in this term. A stroke that affects the right side of the brain can cause contralateral paralysis that affects the left arm and leg. desquamation, lack of dehydration diathrough ____________________________________, diameter ___________________________________________ complete diarrhea ____________________________________ dialysis _____________________________________________ The literal meaning is complete separation (dia-) (-lysis). In hemodialysis, waste is separated from the blood by a machine (artificial kidney) when the kidneys are no longer working. Another form of dialysis is peritoneal dialysis. abnormal, shortness of breath ________________________________________ bad Often caused by breathing or heart problems, strenuous exercise, difficulty or anxiety. painful dysentery _______________________________________________ dystrophy __________________________________________ Muscular dystrophy includes many inherited diseases that cause muscle weakness and wasting. dysplasia ___________ echo, out of ectopic pregnancy ___________________________________ Ectopic means belonging out of place and modifies the noun "pregnancy." See Figure 4-2. endoin, inside the endocardium ____________________________________ endoscope ___________________________________________ endotracheal _______________________________________ An endotracheal tube, which is placed through the mouth and into the trachea, is used to administer oxygen and in general anesthesia procedures. epiupon, on, epithelium ____________________________________ up eugood, euphoria ___________________________________________ normal Feeling of well-being. euthyroid ____________________________________ Normal thyroid function. exout, external exophthalmos _____________________________________ Protrusion of the eyeball associated with enlargement and overactivity of the thyroid gland. hemimea hemiglossectomy __________________________________________

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PREFIX MEANING TERMINOLOGY MEANING hyperexcess, hyperglycemia _____________________________________ up This is a sign of diabetes mellitus. Lack of insulin (type 1 diabetes) or ineffective insulin (type 2 diabetes) causes high blood sugar levels. hyperplasia ________________________________________ Increase in the number of cells. This is a characteristic of tumor growth. hypertrophy ____________________________________ Increase in the size of individual cells. Muscle, cardiac, and renal cells show hypertrophy with increased workload. The opposite of hypertrophy is atrophy (cells shrink in size). See Figure 4-3. hypertension ____________________________________ High blood pressure occurs when the force of the blood against the walls of the arteries is constantly too high. hypodermic hypodermic injection ________________________________ low hypoglycemia _____________________________________ inno insomnia __________________________________________ inside, inside incision _____________________________________________ below, infracostal __________________________________________ below between intercostals __________________________________________ The intercostal muscles lie between adjacent ribs. intrain, inside, intravenous _________ in macro-large macrocephaly ______________________________________ This is a congenital anomaly. Macrocephaly is often associated with excess fluid in the brain (hydrocephalus). malbad malaise ___________________________________________ (mal-AYZ) This is a French word meaning discomfort. It is a symptom of disease, which often marks the beginning of a disease. malignant ____________________________________ From the Latin ignis, meaning fire. Benign (ben- = good) is not cancerous, while malignant means cancerous. Alteration of the metacarpal bones _____________________________________ The five bones of the hand lie beyond the wrist bones, but before the finger bones (phalanges). metamorphosis __________________________________________ Meta- means change in this term. The change in development from the larval (caterpillar) to the adult (butterfly) stage is a form of metamorphosis. Embryonic (immature) stem cells change spontaneously (metamorphoses) to form different types of mature cells. metastasis ________________________________________ Meta- = beyond and -stasis = control, stop. Metastasis is a malignant tumor that has spread to a secondary site. small micro-microscope __________________________________________ microcephaly __________________________________________ Microcephaly is associated with a smaller and underdeveloped brain. Zika virus infection during pregnancy can cause microcephaly. neonate neonate ____________________________________________ The neonatal period is the interval from birth to 28 days. neoplasm ________________________________________ A neoplasm can be benign or malignant. Total pancytopenia ____________________________________ Deficiency of erythrocytes, leukocytes and thrombocytes.

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PREFIX MEANING TERMINOLOGY MEANING paraabnormal, paralysis _____________________________________________ next to, near Abnormal disruption of the connection between nerve and muscle. Originally from the Greek paralusis, meaning separation or loosening of one side, it describes loss of movement on one side of the body (which occurs in stroke patients). parathyroid glands __________________________________ Para- means on the side. The four parathyroid glands lie behind the thyroid gland. They secrete a hormone that regulates calcium levels in the blood and tissues. percutaneous percutaneous ________________________________________ pericardium pericardium ______________________________________ polymeric, highly polymorphonuclear _________________________________ polyneuritis _________________________________________ postpartum, postmortem _____________________________________________ postpartum ________________________________________ preanterior, precancerous _____________________________________________ before antenatal _____________________________________________ preprobing, prodrome ________________________________________ advanced Prodromal signs and symptoms (rash, fever) appear before disease (rash, fever) such as chickenpox) and signal its appearance. Altered mood, fatigue, flashes of light, or stiff muscles may accompany the prodromal migraine aura that occurs before the actual headache. prolapse ________________________________________ The suffix -lapse means to slip, give, or fall. See Figure 4-4. An eyelid prolapse is commonly called ptosis (blepharoptosis). prosbefore, prosthesis __________________________________________ forward An artificial limb is a prosthesis. Figure 4-5 shows Amy Palmiero Winters running with a prosthetic leg. relapse, relapse ____________________________________________ An illness or its signs and symptoms return after an apparent recovery. remission ________________________________________ Signs and symptoms subside and the patient feels better. Remission can be spontaneous or the result of treatment. In some cases, a permanent remission means that the disease is cured. Recombinant DNA ____________________________________ Genetic engineering uses recombinant DNA techniques. See A Closer Look: Recombinant DNA, page 116. retrorenal, retroperitoneal ________________________________________ retroflexion backwards ____________________________________ An abnormal position of an organ, such as the uterus, in that it is bent or tilted backwards. subcutaneous subcutaneous __________________________________________ supra above, suprapubic _______________________________________ superior The pubic bones form the anterior part of the hip bone, as shown in Figure 4-6A. A suprapubic catheter is useful for draining the bladder above the pubic bone. See Figure 4-6B.

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PREFIX MEANING TERMINOLOGY MEANING syn-, together, syndactyly _________________________________________ simcom See Figure 4-7. synthesis ____________________________________ In protein synthesis, complex proteins are built from simpler amino acids. syndrome ___________________________________________ See A Closer Look: Syndromes, page 117. symbiosis _________________________________________ TIP: Before the letters b, myp, syn- becomes sym-. The term symptom is an important example. Be careful with the spelling! Don't forget the p in the symptom. symmetry ________________________________________ Equality of parts on opposite sides of the body. What is asymmetry? symphysis ________________________________________ The symphysis is a joint in which the bony surfaces are firmly held together by a layer of fibrocartilage. See Figure 4-6C. tachy- rapid tachypnea ____________________________________ (tah-KIP-ne-ah) transacross, transfusion ____________________________________ by transferring blood or parts of blood from one person to another. transurethral ________________________________________________ See A Closer Look: Transurethral Resection of the Prostate Gland, page 118. ultrabeyond, ultrasonography _____________________________________ excess See A Closer Look: Ultrasonography, page 118. unilateral union __________________________________________

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FIGURE 4-1 Adrenal glands. These are endocrine glands located on top of each kidney. One of the hormones they secrete is adrenaline (epinephrine). It causes the bronchi to widen, the heart beats faster, and the blood pressure rises.

FIGURE 4-2 Ectopic pregnancy. The normal implantation of the pregnancy takes place in the upper part of the uterus. Ectopic pregnancy most commonly occurs in a fallopian tube (ie, tubal pregnancy). In this condition, the fetus is not viable. Surgery is often needed to remove the ectopic tissue. Tubal surgery can damage a fallopian tube, and scar tissue can cause problems later in pregnancy.

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FIGURE 4-3 Differences between normal cells, hyperplasia, hypertrophy, and atrophy.

FIGURE 4-4 Uterine prolapse. In first degree prolapse, the uterus descends into the birth canal. In second-degree prolapse, the body of the uterus is still inside the vagina, but the cervix bulges out of the vaginal opening (opening). In third degree prolapse (not shown), the entire uterus bulges out of the os. As a treatment, the uterus can be held in position by a plastic pessary (oval support object) that is inserted into the vagina. Some affected women may require a hysterectomy (removal of the uterus).

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FIGURE 4-5 Prosthesis. Amy Palmiero-Winters is the first woman with a prosthetic leg to finish the Badwater 135, a 135-mile race from Badwater in Death Valley to Mount Whitney, California.

FIGURE 4-6 A. Bones of the pelvis (hip). B. Suprapubic catheter. C. Pubic symphysis. This is the area where the pubic bones have grown together.

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FIGURE 4-7 Syndactyly. The left foot (pale) shows syndactyly (webbed toes). The right foot (darker) has normal toes. Syndactyly is a hereditary and congenital abnormality of the fingers or toes.

Sleep apnea

Sleep apnea occurs when breathing stops suddenly during sleep. A CPAP (continuous positive airway pressure) machine is used to keep your airways open.

Anti-yAnte-

Be careful not to confuse these prefixes. Pay attention to their different pronunciations. Anti- is pronounced an-tih, and ante- is pronounced an-te.

autoimmune disease

In an autoimmune disease, the body produces antibodies against its own good cells and tissues, causing inflammation and damage. Examples of autoimmune disorders are rheumatoid arthritis, which affects the joints; celiac disease, which affects the intestinal tract; and Graves' disease, which affects the thyroid gland.

Peritoneal dialysis

In peritoneal dialysis, a special fluid is inserted into the peritoneal cavity through a tube in the abdomen. residues such as urea

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seep into the bloodstream over a period of time. Next, fluids and debris are drained from the peritoneal cavity. See Figure 7-16 on page 223.

signs and symptoms

A sign is an objective finding detected by an examiner, such as fever, rash, or hyperglycemia. A symptom (from the Greek symptom, which means what happens) is a subjective change in the condition perceived by the patient. Examples of symptoms are loss of appetite, abdominal pain, and fatigue (tiredness). Both signs and symptoms are useful clues in the diagnosis of a disease such as diabetes mellitus.

Intra, Inter, Infra

Be careful not to confuse these prefixes: intra- means in, inside, inside; inter- means between; infra- means below, low.

Symbiosis

Symbiosis occurs when two organisms live together in close association, whether for mutual benefit or not. Some examples are: • The bacteria in the intestines and the cells lining the intestines benefit each other. • Parasites (tapeworms and fleas) live on another organism and are harmful to the host. In psychiatry, symbiosis is a relationship between two people who are emotionally dependent on each other.

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More detailed antigens and antibodies; Rh condition An antigen, usually a foreign substance (such as a poison, virus, or bacteria), stimulates the production of antibodies. Antibodies are protein substances produced by white blood cells in response to the presence of foreign antigens. For example, the flu virus (antigen) enters the body and causes the production of antibodies in the bloodstream. These antibodies then bind to and mark the antigens (viruses) that produced them for destruction. The reaction between an antigen and an antibody is an immune response (immuno means protection). See Figure 4-8. When you get a vaccine, you actually get killed or weakened antigens that stimulate your white blood cells (lymphocytes) to make antibodies. These antibodies remain in your blood to protect against these specific antigens when they are encountered in the future.

FIGURE 4-8 Immune response. When antigens (bacteria) enter the body through a wound in the flesh, antibodies are produced to destroy the antigens.

Another example of an antigen-antibody reaction is Rh condition. An Rh positive (Rh+) person has a protein coat (antigen) on their red blood cells (RBCs). This specific antigenic factor is something a person is born with and is normal. People who are Rh negative (Rh-) also have normal red blood cells, but their red blood cells lack the Rh factor antigen.

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If an Rh- woman and an Rh+ man conceive an embryo, the embryo can be either Rh- or Rh+. A dangerous condition arises only when the embryo is Rh+ (because it is different from the Rh− mother). During the delivery of the first Rh+ baby, some of the baby's blood cells that contain Rh+ antigens may leak into the mother's bloodstream. This sensitizes the mother to produce a low level of antibodies against the Rh+ antigen. Since this occurs at birth, the first baby is usually not affected and is normal at birth. Sensitization can also occur after a miscarriage, miscarriage, or blood transfusions (with Rh+ blood). Difficulties arise with the second Rh+ pregnancy. If this embryo is also Rh+, during the pregnancy the antibodies acquired by the mother (from the first pregnancy) enter the bloodstream of the embryo. These antibodies attack and destroy the Rh+ red blood cells of the embryo (hemolysis). The affected baby is born with hemolytic disease of the newborn (HDN). One of the clinical signs of HDN is jaundice (yellow pigmentation of the skin). Jaundice results from excessive destruction of red blood cells. When red blood cells break down, the hemoglobin inside the cells produces bilirubin (a chemical pigment). Elevated levels of bilirubin in the bloodstream (hyperbilirubinemia) cause jaundice. To prevent bilirubin from affecting the baby's brain cells, newborns are treated with exposure to bright lights (phototherapy). The light breaks down the bilirubin, which is then excreted from the baby's body. Doctors give Rh immune globulin to an Rh- woman within 72 hours after each Rh+ childbirth, abortion, or miscarriage. The globulin binds to Rh+ cells that escape the mother's circulation and prevents the formation of Rh+ antibodies. This protects future babies from developing HDN. Figure 4-9 discusses the Rh condition as an example of an antigen-antibody action.

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FIGURE 4-9 Rh condition as an example of an antigen-antibody reaction.

Congenital Anomaly An anomaly is an irregularity in a structure or organ. Examples of congenital abnormalities (those that a baby is born with) include webbed fingers or toes (syndactyly), heart defects, and club feet. See Figure 4-10A. Some birth defects are inherited (passed on to the baby through the chromosomes of the father or the mother, or both), while others are caused by factors present during the pregnancy. For example, when a pregnant woman consumes high levels of alcohol during pregnancy, there is often a pattern of physical and mental defects in her unborn baby. See Figure 4-10B.

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FIGURE 4-10 Congenital anomalies. A, Clubfoot is an inherited congenital anomaly. "Digital clubbing" can affect one or both feet. B, Fetal alcohol syndrome (FAS) is a congenital abnormality caused by environmental factors during pregnancy. Note the facial features of FAS: skin folds at the corners of the eyes; long smooth groove between nose and upper lip; thin upper lip; and flat nose bridge.

Recombinant DNA Recombinant DNA technology is the process of taking a gene (a region of DNA) from one organism and inserting it into the DNA of another organism. For example, recombinant techniques are used to make insulin outside the body. The gene that codes for insulin (ie contains the recipe for making insulin) is removed from a human chromosome (using special enzymes) and transferred into a bacterium, such as Escherichia coli (E. coli). The bacterium then contains the gene to make human insulin and, because it multiplies so quickly, it can make large amounts of insulin. Diabetic patients, unable to produce their own insulin, can use this synthetic product (see Figure 4-11). CRISPR is an acronym for new DNA editing tool that alters DNA sequences to turn genes off or replace them with new versions. CRISPR stands for Clustered Regularly Interspaced Short Palindromic Repeats!

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FIGURE 4-11 Recombinant DNA and insulin production.

Syndromes A syndrome (from the Greek dromos, meaning race) is a group of signs or symptoms that appear together to produce a typical clinical picture of an inherited disease or abnormality. For example, Reye's syndrome is characterized by vomiting, swelling of the brain, increased intracranial pressure, hypoglycemia, and liver dysfunction. It can occur in children after a viral infection treated with aspirin. Marfan syndrome is an inherited disorder of connective tissue characterized by a tall, slender body type with long, spider-like fingers and toes (arachnodactyly), an elongated head and heart, blood vessels, and ophthalmic abnormalities (see Figure 4-12).

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FIGURE 4-12 Marfan syndrome. A and B show people with Marfan. Note the unusually tall body type and long, spidery fingers. Olympic swimmer Michael Phelps (not pictured) has Marfan syndrome. The height of him is 6'4″ and the wingspan of him is 6'7″.

Transurethral resection of the prostate In transurethral resection of the prostate (TURP), a portion of the prostate is removed with an instrument (resectoscope) that is passed through (trans-) the urethra. The procedure is indicated when the prostate tissue is enlarged (hyperplasia) and interferes with urination. This condition is called benign prostatic hyperplasia or BPH. Figure 4-13 shows a TURP procedure.

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FIGURE 4-13 Transurethral resection of the prostate (TURP). The resectoscope contains a light, valves to control the irrigated fluid, and an electrical circuit that cuts the tissue and seals the blood vessels.

Ultrasound Ultrasound is a diagnostic technique that uses ultrasound waves (inaudible sound waves) to produce an image of an organ or tissue. A machine records ultrasonic echoes as they pass through different types of tissue. X-rays are not used! Echocardiograms are ultrasound images of the heart. Figure 4-14 shows a fetal ultrasound image (sonogram).

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FIGURE 4-14 Ultrasonography. A, Check out the facial features of this beautiful 30 week fetus, in a (very) early "baby photo" by my granddaughter, Beatrix Bess Thompson! B, Baby, smiling, at 3 months. (Courtesy of Dr. Elizabeth Chabner Thompson).

Practical applications

Check your answers with Answers to Practical Applications on page 126. There you will find helpful explanations.

A useful weapon against anemia Anemia is a major problem for many patients with chronic renal failure. This is because as kidney function declines, the kidneys secrete less erythropoietin, a hormone that stimulates the production of red blood cells. Under normal conditions, when the body detects a decrease in red blood cells or a deficiency in oxygen supply, more erythropoietin is produced, which increases the number of red blood cells. Epoetin alfa (Epogen or Procrit) is a man-made form of human erythropoietin. It is genetically modified using recombinant DNA technology and stimulates the bone marrow to produce and release red blood cells. As the hematocrit rises, patients experience increased energy, appetite, and increased stamina. The FDA has approved Epogen for the treatment of anemia in patients on dialysis and in patients with chronic renal failure but not on dialysis. It is also effective in counteracting the myelosuppressive effects of chemotherapy. Other hematopoietic drugs produced using recombinant DNA technology include Neupogen (filgrastim) for neutropenia and thrombopoietin (TPO) for thrombocytopenia.

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1. Anemia is a big problem for patients with chronic renal failure because a. the kidney overproduces erythropoietin b. patients may have heart failure and lose consciousness c. patients produce less of a hormone that stimulates red blood cell production 2. The type of erythropoietin used for these patients is a. made in the laboratory using pieces of DNA that code for the hormone b. made from the blood of other patients c. administered by bone marrow transfusion 3. The hematocrit is a. a measurement of the volume of white and red blood cells b. the percentage of red blood cells in a volume of blood c. lower in people with higher stamina and energy levels 4. Dialysis patients when a. are in chronic renal failure b. have a low hematocrit c. are receiving chemotherapy 5. Side effects of myelosuppressive chemotherapy can be treated with a. cytotoxic agents b. Epogen, Neupogen, and thrombopoietin c. hemodialysis or peritoneal dialysis

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Exercises Remember to carefully check your answers against the Answers to Exercises, pages 125–126.

A Gives the meaning of the following prefixes. 1. ante________________________________________________ 2. ab__________________________________________________ 3. ana___________________________________________ 4. anti__________________________________________________ 5. a-, an__________________________________________________ 6. ad__________________________________________________ 7. auto_____________________________________________________ 8. cata____________________________________________ 9. brady________________________________________________ 10. contra_____________________________________________ 11. bi_____________________________________________ 12. with_____________________________________________ B Match the terms listed with the meanings that follow a continuation .

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adductor adrenal analysis anoxia anteflexion antepartum antisepsis bilateral apnea contralateral bradycardia congenital anomaly 1. forward flexion ____________________________________________ ________________________ 2. muscle that pulls the limb toward the body ____________________________________________ _________________________ 3. before birth _____________________________________________ _____________________________ 4. slow heartbeat ____________________________________________ ________________________ 5. gland located next to (above) each kidney _____________________________________________ ________________________ 6. Absence of breathing _________________________________________________ ________________________

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7. referred to the opposite side __________________________________________________ ________________________ 8. against infection __________________________________________ ________________________ 9. to separate _____________________________________________ ________________________ 10. referred to two (both) sides ________________________________________ ________________________ 11. condition of oxygen deprivation in the tissues _____________________________________________ _____________________________ 12. irregularity present at birth _____________________________________________ _____________________________ C Select from the terms listed to match the descriptions below. anabolism antibiotic antibody antigen antitoxin autoimmune disease catabolism congenital anomaly contraindication

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1. A chemical, such as erythromycin (-mycin = mold), made from molds and used against bacterial life. Reason why a doctor would advise against taking a specific medication _____________________________________________ ________________________ 4. a disorder in which the body's own white blood cells produce antibodies that damage its own good tissue __________________________________________ ________________________ 5. a foreign agent (virus or bacteria) that causes the production of antibodies ____________________________________ ________________________ 6. an antibody that works against poisons that enter the body __________________________________________ ______ 7. process of protein formation in cells by assembly of small Small pieces of protein called amino acids ____________________________________________ ________________________ 8. protein produced by lymphocytes in response to presence of a specific antigen in the blood

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_____________________________________________ ________________________ D Give the meaning of the following prefixes. 1. ec________________________________________________ 2. dis__________________________________________________ 3. de__________________________________________________ 4. day__________________________________________________ 5. hemi________________________________________________ 6. hypo________________________________________________ 7. epi__________________________________________________________ 8. hyper________________________________________________________ 9. endo________________________________________________ 10. eu________________________________________________ 11. in_____________________________________________ 12. inter_____________________________________________ 13. intra_____________________________________________

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14. infra_____________________________________________ 15. macro______________________________________________ 16. micro_______________________________________________ E Complete the following terms, according to their given meanings. 1. normal thyroid function: ________________________ thyroid 2. painful breathing: ________________________ apnea 3. misplaced pregnancy (outside the uterus): ________________________ subject 4. instrument to visually examine the inside of the body: endo ________________________________________ 5. removal of half of the tongue: ________________________ glossectomy 6. good (exaggerated) feeling (of well-being): ________________________ phoria 7. belonging to the trachea: endo ________________________________________ 8. condition of blood sugar below normal: ________________________ blood glucose 9. condition (congenital anomaly) of large head: ________________________ headache 10. belonging to between the ribs: ________________________ rib 11. belonging to a vein: intra _____________________________________________

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12. condition of abnormal formation (of cells): dis ___________________________________ 13. condition of excessive formation (number of cells): _____________ plasia 14. structure (membrane) that forms the inner lining of the heart: endo ________________________ 15. belonging below the ribs : infra ________________________________________________________ 16. Excess blood sugar condition: hyper _____________________________________________ 17. A group of congenital disorders that involve abnormal development of muscle mass and strength is: muscle _____________________________________ 18. Zika virus infection during pregnancy can be the cause of a decrease in the development of a child's head and brain: ___________________________________ headache F Combine the listed terms with the following meanings. dehydration dialysis diarrhea exophthalmos (proptosis) incision insomnia malaise malignant metamorphosis

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p metastasis microscope pancytopenia 1. vague feeling of bodily discomfort __________________________________________ ________________________ 2. inability to sleep ________________________________________________ ________________________ 3. lack of water ________________________________________ ________________________ 4. spread of a cancerous tumor to a secondary organ or tissue _____________________________________________ _____________________________ 5. instrument used to visualize small objects _____________________________________________ ________________________ 6. a cut in an organ or tissue __________________________________________ ________________________ 7. external protrusion of the eyeballs _____________________________________________ ________________________ 8. condition of change in shape or shape ____________________________________________ ________________________ 9. watery discharge of waste from the colon ________________________ ________ _________________ ________________ ________

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10. deficiency of all (blood) cells ____________________________________________ ________________________ 11. separation of waste from the blood using a machine that does the work of the kidney ____________________________________________ ________________________ 12. harmful, carcinogenic ____________________________________________ _____________________________ G Give the meaning of the following prefixes. 1. mal__________________________________________________ 2. pan__________________________________________________ 3. per__________________________________________________ 4. goal__________________________________________________ 5. for______________________________________________ 6. peri_________________________________________ 7. poly________________________________________________________ 8. post____________________________________________ 9. pro_____________________________________________

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10. pre_____________________________________________ 11. sub__________________________________________________ 12. supra___________________________________________ 13. re__________________________________________________ 14. retro___________________________________________________ 15. tachy_________________________________________ 16. syn_________________________________________ 17. uni_____________________________________________ 18. trans_____________________________________________ 19. neo________________________________________________ 20. epi____________________________________________ H Underline the prefix in the following terms and give the meaning of the complete term. 1. pericardium ________________________________________ ________________________ 2. percutaneous _________________________________________________ ________________________

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3. retroperitoneal _____________________________________________ ________________________ 4. suprapúbica _____________________________________________ ________________________ 5. polineuritis _____________________________________________ ________________________ 6. retroflexión ________________________________________________ ________________________ 7. transuretral _____________________________________________ ________________________ 8. subcutánea _____________________________________________ ________________________ 9. taquipnea _____________________________________________ ________________________ 10. unilateral ________________________________________________ ________________________ 11. prótesis ________________________________________________ ________________________________________________ 12. bilateral ________________________________________________ _________________________

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13. symptom ____________________________________________ ________________________ 14. syndrome __________________________________________ _______________________ I Combine the listed terms with the following meanings. adrenal neoplasm paralysis prodrome parathyroid prolapse recombinant DNA relapse remission syndactyly syndrome ultrasound 1. return of a disease or its symptoms _____________________________________________ ________________________ 2. loss of movement in the muscles ____________________________________________ _____________________________ 3. congenital anomaly in which the fingers or fingers feet are webbed (formed together)

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_____________________________________________ ________________________ 4. four endocrine glands that are located near (behind) another endocrine gland in the neck _____________________________________________ ________________________ 5. glands located above the kidneys ________________________________________ ________________________ 6. symptoms that come before the actual disease ________________________________________ ________________________ 7. transfer technique material genetics from one organism to another ________________________________________ ________________________ 8. slipping, sinking downward, or forward __________________________________________ ________________________ 9. new growth or tumor ____________________________________________ ________________________ 10. process of using sound waves to create an image of organs and structures in the body _____________________________________________ __________________ ______ 11. group of signs and symptoms that occur together and indicate a particular disorder

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12. The symptoms decrease and the patient feels better _____________________________________________ ________________________ J Complete the following terms, according to their meanings. 1. related to new birth: neo _____________________________________________ ________________________ 2. after death: post _________________________________________________ ________________________ 3. spread of a cancerous tumor: meta ________________________________________ ________________________ 4. branching into two: bi _____________________________________________ _____________________________ 5. increase in development (cell size ): hyper ________________________________________ ________________________ 6. belonging to a chemical substance that acts against bacterial life: ________________________ biotic 7. bones of the hand (other than the wrist): ________________________ carpals 8. protein produced by leukocytes to fight foreign organisms: anti ________________________________________ 9 group of symptoms that occur together: ________________________ drome 10. surface or tissue of the skin of the body: ________________________ th elium

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K Circle the correct term in bold to complete the following sentences. 1. Dr. Tate felt that Ms. Snow was clear (analysis, contraindication, synthesis) to perform elective surgery. 2. Medical science was revolutionized by the introduction of (antigens, antibiotics, antibodies) in the 1940s. Some infections can now be treated with a single dose. 3. Robert's 82-year-old grandfather complained of (malaise, dialysis, insomnia) despite taking sleep medications prescribed by his doctor. 4. During her pregnancy, Ms. Payne described pressure on her (pituitary gland, parathyroid gland, symphysis pubis), making it difficult for her to find a comfortable position, even when she was sitting. 5. People with diabetes often inject too much insulin by accident. This results in such a drop in blood sugar that they can be admitted to the ER with (hyperplasia, hypoglycemia, hyperglycemia). 6. Before the migraine started, John noticed changes in his vision, such as bright spots, zigzag lines, and double vision. His doctor told him that these were symptoms (symbiotic, exophthalmic, prodromal). 7. After hiking the Grand Canyon without adequate water supplies, Julie experienced (hyperglycemia, dehydration, hypothyroidism).

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8. At age 65, Paul Smith often felt a full bladder but had difficulty urinating. He visited his (cardiologist, nephrologist, urologist), who examined his prostate and diagnosed it (hyperplasia, atrophy, ischemia). The doctor advised resection (intracostal, transurethral, peritoneal) of Paul's prostate. 9. After running the Boston Marathon, Elizabeth felt nauseated and dizzy. She realized what was happening (malaise, euphoria, hypoglycemia) and took an isotonic drink with sugar, which made her feel better. 10. While she was taking an antibiotic that reacted with sunlight, Ruth's doctor warned her that sunbathing was (unilateral, contraindicated, contralateral) and could cause severe burns. 11. Puerperal fever (related to childbirth) was an iatrogenic infection; it was taken from one woman to another by the doctor before the days of (antigens, antibodies, antisepsis). 12. Dysplastic nevi (abnormally pigmented lesions or spots) on a patient's skin may be a sign (precancerous, metastatic, unilateral) of a malignant skin cancer called melanoma. 13. Nerve cells in the brain can (relapse, hypertrophy, atrophy) in old age due to ischemia caused by restricted blood flow. 14. Changes in cell growth that result in cells that differ in size, shape, and appearance are the result of chronic inflammation and irritation. When the condition occurs in the cervix, it is known as cervical (prolapse, paralysis, dysplasia).

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Answers to exercises A 1. before, forward 2. far from 3. up, apart 4. against 5. no, no, without 6. towards 7. own, own 8. below 9. slow 10. against, opposite 11. two 12. together, with B 1. anteflexion 2. adductor 3. antepartum 4. bradycardia 5. adrenal 6. apnea 7. contralateral

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8. antisepsis 9. analysis 10. bilateral 11. anoxia 12. congenital anomaly C 1. antibiotic 2. catabolism 3. contraindication 4. autoimmune disease 5. antigen 6. antitoxin 7. anabolism 8. antibody D 1. out, out 2. abnormal, bad, difficult, painful. TIP: Think about the word dysfunctional. 3. below, missing 4. above, complete 5. medium 6. poor, below 7. above, above, above

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8. excessive, above, beyond 9. within, within 10. good, well 11. within, not 12. between 13. within 14. below, below 15. large 16. small AND 1. euthyroid 2. dyspnea 3 ectopic 4 endoscope 5. hemiglossectomy 6. euphoria 7. endotracheal 8. hypoglycemia 9. macrocephaly 10. intercostal 11. intravenous 12. dysplasia 13. hyperplasia

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14. endocardium 15. infracostal 16. hyperglycemia 17. dystrophy 18. microcephaly F 1. malaise 2. insomnia 3. dehydration 4. metastasis 5. microscope 6. incision 7. exophthalmos (proptosis) 8. metamorphosis 9. diarrhea 10. pancytopenia eleven . dialysis 12. malignant G 1. bad 2. all 3. to 4. change, beyond

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5. close, next to, abnormal 6. around 7. many, much 8. after, behind 9. before, in front 10. before, in front of 11. below 12. above 13. behind, again 14. behind, behind 15 fast 16. together, with 17. one 18. through 19. new 20. above, on, in H 1. pericardium: membrane surrounding the heart 2. percutaneous: pertaining to the skin 3. retroperitoneal: pertaining behind the peritoneum 4. suprapubic: above the pubic bone 5. polyneuritis: inflammation of many nerves 6. retroflexion: bending backwards

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7. transurethral: relating to the urethra 8. subcutaneous: relating under the skin 9. tachypnea: rapid rapid breathing 10. unilateral: relating to one side 11. prosthesis: artificial limb or body part (literally, to put 12. bilateral: both sides 13. symptom—subjective change in condition observed by the patient 14. syndrome—group of objective findings characterizing an abnormal condition I 1. relapse 2. paralysis 3. syndactyly 4. parathyroid 5. adrenal 6. prodrome 7 recombinant DNA 8. prolapse 9. neoplasia 10. ultrasonography 11. syndrome 12. remission

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J 1. neonatal 2. postmortem 3. metastasis 4. bifurcation 5. hypertrophy 6. antibiotic 7. metacarpals 8. antibody 9. syndrome 10. epithelium K 1. contraindication 2. antibiotics 3. insomnia 4. symphysis pubis 5. hypoglycemia 6 prodromal 7. dehydration 8. urologist; hyperplasia; transurethral 9. hypoglycemia 10. contraindicated 11. antisepsis

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12. precancerous 13. atrophy 14. dysplasia Answers to practical applications 1. C 2. A 3. B 4. B 5. B Pronunciation of terms

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TERM abductor adductor abnormal adrenal glands anabolism analysis anoxia ante cibum (a.c.) antepartum anteflexion antibody antibiotic antisepsis antitoxin apnea autoimmune disease benign bifurcation bradycardia bilateral catabolism congenital anomaly connective tissue contraindication contralateral dehydration dialysis diameter diarrhea dysentery dysplasia dyspnea dystrophy ectopic pregnancy endocardium endotrachescope epithelium euphoria euthyroid exophthalmos hemiglosectomy hyperglycemia hyperplasia hypertension hypertrophy hypodermic injection hypoglycemia infracostal incision insomnia

PRONUNCIATION ab-DUK-tor ab-NOR-mal ah-DUK-tor ah-DRE-nal glanz ah-NAB-o-liz-im ah-NAL-ih-sis ah-NOK-se-ah AN-te SE- bum an-te-FLEK-shun an-te-PAR-tum an-tih-bi-OT-ik AN-tih-bod-e AN-tih-jen an-tih-SEP-sus an-tih-TOX-in AP-ne-ah aw-to-ih-MUNE dih-ZEEZ beh-NINE bi-fur-KA-shun bi-LAT-er-al bra-de-KAR-de-ah kah-TAB-o-liz-im con-JEN-ih-al ah-NOM-ah-le con-NEK-tiv TIH-shu con-trah-in-dih-KA-shun con-trah-LAT-er-al de-hi-DRA-shun di -AL-ih-sis di-AM-eh-ter di-ah-RE-ah DIS-en-ter-e dis-PLA-ze-ah DISP-ne-ah DIS-tro-fe ek-TOP-ik PREG -nan-se en-do-KAR-de-um EN-do-scope en-do-TRA-ke-al ep-ih-THE-le-um u-FOR-e-ah u-THI-royd ek- sof-THAL-mos hem-e-glos-SEK-to-me hi-per-gli-SE-me-ah hi-per-PLA-ze-ah hi-per-TEN-shun hi-PER-tro-fe hi-po-THER in-JEK-shun hola-po-gli-SE-me-ah in-SIZH-un in-frah-KOS-tal in-SOM-ne-ak

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TERM intercostal intravenous macrocephaly malignant discomfort metacarpal bones metamorphosis metastasis microcephaly neoplasm microscopic pancytopenia neonatal parathyroid glands pericardium percutaneous polymorphonuclear polyneuritis antenatal precancerous postpartum prodrome prolapse prosthesis recombinant DNA relapse retroperitoneal remission subcutaneous retroflexion suprapubic symbiosis symmetry echocardiography syndactyly syndrome unilateral transfusion synthesis

PRONUNCIATION in-ter-KOS-tal in-trah-VE-nus mak-ro-SEH-fah-le mal-AYZ mah-LIG-nant met-ah-KAR-pal bones met-ah-MOR-fuh-sis meh -TAS-tah-sis mi-kro-SEH-fah-le MI-kro-scope ne-o-NA-tal NE-o-plazm pan-si-to-PE-ne-ah pah-RAL-ih-sis par-ah-THI-royd glanz per-ku-TA-ne-us peh-rih-KAR-de-um pol-e-mor-fo-NU-kle-ar pol-e-nu-RI-tis post- MOR-term pos-PAR-tum pré-CAN-serve-us pré-NA-number PRO-drohm PRO-lapse pros-THE-sis re-KOM-bih-nant DNA RE-lapse re-MIH-shun reh-tro -FLEK-shun reh-tro-peh-rih-to-NE-al sub-ku-TA-ne-us su-prah-PU-bik sim-be-O-sis SIM-met-re SIM-fih-sis SIMP-tum sin-DAK-tih-le SIN-drohm SIN-theh-sis tah-KIP-ne-ah tranz-FU-zhun tranz-u-RE-thral ul-trah-so-NOG-rah-fe u- it-LAT-is-al

revision sheet

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prefixes

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PREFIX a-, anabadanaanteantiautobibradicacataconcontradiadysecen-, endoepieuexhemihyperhipoinfrainterintramacromalmetamicroneopanparaperperipolypostpreproprosreretrosubsuprasyn-, symtachytransultrauni-

SENSE ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ _ ___ _ _______________ ____________________ ____________________

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Prefixes with similar meanings PREFIX a-, an-, inante-, pre-, proanti-, contracon-, syn-, symde-, catadia-, per-, transdys-, malec-, ecto-, exendo-, in-, intraepi-, hyper-, supra-hypo-, infra-, subre-, retro-, post-ultra-, meta-

Combined forms COMBINATION FORM carp/o cost/o cutane/o dactyl/o duct/o flex/o gloss/o glyc/o immun/o later/o morph/o mort/o nat/i necr/o norm/ the ophthalm /the ox/the pub/the ren/the seps/the somn/the son/the tens/the the/the thyr/the top/the tox/the trache/the urethra/the ven/o

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Sufixos -crine -drome -fusion -gen -lapse -lysis -meter -mission -or -partum -phoria -physis -plasia -plasma -pnea -ptom -ptosis -rrhea -stasis -trophy

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CHAPTER 5

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Digestive System CHAPTER SECTIONS: Introduction 132 Anatomy and Physiology 132 Vocabulary 142 Terminology 145 Pathology of the Digestive System 151 On the Face: Living with Crohn's Disease 162 Exercises 163 Answers to Exercises 171 Pronunciation of Terms 173

CHAPTER OBJECTIVES • Name the organs of the digestive system and describe their location and functions. • Define forms of combination of organs and know the meaning of related terminology. • Describe signs, symptoms, and conditions of diseases that affect the digestive system.

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Introduction The digestive system is divided into Chapters 5 and 6. Chapter 5 covers the anatomy, physiology, pathology, and basic terminology of the system. Chapter 6 presents additional terminology and a review of digestive system terms, as well as laboratory tests, clinical procedures, and abbreviations. My reason for not combining the chapters is that I didn't want to overwhelm you with an extraordinarily long chapter so early in your study. In my own teaching, I find my students grateful for this separation and especially for pausing and reviewing the terminology in Chapter 6. My choice to begin with the digestive system is based on the understanding that this body system (which is resembles a conveyor belt) with a mouth at the entrance and anus at the exit) is one of the simplest and easiest to understand. Keep in mind, however, that the book is organized so that you can begin your study of body systems with any chapter to create the order that best reflects your interests. The digestive or gastrointestinal tract begins at the mouth, where food enters, and ends at the anus, where solid waste leaves the body. The four functions of the system are ingestion, digestion, absorption, and elimination. First, the complex food material is ingested and placed in the mouth. Second, it is mechanically and chemically digested or broken down as it travels through the GI tract. Digestive enzymes speed up chemical reactions and aid in the breakdown (digestion) of complex nutrients. Complex proteins are digested into simpler amino acids; complicated sugars are reduced to simple sugars like glucose; and large fat molecules (triglycerides) are broken down into simpler substances, such as fatty acids. Digestion takes place in the mouth, stomach, and small intestine. Third, through absorption, nutrients from digested food pass through the lining cells, or epithelium, of the small intestine and into the bloodstream. The nutrients then travel to every cell in the body. The cells then break down the nutrients in the presence of oxygen to release energy. Cells also use amino acid nutrients to build large protein molecules necessary for growth and development. In addition, the fat molecules are absorbed by the lymphatic vessels of the intestine. The fourth function of the digestive system is the removal of solid waste that cannot be absorbed into the bloodstream. The large intestine concentrates this solid waste, called feces, and the waste eventually leaves the body through the anus.

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Anatomy and Physiology Oral Cavity The gastrointestinal tract begins with the oral cavity. Oral means pertaining to the mouth (or/or). Check Figure 5-1 as you learn the major parts of the oral cavity.

FIGURE 5-1 Oral cavity.

The cheeks [1] form the walls of the oval-shaped oral cavity and the lips [2] surround the opening of the cavity. The hard palate [3] forms the anterior portion of the roof of the mouth, and the muscular soft palate [4] lies behind it. Wrinkles are irregular grooves in the mucous membrane that covers the anterior portion of the hard palate. The uvula [5], a small projection of soft tissue, hangs from the soft palate. Helps in the production of sounds and speech. The tongue [6] extends along the floor of the oral cavity, and the muscles ache it up to the lower jaw. Moves food during mastication (chewing) and swallowing (swallowing). The papillae, small raised areas on the tongue, contain taste buds that are sensitive to the chemical nature of food and allow different flavors to be discriminated as the food moves across the tongue.

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The tonsils [7], masses of lymphatic tissue located in depressions in the mucous membranes, are found on either side of the oropharynx (part of the throat close to the mouth). They are filters to protect the body from invading microorganisms and produce lymphocytes, disease-fighting white blood cells. The gums [8] are the fleshy tissue that surrounds the cavities of the teeth [9]. Figure 5-2 shows a dental arch with 16 permanent teeth (there are 32 permanent teeth in the entire oral cavity). The names of the teeth are labeled in Figure 5-2.

FIGURE 5-2 Maxillary permanent teeth within the dental arch. The buccal side faces the cheek, while the lingual side faces the tongue. The labial surface faces the lips. Dentists refer to the labial and buccal surfaces as the facial surface (faci/o = face).

Figure 5-3 shows the internal anatomy of a tooth. Tag him as you read the following description:

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FIGURE 5-3 Anatomy of a tooth.

A tooth consists of a crown [1], which appears above the gum line, and a root [2], which lies within the bony socket of the tooth. The outermost layer of the crown, the enamel [3], protects the tooth. It is the hardest tissue in the human body. Dentin [4], the main substance of the tooth, lies beneath the enamel and extends throughout the crown. The color of the dentin varies from creamy white to yellow and affects the color of the teeth because the enamel is translucent. The cement covers, protects and supports the dentin from the root. A periodontal membrane surrounds the cementum and holds the tooth in place in the socket. The pulp [5] lies beneath the dentin. This soft, delicate tissue fills the center of the tooth. Blood vessels, nerve endings, connective tissue, and lymphatic vessels are found within the pulp canal (also called the root canal). Root canal therapy is often required when disease or an abscess (accumulation of pus) occurs in the pulp canal. A dentist opens the tooth from above and cleans the canal of infected tissue, nerves, and blood vessels. The canal is then disinfected and filled with material to prevent the entry of microorganisms that can cause cavities. Three pairs of salivary glands (Figure 5-4) surround and empty into the oral cavity. These exocrine glands produce saliva, which lubricates the mouth. Saliva contains important digestive enzymes, as well as healing growth factors such as cytokines. Saliva is released from a parotid gland [1], a submandibular gland [2], and a sublingual gland [3] on either side of the mouth. Narrow ducts carry saliva into the oral cavity. The glands produce about 1.5 liters of saliva a day.

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FIGURE 5-4 Salivary glands.

Pharynx See Figure 5-5. The pharynx or throat is a muscular tube, about 5 inches long, lined with a mucous membrane. It serves as a passageway for both air traveling from the nose (nasal cavity) to the trachea (windpipe) and food traveling from the oral cavity to the esophagus. When deglutition (swallowing) occurs, a flap of cartilage tissue, the epiglottis, covers the windpipe so that food cannot enter and lodge there. See Figure 5-5A and B.

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FIGURE 5-5 Swallowing (deglutition). A, The epiglottis closes over the trachea as the food bolus moves down the pharynx into the esophagus. B, The epiglottis opens as the food bolus moves down the esophagus.

Your mother was right! Don't talk while you eat! Talking while eating causes the epiglottis to open, so food can accidentally enter the trachea and cause you to choke.

Figure 5-6 shows the passage of food as it travels from the esophagus through the gastrointestinal tract. Label it as you read the following paragraphs.

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FIGURE 5-6 The gastrointestinal tract.

Esophagus The esophagus [1] is a 9- to 10-inch fibromuscular tube that extends from the pharynx to the stomach. Peristalsis is the involuntary, progressive and rhythmic contraction of the muscles of the esophageal wall (and other gastrointestinal organs), which propel a bolus (food mass) towards the stomach. The process is like putting a marble through a rubber tube.

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Stomach Food passes from the esophagus to the stomach [2]. The stomach (Figure 5-7) has three main parts: fundus (upper), body (midsection), and antrum (lower). Rings of muscles called sphincters control the openings in and out of the stomach. They prevent food from regurgitating (flowing backwards in the normal direction). The lower esophageal sphincter (LES) relaxes and contracts to move food from the esophagus to the stomach. The pyloric sphincter allows food to leave the stomach and enter the small intestine when it is ready. The folds in the mucous membrane (mucosa) that lines the stomach are called rugae. Wrinkles increase the surface area for digestion and contain glands that produce the enzyme pepsin to initiate protein digestion. Hydrochloric acid is also secreted to digest protein and kill any remaining bacteria in food.

FIGURE 5-7 Parts of the stomach. The fundus and body (often collectively referred to as the fundus) are a reservoir for ingested food and an area for the action of acid and pepsin (gastric enzyme). The antrum is a muscle grinding chamber that breaks down food and gradually feeds it to the duodenum.

The stomach prepares food for the small intestine, where it is digested and absorbed into the bloodstream. food leaves

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stomach in 1 to 4 hours or more, depending on the amount and type of food eaten.

Small intestine (Small intestine) (Continue to identify Figure 5-6 on page 136.) The small intestine (small intestine) extends 20 feet from the pyloric sphincter to the first part of the large intestine. It has three parts. The first section, the duodenum [3], is only 30 cm long. It receives food from the stomach, bile from the liver [4] and gallbladder [5], and pancreatic juices from the pancreas [6]. Enzymes and bile help digest food before it passes into the second part of the small intestine, the jejunum [7], which is about eight feet long. The jejunum connects to the third section, the ileum [8], which is about 11 feet long. Ileus hurts in the first part of the large intestine. Millions of tiny microscopic projections called villi line the walls of the small intestine. Tiny capillaries (microscopic blood vessels) in the villi absorb digested nutrients into the bloodstream and lymphatic vessels. Figure 5-8 shows several different views of the villi on the lining of the small intestine.

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FIGURE 5-8 Villi on the lining of the small intestine. The villi increase the surface area for nutrient absorption.

Large intestine (Large intestine) (Continue to identify Figure 5-6 on page 136.) The large intestine extends from the tip of the ileum to the anus. It has three main components: the cecum, the colon, and the rectum. The cecum [9] is a bag on the right side that connects to the ileum at the ileocecal valve (sphincter). The appendix [10] hangs from the cecum. The appendix has no clear function and can become inflamed and infected when it becomes obstructed or blocked. The colon, about 1.5 meters long, has four named segments: ascending, descending, transverse, and sigmoid. The ascending colon [11] extends from the cecum to the undersurface of the liver, where it turns to the left (hepatic flexure) to become the transverse colon [12]. The transverse colon passes horizontally to the left toward the spleen and then turns downward (splenic flexion) into the descending colon [13]. The S-shaped sigmoid colon [14] (sigmoid means similar to the Greek le er sigma, which curves like the letter S), begins at the distal end of the descending colon and leads

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in the rectum [15]. The rectum ends at the lower opening of the gastrointestinal tract, the anus [16]. The large intestine receives the liquid waste products of digestion (the material that cannot pass into the bloodstream) and stores this waste until it can be expelled from the body. As the large intestine absorbs most of the water contained in the waste, the body is able to expel solid stools (faeces). Defecation is the expulsion or passage of feces from the body through the anus. Diarrhea, or passing watery stools, results from reduced absorption of water into the bloodstream through the walls of the large intestine.

Liver, Gallbladder, and Pancreas Three additional important organs of the digestive system—the liver, gallbladder, and pancreas—play crucial roles in the proper digestion and absorption of nutrients. Label Figure 5-9 as you study the following:

FIGURE 5-9 Liver, gallbladder, and pancreas. The ampulla of Vater is at the junction of the pancreatic duct and common bile duct that enters the duodenum.

The liver [1], located in the right upper quadrant (RUQ) of the abdomen, produces a thick, dark orange, sometimes greenish fluid called bile. Bile contains cholesterol (a factory substance), bile acids, and various bile pigments. One of these pigments, bilirubin, is produced from the breakdown of hemoglobin during normal red blood.

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cell destruction. Bilirubin travels through the bloodstream to the liver, where it is conjugated, or converted to a water-soluble form. The conjugated bilirubin then adds to the bile and enters the intestine (duodenum). Bacteria in the colon break down bilirubin into a variety of pigments that give stool a brown color. Bilirubin and bile leave the body in the stool. If the bile duct is blocked or the liver is damaged and cannot excrete bilirubin into the bile, the bilirubin remains in the bloodstream and causes jaundice (hyperbilirubinemia), a yellowing of the skin, whites of the eyes, and mucous membranes. . Also, stools may be lighter due to less bilirubin and bile excreted in the gastrointestinal tract. Figure 5-10 discusses the pathway of bilirubin from breakdown in red blood cells (hemolysis) to elimination with the bile in the feces.

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FIGURE 5-10 Pathway of bilirubin from the bloodstream to its elimination in feces. Increased blood levels of unconjugated bilirubin indicate ongoing hemolysis (destruction of red blood cells). Increased blood levels of conjugated bilirubin indicate obstruction of the bile ducts. Both types of bilirubin are elevated in the blood of patients with liver disease.

(Continue to check Figure 5-9.) The liver continually releases bile, which then passes through the hepatic duct and meets the cystic duct. The cystic duct leads to the gallbladder [2], a pear-shaped sac under the liver that stores and concentrates bile for later use. After meals, in response to the presence of food in the stomach and duodenum, the gallbladder contracts, expelling bile from the cystic duct into the common bile duct [3]. Meanwhile, the pancreas [4] secretes pancreatic juices (enzymes) that are released into the pancreatic duct, which joins the common bile duct as it enters the duodenum [5]. The duodenum thus receives a mixture of bile and pancreatic juices. Bile has a detergent-like effect on duodenal fats. In the emulsification process, bile breaks down large globules of fat, creating more surface area for enzymes in the pancreas to digest fat.

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y p g Without bile, most of the fat ingested by the body remains undigested and the stool may appear mushy. In addition to producing bile, the liver has other vital and important functions:

• Maintain normal blood glucose (sugar) levels. The liver removes excess glucose from the bloodstream and stores it as glycogen (starch) in liver cells. When blood sugar levels drop dangerously low, the liver converts stored glycogen back into glucose through a process called glycogenolysis. Also, when the body needs sugar, the liver can convert protein and fat into glucose, a process called gluconeogenesis. • Manufacture of blood proteins, such as albumin and those necessary for blood clotting. • Release of bilirubin, a bile pigment. • Elimination of drugs and poisons (toxins) from the blood. The portal vein carries blood from the intestines to the liver. Nutrients from digested food pass into the portal vein directly after being absorbed by the capillaries of the small intestine, giving the liver its first opportunity to utilize the nutrients. The pancreas (Figure 5-11) is an exocrine and endocrine organ. As an exocrine gland, it produces enzymes to digest starch, such as amylase (amyl/o = starch, -ase = enzyme); to digest fat, as lipase (lip/o = fat); and to digest proteins, such as protease (prote/o = protein). These pass into the duodenum through the pancreatic duct.

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FIGURE 5-11 The pancreas and its functions.

As an endocrine gland (which secretes into the bloodstream), the pancreas secretes insulin. Needed to help release sugar from the blood, this hormone acts as a transporter to bring glucose into the body's cells to be used for energy. Figure 5-12 is a flowchart that traces the path of food through the GI tract.

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FIGURE 5-12 Path of food through the gastrointestinal tract.

Vocabulary

The following list reviews many of the terms introduced in this chapter. Short definitions and additional information reinforce your

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understanding of the terms. All terms are included in the Pronunciation of terms section later in the chapter.

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absorption

Passage of materials through the walls of the small intestine into the bloodstream. amino acids Small building blocks of protein, released when protein is digested. amylase An enzyme (-ase) secreted by the pancreas and salivary glands to digest starch (amyl/o). anus The terminal end or opening of the digestive tract to the outside of the body. appendix Blind bag hanging from the cecum (in the right lower quadrant [RLQ]). It literally means to hang (pend/o) on (ap-, which is a form of ad-). bile Digestive juice produced in the liver and stored in the gallbladder. Breaks down (emulsifies) large fat globules. Bile was originally called gall (from the Latin bilis, meaning gall or anger), probably because it tastes bitter. It is made up of bile pigments (colored materials), cholesterol, and bile salts. bilirubin A pigment released by the liver into bile. intestine intestine. canine teeth Pointed canine teeth (canine means dog) next to the incisors. Also called canines or canines. cecum First part of the large intestine. colon Portion of the large intestine consisting of ascending, transverse, descending, and sigmoid segments. common bile Carries bile from the liver and gallbladder to the duodenum. Also called the common bile duct. defecation Removal of feces from the digestive tract through the anus. swallow swallow TIP: the pronunciation is de-glu-TISH-un. dentin Primary material found in teeth. It is covered by enamel on the crown and a protective layer of cementum on the root. Digestion Breaks down complex foods into simpler forms. duodenum First part of the small intestine. duo = 2, den = 10; the duodenum is 12 inches long. elimination Removal of materials from the body; in the digestive system, the removal of indigestible materials such as feces. emulsification The breakdown of large globules of fat into smaller globules. This increases the surface area that the enzymes can use to digest the fat. Enamel Hard outer layer of a tooth. enzyme A chemical substance that speeds up a reaction between substances. Digestive enzymes break down complex foods into simpler substances. Enzymes are given names that end in -ase. esophagus Tube that connects the throat with the stomach. That- means interior; phag/o means swallow. fatty acids Substances produced when fats are digested. feces Solid waste; Stool. The term fecal means pertaining to feces. gallbladder Small sac under liver; stores bile. TIP: gallbladder is one word! glucose Simple sugar. starch glycogen; Glucose is stored as glycogen in liver cells. hydrochloric Substance (strong acid) produced in the stomach; helps with digestion. acid ileum Third part of the small intestine from the Greek eilos, meaning twisted. When the abdomen was visualized at autopsy, the intestine appeared twisted and the ileum was often an area of obstruction. incisor Any of the four front teeth in the dental arch. insulin Hormone produced by the endocrine cells of the pancreas. Helps transport sugar to the cells of the body. jejunum Second part of the small intestine. The Latin jejunus means empty; this part of the intestine was always empty when a body was examined after death. TIP: the pronunciation is jeh-JU-num.

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lipase liver

lower esophageal sphincter (LES) for chewing molar teeth

Pancreatic enzyme needed to digest fats. Large organ located in the ruq of the abdomen. The liver secretes bile; stores sugar, iron and vitamins; produces blood proteins; destroys worn-out red blood cells; and filters out toxins. The normal adult liver weighs about 3 pounds. Ring of muscles between the esophagus and the stomach. Also called cardiac sphincter.

Chew. Three large, flat teeth in the back of the mouth, on each side of the dental arch. Premolar teeth are two teeth, before the molars. palate Heaven of mouth. The hard palate lies anterior to the soft palate and is supported by the upper jaw (maxilla). The soft palate is the fleshy back part between the mouth and the throat. pancreas Organ behind the stomach; produces insulin (to transport sugar into cells) and enzymes (to digest food). papillae Small projections on the tongue. Taste buds (taste receptor cells) are located inside the papillae (IL-e-pap). Parotid gland Salivary gland inside the cheek, just anterior to the ear. Note the literal meaning of parotid (par- = close; ot/o = ear). peristalsis Rhythmic contractions of the tubular organs. In the gastrointestinal tract, peristalsis moves the contents at different speeds: stomach - from 0.5 to 2 hours; small intestine, 2 to 6 hours; and colon, from 6 to 72 hours. Peri- means to surround; -stalsis is constriction. TIP: the pronunciation is peh-rihSTAL-sis. Pharynx Throat, the common passage for food from the mouth and air from the nose. portal vein A large vein that carries blood from the intestine to the liver. protease Enzyme that digests proteins. pulp Soft tissue inside a tooth, containing nerves and blood vessels. Pyloric ring of muscle at the end of the stomach, near the duodenum. From the Greek pyloros, sphincter, meaning goalkeeper. It is normally closed, but opens when a peristaltic wave passes over it. pylorus Distal region of the stomach, opening into the duodenum. rectum Last section of the large intestine, connecting the end of the colon and the anus. rugae Ridges on hard palate and stomach wall. TIP: the pronunciation is RU-guy. saliva Digestive juice produced by the salivary glands. Saliva contains the enzyme amylase, which initiates the digestion of starch into sugar. Parotid, sublingual and submandibular salivary glands. glands Inferior sigmoid colon, S-shaped segment of the colon just before the rectum; empties into the rectum. sphincter A circular ring of muscle that constricts a passage or closes a natural opening. Stomach Muscular organ that receives food from the esophagus. The parts of the stomach are the fundus (proximal section), the body (mid section), and the antrum (distal section). triglycerides Fat molecules made up of three parts fatty acids and one part glycerol. Triglycerides (fats) are a subgroup of lipids. Another type of lipid is cholesterol. uvula Soft tissue hanging from the middle of the soft palate. From the Latin uva means bunch of grapes.

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villi (singular: microscopic projections on the wall of the small intestine that the villi absorb) nutrients into the bloodstream.

Portal vein

Note the relationship of the portal vein (also called the hepatic portal vein) between the intestines and the liver (Figure 5-13). This vein is not a true vein because it does not carry blood directly to the heart like other veins do. In liver disease, blood backs up into the portal vein, causing portal hypertension (high blood pressure) and esophageal varices. See page 155.

FIGURE 5-13 Portal vein and its relationship to the liver and small intestine.

Terminology

Write the meaning of the medical term in the space provided. Check the pronunciation of terms on pages 173–176 for any unfamiliar words.

Body parts

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FIGURE 5-14 Stages of appendicitis. A, Obstruction and bacterial infection cause a red, swollen, and inflamed appendix. B, Pus and bacteria invade the wall of the appendix. C, Pus perforates (ruptures) the wall of the appendix into the abdomen, causing peritonitis (inflammation of the peritoneum).

FIGURE 5-15 A. Location of stomata in the ileum and colon. B. Colostomy care.

FIGURE 5-16 Three types of anastomoses. These are examples of an enteroenterostomy. The suffix -stomy, when used with two or more forms combined (enter/o and enter/o), indicates the surgical creation of a new opening between these body parts.

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FIGURE 5-17 Mesentery. The omentum and mesocolon are parts of the mesentery. The omentum (elevated in this figure) actually hangs like an apron over the intestines. The mesentery contains blood and lymphatic vessels. Lymph nodes in the mesentery are important indicators in the spread of colon cancer (colon cancer staging).

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CORRESPONDING TERMINOLOGY OF MEANING FORM OF MEANING without anus perianal ____________________________________________ appendix/or appendix appendectomy __________________________________________ appendix/or appendicitis ____________________________________________ See Figure 5-14. Cheek/buccal mucosa ______________________________________ The mucosa is a mucous membrane that lines cavities or canals that open to the outside of the body. cec/o cecum cecum _____________________________________ celi/o uterus, celiac _____________________________________ abdomen Abdomin/o and lapar/o also mean abdomen. Celiac disease is damage to the lining of the small intestine, which occurs as a reaction to gluten consumption. cheil/o labial cheilosis _____________________________________ Labi/o also means lip. cholecystectomy/cholecystectomy of the gallbladder ________________________________________ Chol/e = gallbladder, bile. common bile duct choledochotomy _____________________________________ common bile duct colon / colostomy colon _______________________________________ The suffix -stomia, when used with a combined form for an organ, means an opening to the outside of the body. A stoma is an opening between an organ and the body surface (Figure 5-15A and B). colon/or colon colon __________________________________________ colonoscopy ________________________________________ dent/i dental tooth ________________________________________ Odont/o also means tooth. duodenum/the duodenal duodenum ______________________________________ enter/the intestine, enterocolitis ______________________________________ usually TIP: When two combined forms for small gastrointestinal organs are in one term, the one for the organ closest to the mouth intestine appears first. Enteroenterostomy __________________________________________ New opening between two parts of the small intestine that were not previously connected. This is an anastomosis, which is any surgical connection between two parts, such as vessels, ducts, or intestinal segments (ana = upward, stoma = opening, -sis = state of) (Figure 516). mesentery ___________________________________ Part of the double fold of the peritoneum that extends around the organs in the abdomen, the mesentery holds the organs in place. Literally, it is located in the middle (mes-) of the intestines, a membrane that connects the intestines to the muscular wall at the back of the abdomen (Figure 5-17). parenteral __________________________________ Par (from para-) means in addition to in this term. An IV line carries parenteral nutrition directly into the bloodstream, bypassing the intestinal tract (enteral nutrition). Parenteral injections can also be subcutaneous or intramuscular.

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MATCH MEANING TERMINOLOGY MEANING FORM esophagus/esophageal esophagus ________________________________________ HINT: Changing the suffix from -al to -eal softens the final g (eh-sof-ah-JE-al). faci/o facial face __________________________________________ gastro/o stomach gastrostomy __________________________________________ gingi/o gums gingivitis ________________________________________ shine/or hypoglossal tongue ________________________________________ Lingu/o also means tongue. hepatoma of the liver __________________________________________ Also called hepatocellular carcinoma. hepatomegaly __________________________________________ ile/or ileocecal sphincter ileus ______________________________________ Also called ileocecal valve. ileitis ______________________________________ ileostomy ______________________________________ See Figure 5-15A, page 146. jejunum/the jejunum choledochojejunostomy ________________________________________ An anastomosis. gastrojejunostomy ____________________________________ This is part of a gastric bypass procedure. See Figure 6-7B, page 187. labial labial ________________________________________ lapar/abdominal laparoscopy ________________________________________ A form of minimally invasive surgery (MIS). Some examples are laparoscopic cholecystectomy (Figure 5-28, page 160) and laparoscopic appendectomy. lingu/o tongue sublingual ______________________________________ mandible/lower jaw, submandibular _______________________________________ mandible odont/orthodontist tooth ________________________________________ Orth/o means straight. periodontist __________________________________ endodontist _____________________________________ Performs root canal therapy. or/or mouth oral ________________________________________ Stoma/o also means mouth. palatoplasty palatoplasty palatoplasty ________________________________________ Procedure to repair cleft palate and cleft lip; Cleft palate repair. pancreas/or pancreatitis pancreatitis ________________________________________ peritonitis/or peritoneum peritonitis ________________________________________ The stem e has been omitted in this term. pharyngeal/pharyngeal ____________________________________ palatopharyngoplasty __________________________________________ Used to treat cases of snoring or sleep apnea caused by obstructions in the throat or nose.

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COMBINATION MEANING TERMINOLOGY MEANING SHAPE proct/or anus and proctologist __________________________________ rectum pylorus/or pyloric pyloroplasty __________________________________________ sphincter rectum/or rectum rectocele ____________________________________________ sialaden/or salivary sialadenitis _____________________________________________ sigmoid gland/or sigmoid sigmoidoscopy ________________________________________ stomatitis colonic _________ stomatitis _________ orucal stomatitis uvulectomy __________________________________________

Substances COMBINATION MEANING TERMINOLOGY MEANING FORM Amyl/or starch amylase ________________________________________ The suffix -ase means enzyme. bile/ibilis, biliary bile ______________________________________ The biliary tract includes the organs (liver and gallbladder) and ducts (hepatic, cystic, and common bile ducts) that secrete, store, and empty bile into the duodenum. bilirubin/o bilirubin hyperbilirubinemia (bile _______________________________________ pigment) cholelithiasis of the gallbladder, biliary cholelithiasis ________________________________________ Lith/o means stone or calculus; -iasis means abnormal condition. hydrochloride/hydrochloric acid ________________________________________________ Absence of gastric juice is associated with gastric carcinoma. gluc/o sugar gluconeogenesis ______________________________________ Liver cells make a new sugar from fat and protein. glycogen/glycogen, animal glycogenolysis ______________________________________ starch Liver cells convert glycogen back to glucose when blood sugar levels drop. lip fat, lipid lipoma ____________________________________ lit/o calculus lithogenesis ________________________________________ protein/o protein protease _____________________________________________ py/o pus itch ________________________________________ Periodontitis; an advanced stage of periodontal disease (gingivitis). salivary saliva, sialolith ______________________________________ fat/salivary steatorrhea _______________________________________ Poorly digested (malabsorbed) fats will appear in the feces.

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Suffixes MEANING TERMINOLOGY MEANING -ase enzyme lipase _______________________________________ Enzymes speed up chemical reactions. Lipase helps in the digestion of fats. In all types of liver disease, liver enzyme levels may be elevated, indicating damage to liver cells. Signs and symptoms include malaise, anorexia, hepatomegaly, jaundice, and abdominal pain. -chezia defecation, hematochezia ____________________________________ elimination (he-mat-o-KE-ze-ah) Bright red blood is found in the stool. waste -iasis choledocholithiasis abnormal ____________________________________ postprandial condition of food __________________________________________ Post prandial cibum (p.c.), seen in written prescriptions, also means after meals.

cholecyst and cyst

Do not confuse cholecyst/o (gallbladder) with cyst/o, which is the urinary bladder.

ileon and ileon

Don't confuse the ileum, which is the third part of the small intestine, with the ilium, the largest, upper part of the pelvis (hip bone).

Chol/e y Col/o

Don't confuse col/e, which means gall or bile, with col/o, which means the colon! The context of the term will help you determine the correct spelling.

Piorrhea and Pyuria

Pyorrhea is the discharge (-rhea) of pus from the gums and pyuria is the presence of pus in the urine (a sign of urinary tract infection).

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Digestive System Pathology This section presents medical terms that describe signs and symptoms (clinical indications of disease) and pathological conditions of the gastrointestinal tract. The sentences that follow each definition describe the etiology (eti/o = cause) of the disease and the treatment. When the etiology (cause) is not understood, the condition is idiopathic (idio/o = unknown). You can find a list of prescription drugs to treat gastrointestinal signs, symptoms, and conditions in Chapter 21, Pharmacology.

signs and symptoms

A sign is an objective finding, such as an increase in body temperature, a rash, or a sound heard when listening to the chest, that indicates the presence of disease as perceived by an examiner. On the other hand, a symptom is a subjective sensation or change in health, such as itching, pain, fatigue, or nausea, that is experienced by the patient. Clearly, both the doctor and the patient can notice the same feature, making it both a sign and a symptom!

signs and symptoms

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FIGURE 5-18 A. Ascites, or abnormal intraperitoneal fluid, can be caused by conditions such as liver disease, peritonitis, and ovarian cancer. B. Ascites in a male patient. The photograph was taken after performing the paracentesis (puncture to remove fluid from the abdomen). Note the gynecomastia (female-type breast condition) in this patient due to excess estrogen, which can accompany cirrhosis, especially in individuals with alcoholism.

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FIGURE 5-19 Jaundice due to liver disease.

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anorexia

ascites

borborygmus (singular: borborygmus) constipation

Diarrhea

dysphagia

belching flatus hematochezia jaundice (jaundice)

Lack of appetite. Anorexia (-orexia = appetite) is usually a sign of malignancy or liver disease. Anorexia nervosa is loss of appetite associated with emotional problems such as anger, anxiety, and an irrational fear of gaining weight. It is an eating disorder and is discussed along with a similar eating disorder, bulimia nervosa, in Chapter 22. Abnormal fluid accumulation in the abdomen (Fig. 5.18A and B). This condition occurs when fluid leaves the bloodstream and accumulates in the peritoneal cavity. It could be a sign of neoplasia or inflammatory disorders in the abdomen, venous hypertension (high blood pressure) caused by liver disease (cirrhosis), or heart failure. Treatment of ascites includes administration of diuretic medications and paracentesis to remove abdominal fluid. Rumbling or gurgling noises produced by the movement of gas, liquid, or both in the gastrointestinal tract. Signs of hyperactive intestinal peristalsis, rumbling (intestinal noises) are often present in cases of gastroenteritis and diarrhea. Difficulty passing stool (stool). When peristalsis is slow, the stool is dry and hard. A diet rich in fruits, vegetables, and water is helpful. Laxatives and cathartics are medicines to promote the movement of stool. Chronic idiopathic constipation (CIC) is persistent constipation without an identifiable cause. Frequent passing of loose, watery stools. The sudden onset of diarrhea immediately after ingestion suggests an acute infection or toxin in the gastrointestinal tract. Untreated severe diarrhea can lead to dehydration. Antidiarrheal drugs are helpful. Difficulty to swallow. This sensation feels like a “lump in the throat” when a swallowed bolus does not progress, either due to a physical obstruction (obstructive dysphagia) or a motor disorder in which esophageal peristalsis is not coordinated (motor dysphagia). Gas expelled from the stomach through the mouth. Belching produces a characteristic sound and is also called belching (burping). Gas expelled through the anus. Flatulence is the presence of excess gases in the stomach and intestines. A sign of intestinal obstruction is the inability to pass gas. Fresh, bright red blood coming from the rectum. The cause of hematochezia is usually hemorrhoids, but it can also be colitis, ulcers, polyps, or cancer. Yellow-orange discoloration of the skin and whites of the eyes caused by high levels of bilirubin in the blood (hyperbilirubinemia). See Figure 5-19. Jaundice can occur when (1) excessive destruction of red blood cells, as in hemolysis, causes excess bilirubin in the blood; (2) malfunction of liver cells (hepatocytes) due to liver disease prevents the liver from excreting bilirubin with the bile; or (3) obstruction to bile flow, such as by choledocholithiasis or a tumor, prevents bilirubin from the bile from being excreted into the duodenum. Black, dark stools; stools containing digested blood. This clinical sign generally reflects a condition in which the blood has had time to be digested (propelled by intestinal juices) and results from

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nausea

steator

bleeding in the upper gastrointestinal tract (duodenal ulcer). A positive result on the guaiac stool test (see page 183) indicates blood in the stool. Unpleasant feeling in the stomach with a tendency to vomit. Common causes are motion sickness, early pregnancy, and viral gastroenteritis. Nausea and vomiting may be symptoms of perforation (hole in the wall) of an abdominal organ; blockage of a bile duct, stomach, or intestine; or exposure to poisons. Fat in the stool. Steatorrhea is the production of foul-smelling, frothy stool that often floats in the toilet. Poor digestion or absorption of fat causes the fat to remain in the intestine. This can occur with disease of the pancreas (pancreatitis) when pancreatic enzymes are not excreted. It is also a sign of intestinal disease involving fat malabsorption.

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Pathological Conditions Oral Cavity and Teeth

FIGURE 5-20 Normal teeth and gums and pathologic conditions. A, Normal teeth and gums. B. Aphthous stomatitis. C, Dental caries. D, Herpetic stomatitis. E, Oral leukoplakia. F. Gingivitis.

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caries aphthous stomatitis

herpetic stomatitis

periodontal disease oral leukoplakia

Inflammation of the mouth with small painful ulcers. The ulcers associated with this condition are commonly called canker sores (KANK-er); the cause is unknown (Figure 5-20B). tooth cavity. Dental plaque is the result of the accumulation of food, salivary proteins and necrotic debris in the dental enamel. Bacteria grow on plaque and cause acid to be produced that dissolves tooth enamel, resulting in a caries (area of decay) (Figure 5-20C). If the bacterial infection reaches the pulp of the tooth, root canal treatment may be necessary. Inflammation of the mouth caused by a herpes virus infection. Painful, fluid-filled blisters on the lips, palate, gums, and tongue, commonly called fever blisters or cold sores (Fig. 5-20D). It is caused by the herpes simplex virus type 1 (HSV1). Genital herpes (due to HSV2) involves the reproductive organs. Both conditions are highly contagious. Plaques or white spots on the lining of the mouth. This precancerous lesion (Fig. 5.20E) may be due to chronic tobacco use (pipe or chewing tobacco). The malignant potential is evaluated by microscopic study of the biopsy tissue. Inflammation and degeneration of the gums, teeth, and surrounding bone. Gingivitis (Figure 5-20F) occurs as a result of the accumulation of dental plaque and dental calculus or tartar (a brownish-yellow calcified deposit on teeth). In a gingivectomy, the periodontist uses a metal instrument to scrape plaque and tartar off the teeth. any pockets of pus (pyorrhea) are drained and removed to allow new tissue to form. Localized infections are treated with systemic antibiotics.

upper gastrointestinal tract

FIGURE 5-21 A. Esophageal varices. B, Endoscopic view of esophageal varices.

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FIGURE 5-22 Hernias. A, hiatal hernia. B. Inguinal hernias. A direct inguinal hernia occurs through the abdominal wall in an area of muscle weakness. An indirect inguinal hernia occurs through the inguinal canal (passage in the lower abdomen), where the herniated tissue/bowel descends into the scrotum.

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acalasia

esophagus cancer

esophageal varices

bowel cancer

gastroesophageal reflux disease (GERD)

hernia

peptic ulcer

Inability of the lower esophageal sphincter (LES) muscle to relax. Achalasia (-chalasia = relaxation) results from loss of peristalsis, so that food cannot easily pass through the esophagus. Both failure to relax the LES and loss of peristalsis cause dilation (widening) of the esophagus above the constriction. Doctors recommend a soft, low-volume diet and mechanical stretching of the LES to relieve symptoms. Malignant tumor of the esophagus. The most common symptom of esophageal cancer is difficulty swallowing (dysphagia). Smoking and chronic alcohol consumption are the main risk factors. Prolonged irritation of the esophagus caused by gastric reflux is a premalignant condition called Barre's esophagus. Surgery, radiation therapy, and chemotherapy are treatment options. Swollen varicose veins in the lower end of the esophagus (Figure 5-21). Liver disease (such as cirrhosis and chronic hepatitis) causes increased pressure in the veins near and around the liver (portal hypertension). This leads to dilated and tortuous esophageal veins with danger of haemorrhage (bleeding). Treatment may include bandaging (tying off inflamed esophageal veins) or sclerotherapy (injecting the veins with a solution that closes them). Drug therapy to reduce portal hypertension can be used to reduce the risk of variceal bleeding. Malignant tumor of the stomach. Smoking, alcohol consumption and chronic gastritis associated with bacterial infection are the main risk factors for gastric carcinoma. Gastric endoscopy and biopsy diagnose the condition. The cure depends on early detection and surgical removal. Solids and liquids return to the mouth from the stomach. Heartburn is a burning sensation caused by the regurgitation of hydrochloric acid from the stomach into the esophagus. Chronic exposure of the esophageal lining to gastric acid and pepsin (an enzyme that digests proteins) causes reflux esophagitis. Drug treatment for GERD includes antacid agents (acid suppressants) and medications to increase the tone of the LES. Protrusion of an organ or part through the tissues and muscles that normally contain it. A hiatal hernia occurs when the upper part of the stomach bulges up through the diaphragm (Figure 5-22A). This condition can lead to GERD. An inguinal hernia occurs when a small loop of intestine protrudes through weak tissue in the lower abdominal wall (fascia) that surrounds the muscles (Figure 5-22B). Surgical repair of inguinal hernias is known as herniorrhaphy (-raffia means suture). An open sore in the lining of the stomach or duodenum. A bacterium, Helicobacter pylori (H. pylori), is responsible for many cases of peptic ulcer. The combination of bacteria, hyperacidity, and gastric juices damages the epithelial linings. Drug treatment includes antibiotics, antacids, and agents to protect the lining of the stomach and intestines.

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Lower gastrointestinal tract (small and large intestine)

FIGURE 5-23 Anal fistula and colonic polyps. A. Anal fistula and two types of polyps. B, Multiple colonic polyps.

FIGURE 5-24 Adenocarcinoma of the colon. This tumor has "pooled" edges and an ulcerated central portion.

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FIGURE 5-25 A. Diverticula (causing diverticulosis) form when the mucous membrane lining the colon protrudes through the weakened muscular wall. B and C, Diverticulitis can occur when fecal matter lodges in the diverticula. Avoiding foods with seeds and nuts reduces the risk of this condition.

FIGURE 5-26 Intussusception and volvulus.

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anal fistula colonic polyps

colorectal cancer

Crohn's disease ("Crohn's")

funny

dysentery

hemorrhoids

inflammatory bowel disease (IBD) ileus intussusception

Abnormal tube-shaped passage near the anus. A fistula is usually the result of a tear or fissure in the wall of the anus or rectum, or of an abscess (infected area) there (Fig. 5.23A). Polyps (benign growths) protrude from the mucous membrane of the colon. Figure 5-23A illustrates two types of polyps: pedunculated (attached to the membrane by a rod) and sessile (located directly on the mucous membrane). Figure 5-23B shows various colonic polyps. Many polyps are premalignant (adenomatous polyps); these growths are usually removed (polypectomy) as a preventative measure and for further examination (biopsy). Adenocarcinoma of the colon or rectum, or both. Colorectal cancer (Fig. 5.24) can arise from polyps in the colon or rectal region. The diagnosis is determined by detecting blood in the stool and by colonoscopy. The prognosis depends on the stage (extent of spread) of the tumor, including the size, depth of invasion, and lymph node involvement. Surgical treatment may require excision of a large part of the colon with the cut ends joined together (anastomosis). Chemotherapy and radiation therapy are given as needed. Chronic inflammation of the intestinal tract. Crohn's disease can occur anywhere from the mouth to the anus, but most often in the ileum (ileitis) and colon. Signs and symptoms include diarrhea, severe abdominal pain, fever, anorexia, weakness, and weight loss. Both Crohn's disease and ulcerative colitis are forms of inflammatory bowel disease (IBD). Treatment is with drugs that control inflammation and other symptoms, or by surgical removal of the diseased parts of the intestine, with anastomosis of the remaining parts. Read the story In Person: Living with Crohn's on page 162. Abnormal lumps (diverticula) in the intestinal wall of the colon. See Figure 5-25A. Diverticulitis is a complication of diverticulosis. When fecal matter becomes trapped in the diverticula, diverticulitis can occur. Pain and rectal bleeding are symptoms. Figure 5-25B and C show diverticulitis in a section of the sigmoid colon. Initial treatment for an attack of diverticulitis includes a liquid diet and oral antibiotics. In severe cases, the patient may require hospitalization, intravenous antibiotics, and surgery to remove the affected area of the colon with anastomosis of the cut ends. Painful inflammation of the intestines commonly caused by a bacterial infection. Often occurring in the colon, dysentery is the result of ingesting food or water that contains bacteria (salmonella or shigella), amoebas (single-celled organisms), or viruses. Symptoms are bloody stools, abdominal pain, and sometimes fever. Swollen and twisted varicose veins in the rectal region. Varicose veins can be internal (inside the rectum) or external (outside the anal sphincter). Pregnancy and chronic constipation, which put pressure on the anal veins, often cause hemorrhoids. Loss of peristalsis with consequent obstruction of the intestines. Surgery, trauma, or bacterial injury to the peritoneum can cause paralytic ileus (acute, transient loss of peristalsis). Inflammation of the colon and small intestine. See Crohn's disease and ulcerative colitis. Telescopic intestines.

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irritable bowel syndrome (IBS)

ulcerative colitis

volvulus

In this condition, one segment of the intestine collapses into the opening of another segment (Fig. 5.26). It occurs frequently in children and in the ileocecal region. Intestinal obstruction with pain and vomiting may occur. A barium enema can successfully diagnose and reduce intussusception. Otherwise, surgery may be required to remove the affected segment of the intestine (followed by anastomosis). Gastrointestinal symptom group (abdominal pain, bloating, diarrhea, constipation) without structural abnormalities in the intestines. IBS can be associated with stress or occur after an infection. Treatment includes a diet high in bran and fiber and laxatives plus antidiarrheals to establish regular bowel movements. Other names for IBS are irritable bowel syndrome and spastic colon. IBS is a type of functional gastrointestinal disorder (FGID). They are disorders of the functioning of the gastrointestinal tract, but without structural or biochemical alterations. A low FODMAP (an acronym for carbohydrates that are poorly absorbed from the intestine) diet has been helpful in improving symptoms for many people with IBS. Chronic inflammation of the colon with the presence of ulcers. This chronic, recurrent, idiopathic diarrheal disease (an inflammatory bowel disease) presents with rectal bleeding and pain. Often starting in the colon, the inflammation spreads proximally and affects the entire colon. Drug treatment and careful attention to diet are recommended. Resection of diseased bowel with ileostomy may be necessary. In some cases, it is cured by total colectomy. Ulcerative colitis patients are at increased risk of developing colon cancer. Intestinal twisting on itself. Volvulus causes intestinal obstruction. Severe pain, nausea and vomiting, and absence of bowel sounds are clinical features. Surgical correction is required to prevent necrosis of the affected segment of the intestine (see Figure 5-26).

Irritable Bowel Syndrome (IBS) and Inflammatory Bowel Disease (IBD)

While IBS is a condition without structural abnormalities of the intestines, IBD (Crohn's disease and ulcerative colitis) involves structural abnormalities.

Liver, gallbladder and pancreas

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FIGURE 5-27 Positions of gallstones in the gallbladder and bile ducts. A, Gallstone causing mild or no symptoms. B, Calculus obstructing the cystic duct, causing pain. C, Calculus obstructing the common bile duct, causing pain and jaundice. D, Stone in the lower end of the common bile duct and pancreatic duct, causing pain, jaundice, and pancreatitis.

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FIGURE 5-28 A. Trocars placed for laparoscopic cholecystectomy. Trocars are used to pierce and enter the abdomen. These devices are metal sleeves made up of a hollow metal tube (cannula) into which an obturator (solid, removable metal instrument with a three-pronged point) fits and is used to perforate the wall. Circled numbers show common positions for trocar insertion: 1 is a 10/11mm umbilical trocar (largest trocar diameter is 15). 2 is a 10/11mm midline trocar. 3 and 4 are 5mm trocars placed in the right upper quadrant of the abdomen. B, gallstones. Mechanical manipulation during laparoscopic cholecystectomy caused fragmentation of several cholesterol gallstones, revealing interiors that are pigmented due to trapped bile pigments. As a result, the lining of the gallbladder becomes red and lumpy.

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FIGURE 5-29 A. Normal liver. B, Liver with alcoholic cirrhosis.

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cholelithiasis

cirrhosis

hepatocellular carcinoma (HCC)

pancreatic cancer

pancreatitis

hepatitis viral

Gallstones. Calculi (stones) prevent bile from leaving the gallbladder and bile ducts (Figure 5-27). Many patients remain asymptomatic and do not require treatment; Symptoms related to gallstones are biliary colic (pain caused by blocked ducts) or cholecystitis (inflammation and infection of the gallbladder), both of which require treatment. Currently, laparoscopic or minimally invasive surgery (laparoscopic cholecystectomy) can be performed to remove the gallbladder and stones (Fig. 5.28A and B). Chronic degenerative liver disease. Cirrhosis is commonly the result of chronic alcoholism, viral hepatitis, iron overload, or other causes. The lobules of the liver become scarred with fibrous tissue, the liver cells degenerate, and the liver becomes infiltrated with fat. Cirrh/o stands for yellow-orange, which describes the color of the liver caused by the accumulation of fat. Figure 5-29 shows a normal liver and a liver with alcoholic cirrhosis. Liver cancer. Cancer that begins in the liver is primary liver cancer (as opposed to secondary liver cancer, which begins in another organ and metastasizes to the liver). HCC is commonly associated with hepatitis B and C virus infections and cirrhosis due to chronic alcohol use. Non-alcoholic steatohepatitis (NASH) is an infiltration of the liver, which can progress to cirrhosis and HCC. Surgery, radiotherapy and chemotherapy are therapeutic options. Hepatocellular carcinomas produce alpha-fetoprotein (AFP), a tumor marker that is often elevated in the blood in patients with this type of cancer. AFP is used to screen for HCC in patients with cirrhosis. Liver cancers that start in the bile ducts are called cholangiocarcinomas. Bile duct cancers can also arise from the gallbladder. Malignant tumor of the pancreas. It often occurs in the head of the pancreas (closer to the duodenum), where it can block the ducts. Although the cause is unknown, pancreatic cancer is more common in smokers and people with diabetes and chronic pancreatitis. Signs and symptoms are abdominal or back pain, fatigue, jaundice, anorexia, diarrhea, and weight loss. The standard surgical treatment, if the tumor can be resected, is a pancreatoduodenectomy (Whipple procedure). Chemotherapy and radiation may also be used. Inflammation of the pancreas. Digestive enzymes attack pancreatic tissue and damage the gland. Other etiologic factors include chronic alcoholism, drug toxicity, common bile duct obstruction by gallstones, and viral infections. Treatment includes medications to relieve epigastric pain, intravenous fluid therapy, bowel rest, and subtotal pancreatectomy if necessary. Inflammation of the liver caused by a virus. Hepatitis A is a viral hepatitis caused by the hepatitis A virus (HAV). It is a disease transmitted by contaminated food or water and characterized by the slow onset of symptoms. Hepatitis B is caused by the hepatitis B virus (HBV) and is transmitted through sexual contact, blood transfusions, or the use of contaminated needles, or it can be acquired through maternal-foetal transmission. A severe infection can lead to destruction of liver cells, cirrhosis, or death. A vaccine that provides immunity is available and is recommended for people at risk of exposure. Hepatitis C is caused by the hepatitis C virus (HCV) and is transmitted through blood transfusions.

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or inoculation with needles (such as among intravenous drug users who share needles). Acute disease can progress to chronic hepatitis and hepatocellular carcinoma. Two drugs recently approved by the FDA for hepatitis C are Mavyret and Vosevi. In all types, liver enzyme levels may be elevated, indicating liver cell damage. Signs and symptoms include malaise, anorexia, hepatomegaly, jaundice, and abdominal pain.

What is "in" gallstones?

Gallstones are made up of cholesterol, bilirubin (bile pigment) and calcium salts. They can range in size and shape from as small as a grain of sand to as large as a golf ball!

Whipple procedure for pancreatic cancer

This surgery consists of:

• removal of the distal half of the stomach (antrectomy) • removal of the gallbladder and common bile duct (cholecystectomy and choledecectomy) • removal of part of the pancreas and duodenum (pancreatoduodenectomy) • reconstruction consists of pancreatojejunostomy, hepaticojejunostomy, and gastrojejunostomy Steve Jobs, co-founder of Apple Inc., and Luciano Pavaroi, an opera singer, performed this surgery.

Living personally with Crohn's disease

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When a friend told me she had the flu yesterday, I was jealous. For someone with a chronic illness like me, having something acute always feels luxurious. Lie in bed, read fancy magazines, take over-the-counter medications, get some sleep, and in a matter of days you'll be fine. I have Crohn's disease, a chronic inflammation of the small intestine characterized by flare-ups and remissions. During the crises I had fever, diarrhea, vomiting, pain and intestinal obstruction. Even in remission, I'm never "right." I am currently in remission two years after a third surgery to remove another part of my small intestine. This time internal bleeding, a rather rare symptom of Crohn's disease, required surgery. I was enduring weekly iron infusions, which turned into bi-monthly blood transfusions when my hemoglobin plummeted to 6 (12 is normal). It was not a way to live. After surgery, the bleeding stopped, but I had urgent episodes of watery diarrhea for a year. That was no way to live either, and unfortunately, as wonderful as my doctor is, I have found that few gastroenterologists want to address the side effects of small bowel surgery. After visiting several doctors and trial and error, I was finally able to control these symptoms with codeine, Lomotil, and Metamucil, but I will never be able to absorb vitamin B12, so I must inject myself monthly for the rest of my life. In addition to taking medication to treat the shrinkage of my small intestine, I take medication in hopes of preventing the next flare-up. Every few weeks, I inject myself with a biologic drug, Humira, but eventually have to stop because it has potential long-term side effects, the scariest of which is lymphoma. However, at 52 years old and with two school-age children, I learned to think about valuing my present quality of life to the maximum, to the detriment of possible unknown dangers that lurk in the future. I often think about the past. What would my life be like if our GP hadn't told my parents that my constant bouts of diarrhea, which I had since I was a child, were caused by "nerves"? By the time I was 21, my weight had dropped to less than 100 pounds and I was writhing in pain after every meal. My father arranged for me to see his own doctor, who gave me a set of small intestines that

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showed that I had Crohn's disease and that a part of my small intestine was "tight as a pencil". By then, it was too late for even prednisone (at the time the drug of choice despite side effects ranging from facial swelling to psychosis) to open up the swollen duct, and I had my first surgery just a few seconds. months after I was diagnosed. Thinking about those moments, as well as any other moment of crisis, makes me shudder. Although you may never relive the pain, you can remember what it was like. In my case, it felt like a large metal bicycle chain was being forced through my sensitive stomach. Before that first surgery, I was fresh out of college and wanted to make my mark on the world, but I spent most nights curled up in my small bedroom, listening to the soft tunes of "Make Believe Ballroom Hour" on the radio. . Or, since vomiting and diarrhea often accompanied the pain, I would lie with my back pressed against the cold bathroom floor. Later, as a mother of two young children, I would lie on the couch watching life revolve around me, feeling guilty that I couldn't participate. There was a silver lining to these outbreaks, and that is the warmth of the people around me: husband, family, and friends. When you have Crohn's disease, no one knows you have it until things get unbearable. It's not the kind of disease you're talking about, but when you have pain and fever, it can bring you closer to those moments when you've been attacked by the flu. However, he knows that it will take more than a shot of Nyquil or a night's sleep for "beer". You know you'll either be faced with another, often unprecedented, course of medication, or you'll probably end up in the hospital for yet another surgery. Nancy J. Brandwein is a writer, editor, and food columnist.

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Exercises Remember to carefully check your answers against the Answers to Exercises, pages 171–172.

A Match the following structures of the digestive system with their meanings below. anus cecum colon duodenum esophagus gallbladder ileum jejunum liver pancreas pharynx sigmoid colon 1. consists of ascending, transverse, descending, and sigmoid sections __________________________ 2. small sac under liver; stores bile _________________ 3. first part of the large intestine _________________ 4. end of the digestive tube that opens to the outside of the body _________________ 5. second part of the small intestine _________________ 6. tube that links the throat to the stomach _________________ 7. third part of small intestine _________________

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p 8. great organ in the ruq; secretes bile, stores sugar, makes blood proteins _________________ 9. throat _________________ 10. lower colon _________________ 11. first part of small intestine _________________ 12. organ below stomach; produces insulin and digestive enzymes _________________ B Give the following flowchart of the pathway of food through the gastrointestinal tract. The required terms are listed below: anus ascending colon cecum descending colon duodenum esophagus gallbladder ileum jejunum liver pancreas pharynx rectum salivary glands sigmoid colon stomach transverse colon

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C Circle the term in bold that fits the given definition. You should be able to define the other terms too! 1. Microscopic projections on the walls of the small intestine:

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papillae rough villi 2. salivary gland near ear: parotid submandibular sublingual 3. ring of muscle at end of stomach: pyloric sphincter uvula lower esophageal sphincter 4. soft inside of tooth: dentin pulp and enamel 5. chemical that accelerates improves reactions and helps digest food: amino acid triglyceride enzyme 6. pigment released with bile: glycogen bilirubin melena 7. hormone produced by endocrine cells of the pancreas: insulin amylase lipase 8. rhythmic contraction of muscles in the walls of the gastrointestinal tract : swallowing, mastication, peristalsis 9. breakdown of large fat globules: absorption, emulsification, anabolism 10. sharp, dog-like tooth medial to premolars: incisor, canine, molar D Complete the following. 1. Labi/o and cheil/o mean ________________________________________________ _________________ 2. Gloss/o and lingu/o mean _________________

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3. Or/o and stomat/o mean _________________ 4. Dent/i and odont/o mean _________________ 5. Lapar/o and celi/o mean _________________ 6. Gluc/o and glyc/o mean _________________ 7. Lip/o, steat/o and adip /o mean _________________ 8. The suffixes -iasis and -osis mean _________________ 9. Chol/e and bil/i mean _________________ 10. Resection and -ectomy mean _________________ E Create medical terms based on the definitions given. 1. removal of a salivary gland _____________________________________________ ______________ 2. pertaining to the throat _________________ 3. herniation of the rectum _________________ 4. enlarged liver _________________ 5. surgical repair of the roof of the mouth _________________ 6. after meals _________________ 7. visual examination of the rectum and anal _________________ 8. study of the cause (of the disease) _________________ 9. incision of the common bile duct _________________ 10. pertaining to the teeth and cheek _________________ 11. state of the disease of the small intestine _________________ 12. new opening between the common bile duct and the jejunum _________________

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13. Related to the anus _________________ 14. New opening of the colon outside the body _________________ 15. Under the jaw _________________ 16. Related to the face _________________ F Match the following doctors or dentists with their specialties. colorectal surgeon endodontist gastroenterologist nephrologist oral surgeon orthodontist periodontist proctologist urologist 1. treats disorders of the anus and rectum __________________________ 2. operates on the urinary tract organs _________________ 3. straightens teeth _________________ 4. performs root canal therapy _________________ 5. operates on the mouth and teeth _________________ 6. treats kidney disorders _________________ 7. diagnoses and treats gastrointestinal disorders _________________

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8. treats the disease of the encías _________________ 9. operates in the intestinal tract _________________ G Create medical terms to describe the following inflammations. 1. inflammation of the appendix _________________ 2. inflammation of the large intestine _________________ 3. inflammation of the passage from the throat to the stomach _________________ 4. inflammation of the membrane surrounding the abdomen _________________ 5. inflammation of the gallbladder _________________ 6. inflammation of the gallbladder third part of the intestine small _________________ 7. inflammation of the pancreas _________________ 8. inflammation of the gums _________________ 9. inflammation of the liver _________________ 10. inflammation of the mouth _________________ 11. inflammation of the salivary gland _________________ 12. inflammation of the small and large intestines _________________ H Match the listed terms with their meanings Next. biliary anastomosis defecation cheilitis

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gluconeogenesis glycogenolysis hyperbilirubinemia hyperglycemia mesentery parenteral mucosa portal vein 1. high blood sugar ______________________________ 2. swelling of the lips _________________ 3. related to the administration of medications and fluids other than by mouth _________________ 4. mucous membrane _________________ 5. passage of feces from the mouth into the body through the anus _________________ 6. breakdown (conversion) of starch to sugar _________________ 7. fan-shaped membrane that connects the small intestine to the abdominal wall _________________ 8. large vessel that carries blood from the intestine to the liver _________________ 9. new surgery connecting structures or organs _________________ 10. pertaining to the bile ducts _________________ 11. process of forming new sugar from protein and fat _________________ 12. elevated levels of a bile pigment in the stream blood ____ _____________

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Name the following gastrointestinal signs or symptoms based on their descriptions. 1. passage of bright red blood through rectum ___________________________________ 2. lack of appetite _________________ 3. fat in stools _________________ 4. dark, very dark stools; stools containing digested blood _________________ 5. abnormal accumulation of fluid in the abdomen _________________ 6. rumbling sounds produced by gas in the gastrointestinal tract _________________ 7. gas expelled from the anus _________________ 8. unpleasant feeling in the stomach and tendency to vomit _________________ 9 loose , liquid stools _________________ 10 Difficulty passing stools _________________ 11. Difficulty swallowing _________________ 12. Gases expelled from the stomach through the mouth _________________ J Write short answers to the following questions. 1. What is jaundice? _____________________________________________ _____________________ 2. List three ways a patient can have jaundice: a. _________________________________________ ____

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_________________________________________ ____

____________________________________ ____ 3. What does it mean when a disease is described as idiopathic? ________________________________ K Select from the list of pathological conditions to make a diagnosis. achalasia anal fistula aphthous stomatitis colonic polyps colorectal cancer crohn's disease caries esophageal cancer herpetic stomatitis oral leukoplakia pancreatic cancer periodontal disease 1. Mr. Jones, a smoker and alcoholic, has complained of dysphagia in recent months. A longstanding condition of Barre's esophagus has resulted in his malignant condition. Diagnosis: _______________________________. 2. An abnormal tube-like passage near his anus caused Mr. Rosen. your doctor

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performed surgery to close the abnormality. Diagnosis: _______________________________. 3. Carol's dentist informed her that the enamel on three of her teeth was damaged by acid-producing bacteria. Diagnosis: _______________________________. 4. Paola's symptoms of chronic diarrhea, abdominal cramps, and fever led her physician to suspect that she had an inflammatory bowel disease affecting the distal portion of her ileum. The doctor prescribed steroid medication to cure her condition. Diagnosis: _______________________________. 5. Mr. Hart learned that his colonoscopy showed the presence of small benign growths protruding from the mucous membrane of his large intestine. Diagnosis: ____________________________. 6. During a routine dental exam, Dr. Friedman discovered white plaques on Mr. Largo's body. He advised Mr. Longo, who was a chronic smoker and alcoholic, to remove these precancerous lesions. Diagnosis: _______________________________. 7. Whenever Carl had a stressful period at work, he would develop a fever blister (sore) on his lip, the result of a reactivation of a previous viral infection. His doctor told him that there was no 100% effective treatment to prevent the reappearance of these lesions. Diagnosis: _______________________________. 8. Mr. Green took a biopsy of a neoplastic lesion in his descending colon. The pathology report indicated

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a malignancy required partial colectomy. Diagnosis: _______________________________. 9. Small ulcers (thrush) appeared on Diane's gums. They were painful and irritating. Diagnosis: _______________________________. 10. Sharon's failure to floss and remove dental plaque regularly led to the development of gingivitis and pyorrhea. Her dentist advised her to see a specialist who could treat her condition. Diagnosis: _______________________________. 11. The images revealed a tumor in a section of Mr. Herrero's pancreas. His doctor told him that since it hadn't spread, he could hope to cure it with surgery. He underwent a pancreatoduodenectomy (Whipple procedure), which was successful. Diagnosis: _______________________________. 12. Mr. Clark complained of pain when swallowing. His doctor explained that the pain was due to the muscles in the lower part of the esophagus not relaxing during swallowing. Diagnosis: _______________________________. L Match the following pathological diagnoses with their definitions. cholecystolithiasis (gallstones) cirrhosis diverticulosis dysentery esophageal varices hemorrhoids

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hiatal hernia ileus intussusception irritable bowel syndrome pancreatitis peptic ulcer ulcerative colitis viral hepatitis volvulus 1. protrusion of the upper part of the stomach through the diaphragm ___________________________ 2. painful and inflamed intestine caused by a bacterial infection _________________ 3. swollen and twisted veins in rectal area _________________ 4 open sore or lesion on the mucous membrane of the stomach or duodenum _________________ 5. loss of peristalsis _________________ 6. twisting of the intestine _________________ 7. inflamed varicose veins on the surface of the distal esophagus _________________ 8 abnormal bulges in the intestinal wall _________________ 9. chronic inflammation of the colon with destruction of its internal surface _________________ 10. dilation of the intestines _________________

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11. inflammation of the liver caused by type A, type B, or type C virus _________________ 12. inflammation of the pancreas _________________ 13. stones in the sac that stores bile _________________ 14. chronic degenerative liver disease with scarring resulting from alcoholism or infectious hepatitis _________________ 15. gastrointestinal symptoms (diarrhea or constipation, abdominal pain, bloating) without evidence of structural abnormalities _________________ M Complete the following terms with the meanings given below. 1. membrane (peritoneal fold) that holds the intestines together: month _____________________________ 2. removal of the gallbladder: ______________________________ ectomy 3. black or dark brown stools that contain blood: honey ________________________ 4. high levels of blood pigment ( jaundice): hyper ________________________ 5 .pertaining to under the tongue: sub ___________________ 6. twisting of the intestine on itself: vol _________________________ 7. organ below the stomach that produces insulin and digestive enzymes: bread __________________ 8. lack of appetite: a _________________________

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9. swollen and twisted veins in the rectal region: _______________________ oids 10. new connection between two previously disconnected tubes: ana _____________________________ 11. absence of stomach acid: a ____________________ 12. return of solids and liquids from the stomach to the mouth: gastro re _________________________ disease 13. removal of soft tissue hanging from the roof of the mouth: _____________________________ectomy 14. stone formation: _______________________ genesis.

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Answers to Exercises A 1. colon 2. gallbladder 3. cecum 4. anus 5. jejunum 6. esophagus 7. ileum 8. liver 9. pharynx 10. sigmoid colon 11. duodenum 12. pancreas B See Figure 5-12 on page 141 .

C 1. Villi. The papillae are nipple-like projections on the tongue where the taste buds are located, and the rugae are folds in the mucous membrane of the stomach and hard palate. 2. Parotid. The submandibular gland is under the lower jaw, and the sublingual gland is under the tongue.

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3. Pyloric sphincter. The uvula is a soft tissue that hangs from the soft palate, and the lower esophageal sphincter is a ring of muscle between the esophagus and the stomach. 4. Pulp. The dentin is the hard part of the tooth directly below the enamel and at the root, and the enamel is the hard outer part of the tooth that forms the crown. 5. Enzyme. A triglyceride is a large fat molecule, and an amino acid is a substance produced when protein is digested. 6. Bilirubin. Glycogen is animal starch produced in liver cells from sugar, and melena is dark, dark feces. 7. Insulin. Amylase and lipase are digestive enzymes produced by the exocrine cells of the pancreas. 8. Peristalsis. Swallowing is swallowing and chewing is chewing. 9. Emulsification. Absorption is the passage of materials through the walls of the small intestine into the bloodstream, and anabolism is the process of building proteins in a cell (protein synthesis). 10. Canine. An incisor is one of the four front teeth in the dental arch (not sharp or dog-tooth-like), and a molar is any of the three large teeth just behind (distal) the two premolars. D 1. lip

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2. tongue 3. mouth 4. tooth 5. abdomen 6. sugar 7. fat 8. abnormal condition 9. gallbladder, bile 10. excision, excision E 1. sialadenectomy 2. pharyngeal 3. rectocele 4. hepatomegaly 5. palatoplasty 6 postprandial (post-cibum—cib/o refers to meals or feeding) 7. proctoscopy 8. etiology 9. choledochotomy 10. dentifrice 11. enteropathy 12. choledochojejunostomy

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13. perianal 14. colostomy 15. submandibular 16. facial F 1. proctologist 2. urologist 3. orthodontist 4. endodontist 5. oral surgeon 6. nephrologist 7. gastroenterologist 8. periodontist 9. colorectal surgeon G 1. appendicitis 2. colitis 3 . esophagitis 4. peritonitis (note e omitted) 5. cholecystitis 6. ileitis 7. pancreatitis 8. gingivitis

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9. Hepatitis 10. Stomatitis 11. Sialadenitis 12. Enterocolitis (when two combined forms for gastrointestinal organs are in one term, use the one closest to the mouth first) H 1. Hyperglycemia 2. Cheilitis 3. Parenteral 4. Mucosa 5 Defecation 6 .glycogenolysis 7. mesentery 8. portal vein 9. anastomosis 10. biliary 11. gluconeogenesis 12. hyperbilirubinemia I 1. hematochezia 2. anorexia 3. steatorrhea

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4. melena 5. ascites 6. rumbling (bowel noises) 7. flatulence 8. nausea 9. diarrhea 10. constipation 11. dysphagia 12. belching J 1. yellow-orange discoloration of skin and other tissues (hyperbilirubinemia) 2. a . any disease of the liver (disease of the liver, such as cirrhosis, hepatoma, or hepatitis) in which bilirubin is not broken down into bile and cannot be excreted in the feces b. obstruction of the flow of bile, so that bile and bilirubin are not excreted and accumulate in the bloodstream c. excessive hemolysis leading to excessive bilirubin production and elevated levels in the bloodstream 3. unknown cause K 1. esophageal cancer 2. anal fistula 3. dental caries

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4. Crohn's disease (Crohn's disease) 5. Colonic polyps 6. Oral leukoplakia 7. Herpetic stomatitis 8. Colorectal cancer 9. Aphthous stomatitis 10. Periodontal disease 11. Pancreatic cancer 12. Achalasia L 1. Hiatal hernia 2. Dysentery 3. Hemorrhoids 4 . peptic ulcer 5. ileus 6. volvulus 7. esophageal varices 8. diverticulosis 9. ulcerative colitis 10. intussusception 11. viral hepatitis 12. pancreatitis 13. cholelithiasis (gallstones)

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14. cirrhosis 15. irritable bowel syndrome M 1. mesentery 2. cholecystectomy 3. melena 4. hyperbilirubinemia 5. sublingual 6. volvulus 7. pancreas 8. anorexia 9. hemorrhoids 10. anastomosis 11. achlorhydria 12. gastroesophageal reflux disease 13. uvulectomy 14 Lithogenesis Pronunciation of terms

The terms you learned in this chapter are presented here with their pronunciations. The meanings of all the terms are found in the mini-dictionary starting on page 897. You can also listen to the pronunciation of each term on the Evolve website (h p://evolve.elsevier.com/Chabner/language/).

Vocabulary and Terminology

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TERM absorption achlorhydria amino acids amylase anastomosis anus appendicitis biliary appendix bilirubin intestine buccal mucosa canine teeth cecum cecum celiac cheilosis choledochojejunostomy choledocholithiasis choledocholithiasis cholelithiasis colonoscopy colostomy common bile duct defecation swallowing dentin enteroenamel duodenal removal entero-entero-colitis entero-entero-enamel entero-entire entero-colitis entero- entero- entero-enamel removing enzymes duodenum-emulsion facial esophagus folic acid feces gallbladder gastrointestinal tract gastrojejunostomy gastrostomy

PRONUNCIATION ab-SORP-shun a-chlor-HI-dre-ah ah-ME-no AS-idz AM-ih-layz ah-nas-to-MO-sis A-nus ah-pen-DEK-to-me ah -pen-dih-SI-tis ah-PEN-diks bile BIH-le-er-e bih-le-RU-bin BOW-el BUK-al mu-KO-sah KA-nove dentes SE-kal SE-kum SE -le-ak ki-LO-sis ko-le-sis-TEK-to-me ko-leh-do-ko-jeh-ju-NOS-to-me ko-leh-do-ko-lih-THI-ah -sis ko-leh-do-KOT-o-me ko-le-lih-THI-ah-sis KO-lon ko-LON-ik ko-lon-OS-ko-pe ko-LOS-to-me KOM- sin conductor deh-feh-KA-shun de-glu-TIH-shun den-tih-BUK-al DEN-tin di-JEST-shun du-o-DE-nal do-o-DE-num e-lim- ih-NA-shun e-mul-sih-fih-KA-shun e-NAM-el en-do-DON-tist en-ter-o-ko-LI-tis en-ter-o-en-ter-OS -para-me EN-zime eh-sof-ah-JE-al eh-SOF-ah-gus FA-shul FAH-te AS-idz FE-seez GAWL-blah-der gas-through-in-TES-that- gas make deal nal-through jeh-ju-US-for-mim gas-THROUGH-mim

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TÉRMINO gingivitis gluconeogénesis glucosa glucógeno glucogenólisis hepatoma hepatomegalia ácido clorhídrico hiperbilirrubinemia hiperglucemia hipogloso ileítis esfínter ileocecal ileostomía íleon incisivo insulina yeyuno laparoscopia labial lipasa litogénesis hígado esfínter esofágico inferior masticación melena mesenterio dientes molares oral ortodoncista paladar palatofaringoplastia palatoplastia páncreas pancreatitis papilas peringeal parenteral glándula parotiditis peringeal faringe veia porta pre-molar teeth post-prandial proctologist protease pulp pyloric sphincter pyloroplasty

PRONUNCIATION jin-jih-VI-tis glu-ko-ne-o-JEN-eh-sis GLU-kohs GLI-ko-jen gli-ko-je-NOL-ih-sis hep-ah-TO-mah hep-ah -to-MEG-ah-le hi-dro-CHLOR-ik AS-id hi-per-bih-le-ru-bih-NE-me-ah hi-per-gli-SE-me-hi-po- GLOS -al il-e-I-tis il-e-o-SE-kal SFINK-ter il-e-OS-to-me IL-e-um in-SI-zor IN-su-lin je-JU-num LA-be - al lap-ah-ROS-ko-pe LI-payz lith-o-JEN-eh-sis LIV-er LO-er eh-sof-ah-JE-al SFINK-ter mas-tih-KA-shun MEL-en -ah MES-en-ter-e MO-lar dientes OR-al or-tho-DON-tist PAH-lat pah-lat-o-fah-RIN-go-plas-te pah-LAT-o-plas-te PAN-kre-as pan-kre-ah-TI-tis pap-IL-e par-EN-ter-al par-OT-id glândula peh-re-A-nal peh-re-o-DON-tist peh - rih-STAL-sis peh-rih-to-NI-tis fah-ran-JE-al FAH-rinks POR-tal videira pos-PRAN-de-al pré-MO-lar teeth proc-TOL-o-jist PRO - tea-eyes pulp pi-LOR-ic SPHIN-ter pi-LOR-o-plas-te

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TERM pylorus rectocele rectum wrinkles saliva salivary glands sialadenitis sialolith sigmoid colon sigmoidoscopy sphincter steatorrhea stomach sublingual stomatitis submandibular triglycerides uvula uvulectomy villi

PRONUNCIATION pi-LOR-us REK-to-seel REK-tum RU-guy sah-LI-vah SAH-lih-vah-re gland si-al-ah-deh-NI-tis si-AL-o-lith SIG- . moyd KO-lon sig-moyd-OS-ko-pe SFINK-ter ste-at-o-RE-ah STUM-ak sto-mah-TI-tis sub-LING-wal sub-man-DIH-bu-lar tri -GLIS-eh-ridez U-vu-lah u-vu-LEK-to-me VIL-i

pathological terminology

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TÉRMINO acalasia fístula anal anorexia estomatitis aftosa ascitis borborígmica colelitiasis cirrosis pólipos colónicos cáncer colorrectal estreñimiento enfermedad de Crohn caries dental diarrea diverticulosis disentería disfagia eructos cáncer de esófago várices esofágicas etiología flatulencia cáncer gástrico reflujo gastroesofágico hematoquecia hemorroides carcinoma hepatocelular estomatitis herpética hernia hiatal hernia idiomática intestinal intususcepción síndrome irritable bowel jaundice lipoma melena oral nausea leukoplakia pancreatic cancer pancreatitis peptic ulcer periodontal disease pyorrhea ulcerative colitis viral hepatitis volvulus

PRONUNCIATION ak-ah-LA-jah A-nal FIS-tu-la an-ou-EK-se-ah AF-assim sto-mah-TI-tis ah-SI-teez bor-bor-IG-me ko-le -lih-THI-ah-sis sih-RO-sis co-LON-ik POL-ips co-lo-REK-tal CAN-see con-stih-PA-shun KROHN dih-ZEEZ DEN-tal KAH-reez di- ah-RE-ah di-ver-TIH-ku-lah di-ver-tih-ku-LO-sis DIS-en-ter-e dis-PHA-je-ah e-ruk-TA-shun eh-sof- ah-JE-al CAN-ver eh-sof-ah-JE-al VAR-ih-seez e-te-OL-o-je FLA-tus GAS-truco CAN-ver through-eh-sof the gas - JE-al RE-flux dih-ZEEZ he-mah-to-KE-se-ah HEH-mah-roydz hep-at-o-SEL-u-lar kar-sih-NO-mah her-PET-ik sto - mah-TI-tis hi-A-tal HER-ne-ah IK-ter-us id-e-o-PATH-ik IL-e-us in-FLAM-ah-tor-e BOW-el dih-ZEEZ IN- gwih -nal HER-ne-ah-in-sow-SEP-shun IR-it-ah-bel BOW-el SIN-drohm JAWN-dis li-PO-mah MEL-en-ah NAW-ze-ah OR-al head -ko-PLA-ke-ah pan-kre-AH-tik CAN-ser pan-kre-ah-TI-tis PEP-tic UL-ser peh-re-o-DON-tal dih-ZEEZ pi-or- RE -ah UL-ser-ah-tiv ko-LI-tis VI-ral hep-ah-TI-tis VOL-vu-lus

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Note: A combined review sheet for this chapter and the next is provided in Chapter 6 on page 201.

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CHAPTER 6

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Additional Suffixes and Digestive System Terminology CHAPTER SECTIONS: Introduction 178 Suffixes 178 Terminology 181 Laboratory Tests and Clinical Procedures 183 Abbreviations 190 Face to Face: Cholecystectomy 191 Practical Applications 192 Exercises 192 Answers to Exercises 198 Pronunciation of Terms 199 Review Sheet 201

CHAPTER OBJECTIVES • Define new suffixes and use them to form terms related to the digestive system. • List and explain laboratory tests, clinical procedures, and abbreviations relevant to the digestive system. • Apply their new knowledge to understand medical terms in their proper context, such as in medical reports and records, and in personal vignettes.

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Introduction This chapter provides practice in building words, although it does not introduce a large number of new terms. You use a lot of familiar terms from Chapter 5, which should give you pause after your hard work. Study the suffixes below and fill in the meanings of the terms. Checking the meanings of terms with a dictionary can be helpful and add another dimension to your understanding. The information included in Laboratory Tests and Clinical Procedures and in the Abbreviations section refers to the gastrointestinal system and will be useful for working on clinical or laboratory cases. The Practical Applications section provides examples of medical language in context. Congratulate yourself as you unscramble medical rulings, operational reports, and case studies.

suffixes

Write the meaning of the medical term in the space provided.

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MEANING OF SUFFIX -ectasia, dilation -ectasia (dilation), dilation -emesis vomiting

TERMINOLOGY MEANING cholangiectasia _________________________________ Cholangi/o means bile duct (vessel). Obstruction of the bile duct can cause cholangiectasia (ko-lan-je-EK-tah-sis). hematemesis __________________________________ Bright red blood is vomited, often associated with esophageal varices or peptic ulcer. -pepsia digestion dyspepsia __________________________________ -food phagia, polyphagia __________________________________ swallowing Excessive appetite and uncontrolled eating. dysphagia ____________________________________ -plasty surgical correction abdominoplasty _________________________________ This is commonly known as a “tummy tuck”. Other surgical repairs are rhinoplasty and blepharoplasty. -ptise spi ing hemoptysis _________________________________ (he-MOP-tih-sis) Effusion of blood from the respiratory tract and lungs. -ragia, burst of bleeding _____________________________________ -ragia (of blood) Loss of a large amount of blood in a short period. gastrorrhagia ____________________________________ suture herniorrhaphy ______________________________________ rrraphy (her-ne-OR-ah-fe) Repair (as in stitches or sutures) of a hernia. Hernioplasty is synonymous. -rhea flux, diarrhea _________________________________ flux The embedded root rrh means flux or flux. -spasm involuntary pylorospasm ______________________________________ contraction of bronchospasm ______________________________________ muscles A main feature of bronchitis and asthma. - arrest of stasis, cholestasis _________________________________ control The flow of bile from the liver to the duodenum is stopped. stenosis, pyloric stenosis _____________________________________ stenosis stenosis This is a birth defect in newborns that blocks the flow of food into the small intestine. -tresia Atresia of the opening ____________________________________ Absence of a normal opening. Esophageal atresia ____________________________________ A congenital abnormality in which the esophagus does not connect to the stomach. A tracheoesophageal fistula often accompanies this abnormality (Fig. 6.1). Biliary atresia ________________________________________ Congenital hypoplasia or failure of formation of the bile ducts causes cholestasis and neonatal jaundice.

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FIGURE 6-1 Esophageal atresia with tracheoesophageal fistula.

-ectasia, -ectasia

These suffixes are commonly used in respiratory system terminology in Chapter 12. Examples are bronchiectasis and atelectasis (a- = no, tel = complete), which is a collapsed lung.

Dysphagia/Dysplasia/Dysphasia

Do not confuse dysphagia, which is difficulty swallowing, with dysplasia, which is abnormal formation (plas/o = formation), or dysphasia, which is abnormal speech (fas/o = speech).

Hemoptysis and Hematemesis

Hemoptysis is the splashing of blood from the respiratory tract, a sign of bleeding and disease within the bronchi and lungs. Hematemesis is the vomiting of blood, a sign of bleeding from the upper gastrointestinal tract.

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- rréia

The suffix -rrhea is used to indicate the flow or discharge of various substances: • rhinorrhea - mucus from the nose • menorrhea - menstrual blood (men/o) from the uterine lining • leucorrhea - yellowish-white fluid from the vagina

Stenosis

Stenosis comes from the Greek and means "narrowing". It is sometimes called a stricture. Although this term is used in the gastrointestinal system to describe strictures, such as intestinal obstruction, biliary tract strictures, and pyloric stenosis, other types of strictures also exist. These include: • arterial stenosis • heart valve stenosis • spinal stenosis • tracheal stenosis Examples of suffixes used alone as separate terms are: emesis An emesis container is a kidney-shaped container placed next to a hospital bed for collecting (emetic) vomiting. If a child swallows poison, the doctor may prescribe a drug to induce emesis. An emetic is a strong solution, such as syrup of ipecac, given to induce vomiting after the patient has swallowed poison. spasm Eating spicy foods can cause spasms of the gastric sphincters. Stasis Overgrowth of bacteria in the small intestine can cause stasis of the intestinal contents. stenosis Vomiting in an infant during feeding is a clinical sign of pyloric stenosis.

Terminology

Write the meaning of the terms in the spaces provided.

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AGREEMENT MEANING TERMINOLOGY MEANING SHAPE buccal/or _____________ buccal ________________________________________ cec/o ______________ cecal volvulus ________________________________________ celi/o ______________ celiac disease ____________________________________________ Damage to the lining of the small intestine that occurs as a reaction to eating gluten (a protein found in wheat, the barley and rye). Result of malabsorption and malnutrition. Treatment consists of a lifelong gluten-free diet. It is also called celiac disease. cheil/o ______________ cheilosis ____________________________________ Characterized by scaling and cracking of the lips and as a result of a deficiency of vitamin B2 (thiamine) in the diet. col/e _____________ cholelithiasis ________________________________________ cholangi/o _____________ cholangitis ________________________________________ In this term, an i is removed. The most common cause of this condition is bacterial infection. cholangiocarcinoma ________________________________________ cholecysto _____________ cholecystectomy ______________________________________ choledochus _____________ choledochus ________________________________________ choledochetasis ________________________________________ col/o _____________ colectomy ____________________________________________ Surgeons perform a LAP (laparoscopic) colectomy as an alternative to open colectomy to remove non-metastatic colorectal carcinomas. colon ______________ colonoscopy ________________________________________ dent/i ______________ dental pain _______________________________________ duodenum/or _____________ duodenal ________________________________________ inlet/or ______________ gastroenteritis ________________________________________ esophagus/or ______________ esophageal atresia _____________________________________________ This congenital anomaly must be corrected surgically. gastrostomy ______________ gastrojejunostomy _______________________________________ gastrostomy _______________________________________ A gastrostomy is also called a gastric tube or “button”. One type is a PEG (percutaneous endoscopic gastrostomy) tube, which is inserted (laparoscopically) through the abdomen into the stomach to deliver food and fluids when swallowing is impossible. gingivectomy ______________ gingivectomy ________________________________________

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MATCH MEANING TERMINOLOGY MEANING SHAPE gloss/o _____________ glossectomy ________________________________________ gluc/o _____________ gluconeogenesis ________________________________________ glycogen ______________ Glycogen ____________________________________________ A form of sugar stored in the liver. hepat/o _____________ hepatomegaly ________________________________________ hernia/o ______________ herniorrhaphy ______________________________________ ile/o _____________ ileostomy ________________________________________ jejunum/o _____________ cholecystojejunostomy ____________________________________________ lip/o ______________ labiodental _____________________________________________ tongue ______________ sublingual _____________________________________________ labial/o ______________ lipase _____________________________________________ lit/o ______________ o________________ cholecystolithiasis periodontal membrane ________________________________________ or/or ______________ oropharynx __________________________________________ Tonsils are located in the oropharynx. palat/o ______________ palatoplasty ____________________________________ Also called palatorrhaphy; This procedure corrects a cleft (split) palate, a congenital anomaly. pancreas/the _____________ pancreas ________________________________________ pancreatoduodenectomy __________________________________________ Sometimes called pancreatoduodenectomy. This is a Whipple procedure, a surgical treatment for pancreatic cancer. See page 192. proct/o _____________ proctosigmoidoscopy __________________________________________ pilor/o _____________ pyloric stenosis ________________________________________ rectum/o _____________ rectal carcinoma ____________________________________________ sialaden/o ______________ sialadenectomy ________________________________________ spleen/o ______________ splenic flexion ________________________________________ The downward curvature in the transverse colon near the spleen. The hepatic angle is the curve in the transverse colon near the liver. steato/o ______________ steatorrhea ____________________________________ stoma/o ______________ aphthous stomatitis ________________________________________

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Laboratory Tests and Clinical Procedures Focus on learning the meanings in bold next to the laboratory test or procedure. Additional information is provided to enhance your understanding of the terms.

Laboratory tests Amylase and lipase tests Liver function tests (LFT)

stool culture guaiac stool test or Hemoccult test

Checks the levels of the enzymes amylase and lipase in the blood. Elevated levels are associated with pancreatitis. Tests for the presence of enzymes and bilirubin in the blood. Liver function tests are performed on blood serum (the clear fluid that remains after the blood is shut off). Examples of LFT are the ALT (alanine transaminase) and AST (aspartate transaminase) tests. ALT and AST are enzymes present in many tissues. Levels are elevated in the serum of patients with liver disease. Elevated ALT and AST levels indicate liver cell damage (as in hepatitis). Alkaline phosphatase (alk phos) is another enzyme that can be elevated in patients with liver, bone, and other diseases. Serum bilirubin levels are elevated in patients with liver disease and jaundice. A direct bilirubin test measures conjugated bilirubin. Elevated levels indicate liver disease or biliary obstruction. An indirect bilirubin test measures unconjugated bilirubin. Elevated levels suggest excessive hemolysis, as can occur in a newborn. Test for microorganisms present in feces. The feces are placed in a growth medium and examined microscopically. (Figure 6-2A). Test for occult (occult) blood in the stool. This is an important screening test for colon cancer. Guaiac (GWĪ-ăk) is a chemical in the wood of trees. When added to a stool sample, it reacts with any blood present in the stool. See Figure 6-2B.

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FIGURE 6-2 A, Culture of stool. B, stool guaiac test.

Clinical procedures X-ray tests X-ray images are used in a variety of ways to detect pathological conditions. In dental practice, X-ray images are commonly used to locate caries (cavities). Many of the X-ray tests listed here use contrast dye (a substance that X-rays cannot penetrate) to view a specific area of the digestive system. Contrast, due to its higher density relative to body tissue, makes it possible to distinguish organs and parts from one another on film or on a screen.

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lower gastrointestinal series (barium enema) upper gastrointestinal series

cholangiography

computed tomography (CT)

X-ray images of the colon and rectum obtained after barium injection into the rectum. Radiologists inject barium (a contrast dye) through an enema into the rectum. Figure 6-3A shows a barium enema study of a colon with diverticulosis. X-ray images of the esophagus, stomach, and small intestine obtained after oral administration of barium. Often performed immediately after an upper GI series, a small bowel follow-up study shows sequential X-ray images of the small intestine as the barium is passed (Figure 63B). A barium swallow is a study of the esophagus. X-ray examination of the biliary system performed after contrast injection into the bile ducts. In percutaneous transhepatic cholangiography, contrast medium is injected through a needle that is placed through the abdominal wall into the bile vessels of the liver. In endoscopic retrograde cholangiopancreatography (ERCP) (Figure 6-4A), contrast medium is delivered through an oral catheter (tube) and then passes through the esophagus, stomach, and duodenum into the bile ducts. This procedure helps diagnose problems involving the bile ducts, gallbladder, and pancreas. A series of X-ray images are taken in multiple views (especially cross sections). A CT scan uses a circular array of X-ray beams to produce a cross-sectional image based on differences in tissue densities. The use of contrast material allows visualization of organs and blood vessels and highlights differences in blood flow between normal and diseased tissues (Figure 6-4B and Figure 6-5A and B). Tomography (tom/o stands for cu ing) produces a series of X-ray images that show multiple views of an organ. An earlier name for a CT scan is a "CAT scan" (computerized axial tomography).

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FIGURE 6-3 A. Barium enema. This X-ray image of a barium enema study demonstrates diverticulosis. Arrows point to diverticula throughout the colon. Most patients with diverticula are asymptomatic, but complications (diverticulitis, perforated diverticulum, obstruction, or hemorrhage) can occur. B, An x-ray image of a small bowel follow-up study demonstrating the normal appearance of the jejunum (J) in the left upper abdomen and the ileum (I) in the right lower abdomen. Note the contrast material within the stomach (S) and cecum (C).

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FIGURE 6-4 A. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrating choledocholithiasis in a patient with biliary colic (pain). Multiple stones are visible in the gallbladder and common bile duct. Calculi (arrows) are seen as filling defects in the gallbladder and contrast-pacified duct. This patient was treated with open cholecystectomy (performed by laparotomy) and choledocholithotomy. B, Contrast-enhanced CT scan demonstrates a large “porcelain stone” in the gallbladder. The patient was asymptomatic, but a therapeutic option with this type of stones is the removal of the gallbladder (by videolaparoscopy) to avoid future problems (such as cholecystitis or gallbladder carcinoma). (B, Courtesy Department of Radiology, Massachusetts General Hospital, Boston).

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FIGURE 6-5 Computed tomography (CT) images of normal and diseased liver. A, Normal liver. Contrast material was injected intravenously, which made the blood vessels appear bright. The liver (L) and spleen (S) have the same density in this CT image. B. Fatty liver. The radiodensity of liver tissue is reduced due to the large volume of fat it contains, making it appear darker than normal. Excess fat can cause inflammation of the liver and cirrhosis.

Ultrasound tests Abdominal ultrasound Endoscopic ultrasound (EUS)

Sound waves radiating into the abdomen produce an image of the abdominal viscera. Ultrasound is especially useful for examining fluid-filled structures, such as the gallbladder. Use of an endoscope combined with ultrasound to examine the organs of the gastrointestinal tract. An endoscope is inserted through the mouth or rectum and ultrasound images are obtained. This test is often used in the evaluation of cancers of the esophagus, pancreas, and rectum.

Magnetic Resonance Imaging by Magnetic Resonance (MRI)

Magnetic waves produce images of organs and tissues in all three planes of the body. This technique does not use X-rays. It detects subtle differences in tissue composition, water content, and blood vessel density and can show sites of trauma, infection, or cancer. See Figure 6-6, which shows an MRI scan of a patient with rectosigmoid carcinoma and rectal polyps. A CT scan would not have shown these lesions as clearly.

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FIGURE 6-6 Rectal (MRI). A 68-year-old man presented with rectal bleeding. MRI demonstrates (A) colonic adenocarcinoma in the rectosigmoid area and (B) villous adenoma in the rectum.

HIDA scan Nuclear Medicine exam

Radioactive imaging procedure that tracks the production and flow of bile from the liver and gallbladder to the intestine. HIDA stands for hepatobiliary iminodiacetic acid. Cholecintigraphy is another name for this test, which determines if the gallbladder is working properly.

Other Procedures

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fecal transplant

bariatric surgery

endoscopia gastrointestinal

laparoscopy

liver biopsy

nasogastric intubation paracentesis (abdominocentesis)

Transfer of stool from a healthy donor to the gastrointestinal tract of a recipient. Extensive use of antibiotics can kill normal bacteria in the colon and can lead to infection with C. difcile (harmful bacteria that cause diarrhea and colitis). A fecal transplant restores normal bacteria in the stool through a colonoscopy. Procedures used to achieve weight loss in people with severe obesity. One type of bariatric surgery is sleeve gastrectomy (bar/o = weight, iatr/o = treatment), removal of a large part of the stomach (Fig. 6-7A). Another bariatric procedure is the gastric bypass. This surgery reduces the size of the stomach to a volume of 2 tablespoons and bypasses much of the small intestine (Figure 6-7B). Visual examination of the gastrointestinal tract using an endoscope. A doctor places a flexible fiberoptic tube through the mouth or anus to view parts of the gastrointestinal tract. Examples are esophagogastroduodenoscopy (EGD) (Figure 6-8), colonoscopy (Figures 6-9 and 6-10), sigmoidoscopy, proctoscopy, and anoscopy. Virtual colonoscopy (CT colonography) combines computed tomography and computer technology to allow doctors to examine the entire length of the colon using X-ray images in just a few minutes. Patients with abnormal findings require a conventional colonoscopy later for further evaluation or treatment, such as a biopsy or polypectomy. Visual (endoscopic) examination of the abdomen with a laparoscope inserted through small incisions in the abdomen. Laparoscopic cholecystectomy (see Figure 5-28, page 160) and laparoscopic appendectomy are performed by general and gastrointestinal surgeons. See the story in person: Cholecystectomy of a woman who underwent laparoscopic cholecystectomy (see page 191). Removal of liver tissue for microscopic examination. A doctor inserts a needle into the skin to remove a small piece of tissue for microscopic examination. The average specimen is less than 1 inch long. The procedure helps doctors diagnose cirrhosis, chronic hepatitis, and liver tumors. Insertion of a tube through the nose into the stomach. Doctors use a nasogastric (NG) tube to remove fluid from the stomach and intestines after the operation (NG decompression). See Figure 6-11. Drill to remove fluid from the abdomen. This procedure is necessary to drain fluid (accumulated in ascites) from the peritoneal (abdominal) cavity.

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FIGURE 6-7 A. Sleeve gastrectomy. B. Gastric bypass. First (a) the stomach is stapled to reduce its size to a small pouch. Then (b) a shortened jejunum is inserted to connect with the smaller stomach. This diverts food so it has a shorter travel time through the intestine and less food is absorbed into the bloodstream.

FIGURE 6-8 A. Normal esophageal endoscopy. B, Esophagogastroduodenoscopy. This endoscopic view shows severe esophagitis in a patient with gastroesophageal reflux disease (GERD).

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FIGURE 6-9 Colonoscopy with polypectomy. Before the procedure, the patient swallows agents to clean the intestines of feces. The patient is sedated, and the gastroenterologist advances the instrument in a retrograde fashion, guided by images from a video camera at the tip of the colonoscope. When a polyp is located, a wire loop is passed through the endoscope and wrapped around the stem. After carefully tightening the loop, an electrical current is applied to cut the stem. The polyp is removed (biopsy) for microscopic examination of the tissue.

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FIGURE 6-10 Case report of colonoscopy. A 60-year-old man with a history of multiple prominent colonic adenomas (with some areas of high-grade dysplasia) underwent colonoscopy. The endoscope was passed through the anus and advanced toward the cecum. Two pedunculated polyps (arrows) were found in the hepatic flexure. The polypectomy was performed with a hot loop. Resection and recovery are complete.

FIGURE 6-11 Nasogastric intubation. The nasogastric tube aspirates secretions from the patient's stomach and intestines. The patient had a torsion-obstructed bowel (ileus) and suction relieved the pressure so that the bowel untwisted and decompressed without surgery.

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Abreviaturas AFP alk phos ALT, AST BE BM BRBPR CD CIC CT EGD EPI ERCP ESLD EUS FOBT G tube GAVE

alpha-fetoprotein - tumor marker for liver cancer alkaline phosphatase

alanine transaminase, aspartate transaminase - enzymes measured in blood to assess liver function barium enema evacuation bright red blood from rectum - hematochezia celiac disease chronic idiopathic constipation computed tomography esophagogastroduodenoscopy exocrine pancreatic insufficiency endoscopic retrograde cholangiopancreatography end-stage liver disease endoscopic ultrasound test fecal occult blood gastrostomy tube—feeding tube gastric antral vascular ectasia—small dilated blood vessels in the antrum (the last part of the stomach) GB gallbladder GERD gastroesophageal reflux disease GI gastrointestinal HBV hepatitis B virus IBD inflammatory bowel disease ( Crohn's disease and ulcerative colitis) J- jejunostomy tube tube: feeding tube LAC laparoscopic-assisted colectomy LAP LFT liver function tests: alka phosphorylation, bilirubin, AST, ALT MRI MRI NASH steatoh nonalcoholic epatitis (fa and liver) N G nasogastric tube NPO tube oral swimming (Latin null for os) PEG percutaneous endoscopic gastrostomy tube: feeding tube PEJ percutaneous endoscopic jejunostomy tube: feeding tube PTHC percutaneous transhepatic cholangiography PUD peptic ulcer nutrition total parenteral TPN IV solutions contain sugar, amino acids, electrolytes, and vitamins A special T-shaped tube (L-shaped and T-shaped) that is placed into the bile duct for drainage into a small bag (biliary sac) on the outside of the body

In person

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cholecystectomy

This first-person narrative describes the symptoms and treatment of a woman with gallstones. Everyone likes to have a little dessert after dinner, but when ice cream or a creamy cake causes pain, most avoid it. I had a sweet tooth, and despite the vengeance they had on my waistline, I still couldn't pass up an ice cream cone, until my gallbladder decided enough was enough. After spending several nights doubled over in pain, I tried to avoid bad foods, but couldn't resist the temptation of frozen yogurt. With one hand, I pushed my cart through the supermarket; on the other hand, I fueled myself with delicious low-fat (not low-fat) frozen yogurt. I never dreamed that the customer at the quick-service window would actually give me ice cream. Ten minutes into eating the questionable yogurt, I broke out in a sweat; a wave of nausea washed over me and a sharp pain shot through my right upper quadrant. It hurt even more when I pressed my hand to the area in an effort to stave off the pain. Several months earlier, after a similar painful episode, I had an ultrasound of my gallbladder and the surgeon recommended a cholecystectomy. The U/S showed several stones in my gallbladder. Most of the stones were just the right size to lodge in the common bile duct and block the flow of bile that occurs after a family meal. When i heard the ultrasound results i gave up all fay foods. I just didn't realize that ice cream masquerading as "low fat yogurt" would be the last straw! I soon abandoned my shopping cart and apologized to the store manager for throwing up all over aisle 4. The unrelenting pain didn't stop when I threw up, it just intensified. I have no idea how I got home to bed, but my husband found me several hours later in a profuse sweat. I was able to call my surgeon and schedule "semi-emergent" surgery the next morning.

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Doctor Fernández and his team performed a laparoscopic cholecystectomy on me and they told me when I came out of anesthesia that I no longer had a "bag of balls" for a gallbladder. I had a bloated and gassy feeling in my abdomen for two weeks after surgery (carbon dioxide was injected into my abdomen before surgery to allow space between the abdominal organs). The first few days I felt “tight as a drum” and every day it went away. My four small incisions healed well and in about 2 weeks I felt back to "normal". Now I can eat ice cream all I want, just suffering from the swelling around my waist, not the sharp pain just above. Without missing a beat, my liver now sends bile to my small intestine right after I eat a large meal. Bile emulsifies (breaks down) fat. I just don't have a storage bag to keep the bile in reserve. I had an appendectomy, had my wisdom teeth removed and now I have given up on my gallbladder! How many “useless” body parts are missing? Elizabeth Chabner Thompson is CEO/Founder of Masthead, a company dedicated to bringing innovative products to breast cancer patients. She is a doctor, swimmer, cross-country skier, and proud mother of four children, ages 16-21.

Practical applications

Answers to questions about the case report are on page 199.

Case Report: Pancreatic Cancer and the Whipple Procedure A 62-year-old man presented to the emergency room complaining of fatigue, weight loss, jaundice, and anorexia. Diagnostic studies including contrast-enhanced abdominal CT, ERCP, and EUS were performed. CT scan showed a 4 cm resectable mass in the head of the pancreas, and ERCP revealed evidence of bile duct obstruction; a stent was placed to open the duct. Examination of a tissue biopsy sample obtained under ultrasound guidance confirmed an adenocarcinoma of the head of the pancreas. Additional studies showed no evidence of liver or other metastases. Surgical treatment with the Whipple procedure was recommended. This procedure was performed and included pancreaticoduodenectomy, choledochojejunostomy, and gastrojejunostomy. Removal of lymph nodes and cholecystectomy were part of the surgical procedure. During surgery, it was determined that the tumor was confined to the head of the pancreas. Despite the removal of

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tumor, the probability of recurrence is high, with a cure rate of only about 20%. Case Report Questions 1. What caused the patient's jaundice? a. Excessive hemolysis b. viral hepatitis c. Obstruction of the bile duct d. Cholelithiasis 2. Which test identified the mass as an adenocarcinoma? a. Whipple procedure b. Endoscopic ultrasound biopsy c. Contrast-enhanced CT scan d. ERCP 3. What is included in a Whipple procedure? a. Removal of the pancreas (malignant area) and duodenum b. Removal of the gallbladder c. Removal of lymph nodes d. All of the above 4. What anastomosis was performed? a. Gallbladder and duodenum united. B. Common bile duct, pancreatic duct, and small intestine, all connected. C. Reconnected stomach and pancreas. d. Liver and pancreas connected to the stomach.

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Exercises Remember to check your answers carefully with the Answers to the exercises, pages 198 and 199.

A Give the meaning of the following suffixes. 1. -pepsia __________________________________________________ _____________________________ 2. -pthisis _________________________________________________ _____________________________________ 3. -emesis ________________________________________________ _____________________________ 4. -phagia ____________________________________________ _____________________________________ 5. -rhea _____________________________________________ _____________________________________ 6. -ragia, -ragia ________________________________________________ _____________________________ 7. -raffia _____________________________________________ _____________________________________ 8. -plasty _____________________________________________ ________________________________ 9. -ectasia, -ectasia _________________________________________________ _____________________________________

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10. -stenosis ____________________________________________ _____________________________________ 11. -stasis _________________________________________________ _____________________________________ 12. -spasm _____________________________________________ _____________________________________ 13. -tresia ____________________________________________ _____________________________________ B Construct medical terms for the following definitions. Use the listed forms of combination as appropriate to create terms. col/e cholangi/o choledoch/o gastr/o hemat/o hem/o herni/o palate/o pylor/o 1. interruption of bile (flow) ______________________________________ 2. suture of a hernia ______________________________________ 3. dilation of the ducts bile ________________________________________________

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4. Sneezing blood (from the respiratory tract) ____________________________________ 5. Vomiting blood (from the digestive tract) ________________________________________ 6. Surgical repair of the roof of the mouth ________________________________________ 7. Narrowing of the pyloric sphincter ________________________________________ 8. Explosion of blood from the stomach ________________________________________ 9. Contraction sudden and inadvertent injury to muscles in the distal region of the stomach _____________________________________ 10. Bleeding ______________________________________ 11. Common bile duct incision _____________________________________ C Give the meaning of the following terms. 1. dysphagia __________________________________________________ ___________________________ 2. polyphagia _________________________________________________ ___________________________ 3. dyspepsia _____________________________________________ ___________________________ 4. biliary atresia _____________________________________________ ___________________________

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5. rhinorrhea __________________________________________________ __________________________ 6. cholestasis _________________________________________________ ___________________________ 7. esophageal atresia _____________________________________________ ___________________________ 8. pyloroplasty ____________________________________________ __________________________________ 9. splenorrhea _____________________________________________ ___________________________ 10. proctosigmoidoscopy _____________________________________________ __________________________________ 11. hemorrhage _____________________________________________ ___________________________ 12. cholangitis ___________________________________ D Combine the listed surgical procedures with the listed surgical procedures following. abdominoplasty cecostomy cholecystectomy cholecystojejunostomy

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colectomy gingivectomy herniorrhaphy ileostomy palatoplasty pancreaticoduodenectomy paracentesis sphincterotomy 1. removal of the gallbladder ________________________ 2. resection of the large intestine ________________________ 3. suture of a weakened muscle wall (hernia) ________________________ 4. reopening of the first part of the colon outside the body ________________________ 5. surgical repair of the abdomen ________________________ 6. incision of a ring of muscles ____________________________ 7. removal of the pancreas and duodenum ________________________ 8. opening of the third part of the small intestine outside the body ________________________ 9. removal of the gum tissue ________________________ 10. anastomosis between bile from the gallbladder and the second part of the small intestine

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p ________________________ 11. Puncture of the abdomen to remove fluid ____________________________ 12. Surgical correction of the roof of the mouth __________________________ E Use the given meanings to complete the following terms. 1. secretion of fat: steat ________________________ 2. difficulty swallowing: disease ________________________ 3. abnormal condition of gallstones: paste ________________________ 4. pertaining to cheek: ________________________ to 5. pertaining to lips and teeth: ________________________ dental 6. vomiting with blood: hematoma ________________________ 7 enlarged liver: hepato ________________________ 8. belonging to under the tongue: sub ________________________ 9. removal of the gallbladder: ________________________ectomy 10. belonging to the common bile duct: paste ________________________ 11. bleeding from the stomach: gastro ________________________ F Give the meaning of the following terms.

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1. vólvulo cecal _____________________________________________ _______________________ 2. estomatitis aftosa _____________________________________________ _______________________ 3. enfermedad celíaca ________________________________________________ _______________________ 4. lipasa ________________________________________________ _______________________ 5. queilosis ________________________________________________ _______________________ 6. orofaringe ________________________________________________ _______________________ 7. glucógeno ________________________________________________ _______________________ 8. glosectomía _____________________________________________ _______________________ 9. sialoadenectomía _____________________________________________________________ 10. _____________________________________________________________ 1. Periodontal membrane ______________________________________________ _____________________________

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11. Choledochactasia ______________________________________ _______________________ 12. Cholangiocarcinoma _______________________________________ _________________________ G Match each listed laboratory test or clinical procedure with its description. • abdominal ultrasound • barium enema • abdominal CT scan • endoscopic retrograde cholangiopancreatography • endoscopic ultrasound • bariatric surgery/gastric bypass • gastrostomy (G-tube) • HIDA scan • laparoscopy • liver biopsy • nasogastric intubation • percutaneous transhepatic cholangiography • serum bilirubin • small intestine monitoring • stool culture • guaiac stool (Hemoccult) 1. measurement of bile pigment in blood _________________________________ 2. placement of stool in culture medium for bacterial analysis _________________________________

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3. x-ray of the lower gastrointestinal tract _________________________________ 4. imaging of the abdominal viscera using sound waves _________________________________ 5. test to reveal hidden blood in the stool _________________________________ 6. sequential x-rays of the small intestine _________________________________ 7. injection of contrast material through the skin on the liver, for X-ray images of the bile vessels _________________________________ 8. insertion of a tube through the nose into the stomach _________________________________ 9. cross-sectional X-ray images of the abdominal organs _________________________________ 10. injection of contrast material through an endoscope to x-ray the pancreas and bile ducts _________________________________ 11. Stomach reduction and gastrojejunostomy _________________________________ 12. Insertion of an endoscope and us or ultrasound to visualize the organs of the gastrointestinal tract _______ ___ _______________________ 13. Percutaneous removal of liver tissue followed by microscopic examination _________________________________ 14. Visual (endoscopic) examination of the abdominal viscera through small abdominal incisions _________________________________

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15. reopen the stomach to the outside of the body for nutrition _________________________________ 16. radioactive images of the liver, gallbladder, and intestine _________________________________ H Give the meaning of the abbreviations in Column I. Then select the letter of the correct description in Column II . COLUMN I 1. TPN ___________________ 2. PUD ___________________ 3. EGD ___________________ 4. IBD ___________________ 5. BE ___________________ 6. BRBPR ___________________ 7. LFTs ___________________ 8. GERD ___________________ 9. HBV ___________________ 10. CT ___________________

_______ _______ _______ _______ _______ _______ _______ _______

COLUMN II A. Tests such as measurement of ALT, AST, alk phos, and serum bilirubin. B. Heartburn is a symptom of this condition. C. Includes Crohn's disease and ulcerative colitis. D.H. pylori causes this condition. E. Intravenous injection of nutrition. F. This is a lower GI series. G. X-ray procedure producing a series of cross-sectional images. H. This infectious agent causes chronic inflammation of the liver. I. Hematochezia describes this gastrointestinal symptom. J. Endoscopic visualization of the upper gastrointestinal tract.

_______ _______

I provide suffixes for the following terms. 1. burst (of blood) _________________________ 2. discharge, discharge _________________________ 3. suture _________________________ 4. dilation _________________________ 5. narrowing (stenosis) _________________________ 6. vomiting _________________________ 7. sneezing _________________________ 8. excision ________________________

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9. digestion _________________________ 10. eat, swallow _________________________ 11. harden _________________________ 12. stop, control _________________________ 13. surgical repair _________________________ 14. opening _________________________ 15. surgical puncture _________________________ 16. involuntary contraction _________________________ 17. re-opening _________________________ 18. incision ________________________ J Explain what happens in a fecal transplant and why it is necessary. ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ ________________________ K Circle the correct term in bold in parentheses to complete each sentence. 1. When Mrs. Smith began to have diarrhea and abdominal cramps, she consulted her (urologist, nephrologist, gastroenterologist) and feared that the cause of her symptoms might be (inflammatory bowel disease, esophageal varices, achalasia). 2. After taking a careful history and performing a complete physical examination, Dr. Blakemore diagnosed Mr. Bean, a long-time alcoholic with

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(hemorrhoids, pancreatitis, appendicitis). Mister. Bean complained of acute epigastric pain and a change in bowel habits. 3. Many pregnant women cannot lie down after eating without feeling a burning sensation in their chest and throat. The usual cause of this symptom is (volvulus, dysentery, gastroesophageal reflux). 4. Mr. and Mrs. Cho brought her newborn son to the clinic after he had several episodes of projectile vomiting. The pediatric surgeon suspected the diagnosis of (inguinal hernia, pyloric stenosis, ascites). 5. Boris had terrible problems with his teeth. He needed not only a periodontist for his (phthous stomatitis, oral leukoplakia, gingivitis) but also one (endodontist, oral surgeon, orthodontist) to correct his teeth. 6. After 6 weeks of radiation therapy to the throat, Bey developed severe esophageal irritation and inflammation. He complained to his doctor about his results (dyspepsia, dysphagia, hematemesis). 7. Seven-year-old Steven is brought to the clinic for recurrent abdominal pain, occasional constipation and diarrhea, and weight loss. His pediatrician's diagnosis is (lipase deficiency, dysentery, celiac disease) and he recommends a (fat, gluten, sugar) free diet. 8. Chris has been drinking heavily throughout his adult life. His wife noted worsening yellow discoloration of the whites of his eyes and skin. After the physical examination and blood tests,

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the family doctor told her that her (colon, skin, liver) was sick. The yellow coloration was (jaundice, mane, flatulence) and his condition was (cheilosis, cirrhosis, steatorrhea). 9. When Carol was working as a phlebotomist, she accidentally cut her finger while she was drawing blood from a patient. Unfortunately, the patient had it (pancreatitis, hemoptysis, hepatitis) and the HBV was passed on to Carol. Blood tests and tests (liver biopsy, GI endoscopy, stool culture) confirmed Carol's unfortunate diagnosis. Her doctor told her that her condition was chronic and that she might be a candidate for a transplant procedure (bone marrow, liver, kidney) in the future. 10. Operación Sonrisa is a rescue project that performs surgical correction including (herniorrhaphy, oral gingivectomy, palatoplasty) in children with congenital cleft palate. 11. After months of antibiotic treatment, Anne developed abdominal pain and severe chronic diarrhea. The harmful bacteria C. difcile has taken over it (stomach, colon, esophagus). To restore normal bacteria in the intestine, she had a (gastric bypass, laparoscopic sleeve gastrectomy, fecal transplant).

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Answers to exercises A 1. digestion 2. sneezing (from the respiratory tract) 3. vomiting 4. eating, swallowing 5. discharge, discharge 6. bloody rash 7. suturing 8. surgical repair 9. dilation (dilation), enlargement 10. narrowing, tightening 11. butt; control 12. Sudden and involuntary muscle contraction 13. Opening B 1. Cholestasis 2. Herniorrhaphy 3. Cholangiectasia 4. Hemoptysis 5. Hematemesis 6. Palatoplasty

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7. Pyloric stenosis 8. Gastrorrhagia 9. Pylorospasm 10. Hemorrhage 11. C choledochotomy 1. Difficulty swallowing 2. Overeating (too much) 3. Difficult digestion 4. Bile ducts not opening (congenital anomaly) 5. Secretion of runny nose 6 . interruption of bile flow 7. the esophagus not open (closed) at birth (congenital anomaly) 8. surgical repair of the pyloric sphincter 9. bursting of blood (bleeding) from the spleen 10. visual (endoscopic) examination of the rectum and sigmoid colon 11. bleeding 12. inflammation of the bile duct (vessel) D 1. cholecystectomy 2. colectomy

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3. herniorrhaphy 4. cecostomy 5. abdominoplasty 6. sphincterotomy 7. pancreaticoduodenectomy 8. ileostomy 9. gingivectomy 10. cholecystojejunostomy 11. paracentesis (abdominocentesis) 12. palatoplasty E 1. steatorrhea 2. dysphagia 3. cholelithiasis 6. vestibular 5. buccal 5 . hematemesis 7. hepatomegaly 8. sublingual 9. cholecystectomy 10. common bile duct 11. gastrorrhagia F

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1. twisted intestine in the cecum area 2. inflammation of the mouth with small ulcers 3. autoimmune disorder in which the villi on the lining of the small intestine are damaged, as a result of a reaction to foods containing gluten, such as wheat , barley and rye 4. enzyme to digest fat 5. abnormal condition of the lips 6. the part of the throat near the mouth 7. form of sugar storage 8. removal of part or all of the tongue 9. removal of a salivary gland 10. membrane surrounding a tooth 11. dilated common bile duct 12. malignant tumor of the biliary vessels G 1. serum bilirubin 2. stool culture 3. barium enema 4. abdominal ultrasound 5. guaiac stool (Hemoccult) 6. small bowel monitoring 7. percutaneous transhepatic cholangiography (PTHC) 8. nasogastric intubation

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9. CT scan of the abdomen 10. Endoscopic retrograde cholangiopancreatography (ERCP) 11. Bariatric surgery (gastric bypass) 12. Endoscopic ultrasound (EUS) 13. Liver biopsy 14. Laparoscopy (minimally invasive form of surgery) 15. Gastrostomy (G-tube) ) 16. HIDA scan H 1. total parenteral nutrition: E 2. peptic ulcer: D 3. esophagodenoscopy: J 4. inflammatory bowel disease: C 5. barium enema: F 6. bright red blood from rectum: I 7. liver function of tests: A 8. gastroesophageal reflux disease: B 9. hepatitis B virus: H 10. computed tomography: G I 1. -rhea, -rhea 2. -rhea

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3. -raffia 4. -ectasia, -ectasia 5. -stenosis 6. -emesis 7. -ptysis 8. -ectomy 9. -pepsia 10. -phagia 11. -sclerosis 12. -stasis 13. -plasty 14. - tresia 15. -centesis 16. -spasm 17. -stomy 18. -J-stomy In a fecal transplant, stool from a healthy donor is transferred to the colon of a patient/recipient. This is necessary when the patient's colon contains harmful bacteria such as C. difcile. After the transplant, normal bacteria from the stool populate the patient's colon.

K 1. gastroenterologist; 2. inflammatory bowel disease pancreatitis

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3. gastroesophageal reflux 4. pyloric stenosis 5. gingivitis; orthodontist 6. dysphagia 7. celiac disease; gluten 8. liver; jaundice; cirrhosis 9. hepatitis; liver biopsy; liver 10. palatoplasty 11. colon; Fecal Transplantation Answers for Practical Applications Case Report: Pancreatic Cancer and the Whipple Procedure

1. c 2. b 3. d 4. b Pronunciation of terms

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TERM abdominal ultrasonography abdominoplasty amylase and lipase tests aphthous stomatitis atresia bariatric surgery biliary atresia bronchospasm buccal cecal volvulus celiac disease cheilosis cholangiectasis cholangiocarcinoma cholangiography cholangiopancreatography cholangitis cholecystectomy cholecystojejunostomy cholecystolithiasis choledochal choledochectasia cholelithiasis cholestasis colectomy colonoscopy computed tomography dentalgia diarrhea duodenal dyspepsia dysphagia endoscopic ultrasonography esophageal atresia fecal transplant gastroenteritis endoscopia gastrointestinal gastroyeyunostomía gastrorragia gastrostomía gengivectomia glosectomía gliconeogênese glicogênio hematêmese hemoptise hemorragia hepatomegalia herniorrafia HIDA scan ileostomía labiodental

PRONUNCIATION ab-DOM-in-al ul-trah-so-NOG-rah-fe ab-DOM-in-o-plas-te AM-ih-lays e LI-pays testes AF-so sto-mah-TI-tis a-TRE-ze-ah bah-re-AH-trk SUR-jeh-re BIH-le-ah-re a-TRE-ze-ah BRONG-ko-spasmo BUK-al SE-kal VOL-vu-lus SE -le-ak dih-ZEEZ ki-LO-sis ko-lan-je-EK-tah-sis ko-lan-je-o-kar-sih-NO-mah ko-lan-je-OG-rah-fe ko -lan-je-o-pan-kre-uh-TOG-rah-fe ko-lan-JI-tis ko-le-sis-TEK-to-me ko-le-sis-to-jeh-jun-NOS- para mim ko-le-sis-to-lih-THI-ah-sis ko-le-DOK-al ko-le-do-kek-TA-se-ah ko-le-lih-THI-ah-sis ko - le-STA-sis this-LEK-to-me this-lon-OS-this com-PU-ted to-MOG-rah-fe den-TAL-jah di-ah-RE-ah du-o- DE -nal dis-PEP-se-ah dis-FA-je-ah en-do-SKOP-ikul-trah-so-NOG-rah-fe eh-sof-ah-JE-al a-TRE-ze-ah fe -go tranz-plant gas-through-en-teh-RI-tis gas-through-in-TES-this-nal en-DOS-cope gas-through-jeh-ju-NOS-to-me gas- tro -RA-jah gas-TROS-for-me gin-gih-VEK-for-me gloss-EK-for-me glu-co-ne-o-JEN-eh-sis GLI-co-jen he-mah- TEM -eh-sis he-MOP-que-sis HEM-or-ij hep-ah-to-MEG-ah-le her-ne-OR -ah-fe HIH-dah scan il-e-OS-to-me o-see-o-THE-number

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TERM laparoscopy lipase liver biopsy liver function tests lower GI series magnetic resonance imaging nasogastric intubation oropharynx palatoplasty pancreatoduodenectomy pancreatic paracentesis periodontal membrane polyphagia proctosigmoidoscopy pyloric stenosis pylorospasm rectal carcinoma sialadenectomy splenic flexion steatorrhea stool culture sublingual guaiac upper GI series

PRONUNCIATION lap-ah-ROS-here LI-pays LIV-er bi-OP-se LIV-er FUNK-shun testes LO-er gas-through-in-TES-tin-al SE-reez mag-NET-ik REH-zo-nants IM-aj-ing na-zo-GAS-trick in-to-BA-shun or-o-FAH-rinks pah-LAT-o-plas-te pan-cre-AH-tik pan-cre -ah-to-du-o-deh-NEK-to me par-ah-sen-TE-sis peh-re-o-DON-tal MEM-brayn pol-e-FA-je-ah prok-to-sig -moyd-OS-co-pe pi-LOR-ik steh-NO-sis pi-LOR-o-spasm REK-number kar-sih-NO-mah si-al-ah-deh-NEK-to-me SPLEN- ik FLEK-shur banquinho ste-ah-to-RE-ah banquinho COOL-chur GWI-ak sub-LING-wal UP-er gas-through-in-TEST-in-al SER-eez

revision sheet

Write meanings to match forms and suffixes in the spaces provided. Check your answers with the information in Chapter 5 and this chapter or the Glossary (Parts of Medical Words—English) at the end of this book.

match shapes

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HOW TO COMBINE abdomin/o amyl/o an/o append/o, apendic/o bil/i bilirubin/o bucc/o cec/o celi/o cervic/o cheil/o chlorhydr/o chol/e cholangi/o cholecyst / the common bile duct / the cyb / the cirrus / the cervix uterus / the colon / the tooth / the duodenum / the entrance / the esophagus / the eti / the gastric / the gum / the shine / the gluc / the, glyco / glycogen / el hem/the, hemat/the hepat/the hernia/the idi/the ile/the pancreas/the peritoneum/the pharynx/the proct/the prote/the py/the pylor/the rectum/the sialaden/the spleen/ the stetum /stomata/tonsil/the

SENSE ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________ ____________________

suffixes

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SUFFIX -ase -centesis -quezia -ectasia -ectasia -ectomy -emesis -emia -genesis -graphia -iase -megaly -orexia -ptosis -ragia -rragia -rraffia -rhea -scopy -spasm -stasis -stenosis -stomy -tomy - tresia

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CHAPTER 7

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Urinary System CHAPTER SECTIONS Introduction 204 Anatomy of Major Organs 204 Physiology: How the Kidneys Produce Urine 206 Vocabulary 209 Terminology: Urinary Structures, Substances, and Signs and Symptoms 211 Urinalysis 216 Pathology Terminology: Kidney, Bladder, and Associated Conditions 217 Tests and Laboratory Procedures Clinic 220 Abbreviations 225 Practical Applications 226 Face to Face: Kidney Transplant 228 Exercises 229 Answers to Exercises 234 Pronunciation of Terms 236 Review Sheet 238

CHAPTER OBJECTIVES • Name the essential organs of the urinary system and describe their location and functions. • Identify common pathological conditions that affect the urinary system. • Recognize how urinalysis is used and interpreted as a diagnostic test. • Define combination forms related to the urinary system, prefixes and suffixes. • List and explain laboratory tests, clinical procedures, and abbreviations referring to the urinary system.

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• Understand medical terms in their proper contexts, such as medical reports and records.

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Introduction When cells in the body consume food that contains protein, nitrogenous waste products (urea, creatinine, and uric acid) are released into the bloodstream. The urinary system removes these nitrogenous wastes from the blood so that they do not accumulate and become harmful. As blood passes through the kidneys, the kidneys filter nitrogenous waste to form urine (made up of water, salts, and acids). Urine leaves the body through the ureters, urinary bladder, and urethra. Every day, the kidneys process about 200 liters of blood to filter 2 quarts of urine. In addition to removing urea and other nitrogenous waste products from the blood, the kidneys maintain the proper balance of water, electrolytes, and acids in body fluids. Electrolytes such as sodium (Na+) and potassium (K+) are small molecules that conduct an electrical charge. Electrolytes are necessary for the proper functioning of muscle and nerve cells. The kidney adjusts the amounts of water and electrolytes by secreting some substances into the urine and retaining others in the bloodstream for use in the body. This is an example of homeostasis, which is the body's ability to maintain balance in its internal environment. Home/o means equality. In addition to making and excreting (removing) urine from the body, the kidneys secrete an enzyme called renin (RE-nin) and a hormone called erythropoietin (eh-rith-ro-POY-it-in). Renin increases blood pressure (to keep blood circulating through the kidneys). Erythropoietin (EPO) stimulates the production of red blood cells in the bone marrow. The kidneys also secrete calciferol, an active form of vitamin D, necessary for the absorption of calcium from the intestine. In addition, the kidneys break down and remove hormones such as insulin and parathyroid hormone from the bloodstream. Table 7-1 reviews the functions of the kidneys.

Box 7-1

Kidney Functions • Eliminate nitrogenous waste: urea, creatinine, uric acid • Balance water and electrolytes (sodium, potassium) • Release substances: renin, erythropoietin, calciferol • Degrade and eliminate hormones from the bloodstream

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Anatomy of the Major Organs The following paragraphs describe the organs of the urinary system. Check off Figure 7-1 as you identify each organ.

FIGURE 7-1 Male urinary system.

The kidney [1] is one of two bean-shaped organs found behind the abdominal (retroperitoneal) cavity on either side of the spine in the lumbar region. A cushion of adipose tissue (fay) and fibrous connective tissue surrounds each kidney for protection. Each kidney (about the size of a fist) weighs between 4 and 6 ounces. The kidneys consist of an outer cortex region (cortex means bark, like the bark of a tree) and an inner medulla region (medulla means marrow). The hilum is a depression in the medial border of the kidney. Blood vessels and nerves pass through the hilum.

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The ureter [2] is one of two muscular tubes (16 to 18 inches long) lined with a mucous membrane. The ureters carry urine in peristaltic waves from the kidneys to the urinary bladder. The urinary bladder [3], a hollow muscular sac, is a temporary reservoir for urine. The trigone is a triangular region at the base of the bladder where the ureters enter and the urethra exits. The urethra [4] is a tube that carries urine from the urinary bladder to the outside of the body. The process of expelling urine through the urethra is called urination or urination. The external opening of the urethra is the urinary meatus. The male urethra, about eight inches long, extends down through the prostate to the urinary meatus at the tip of the penis. In the female urinary system, the urethra, about 5 cm long, lies anterior to the vagina. See Figure 7-2A, which illustrates the female urinary system. When a patient is unable to empty the bladder, a tube called a catheter is usually inserted through the urethra to drain urine from the bladder. See Figure 72B.

FIGURE 7-2 A. Female urinary system. B. Urinary catheter placement.

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Physiology: How the Kidneys Produce Urine Blood enters each kidney through the aorta via the left and right renal arteries. After the renal artery enters the kidney (at the hilum), it branches into smaller and smaller arteries. The smallest arteries are called arterioles (Figure 7-3A).

FIGURE 7-3 A. Branching of the renal artery to form smaller arteries and arterioles and glomeruli. B, Glomerulus and glomerular capsule. The afferent arteriole carries blood to (in this term, af- is a form of ad-) the glomerulus. The efferent arteriole carries blood (ef- is a form of ex-) from the glomerulus.

Because arterioles are small, blood slowly but steadily passes through them. Blood flow through the kidney is so essential that the kidneys have their own special device to maintain blood flow. If blood pressure falls in the kidney's vessels so that blood flow decreases, the kidney produces renin and releases it into the blood. Renin promotes the formation of a substance that stimulates the contraction of arterioles. This increases blood pressure and restores blood flow in the kidneys to normal. Each arteriole in the cortex of the kidney leads to a mass of very small, coiled, and intertwined blood vessels called glomeruli (see Figure 73A). Each glomerulus (singular) is a collection of small capillaries formed in the shape of a small ball. There are about 1 million glomeruli in the cortical region of each kidney. The kidneys produce urine by filtering. As blood passes through the many glomeruli, the thin walls of each glomerulus (the filter) allow water, salts, sugar, and urea (along with other nitrogenous waste products, such as creatinine and uric acid) leave the bloodstream. These materials accumulate in a minute cup-shaped structure, a glomerular (Bowman's) capsule, that surrounds each glomerulus (Figure 7-3B). The walls of the glomeruli store large substances, such as

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proteins and blood cells, from the filtrate in the urine. These substances remain in the blood and do not normally appear in the urine. Attached to each glomerular capsule is a long, twisted tube called the renal tubule (Figure 7-3B; see also Figure 7-4). As water, sugar, salts, urea, and other wastes pass through the renal tubule, most of the water, all of the sugar, and most of the sodium return to the bloodstream through tiny capillaries around each kidney. tubule. This active reabsorption process ensures that the body retains essential substances such as sugar (glucose), water, and sodium, while allowing waste products to be eliminated in the urine. The final process in the formation of urine is the secretion of some substances such as potassium, acids and drugs from the bloodstream into the renal tubule. Each renal tubule, which now contains urine (95% water and 5% urea, creatinine, salts, and acids), connects to a larger collecting duct.

FIGURE 7-4 A. Three steps in urine formation: (1) Glomerular filtration of water, sugar, wastes (urea and creatinine), and sodium; (2) Tubular reabsorption of water, sugar, and sodium; and (3) tubular secretion of acids, potassium, and drugs. B, A nephron is the combination of a glomerulus and a renal tubule.

Refer to Figure 7-4A, which reviews the steps involved in the formation of urine. Be aware that waste products can build up in the body as a result of kidney failure and can interfere with the function of vital organs, including the brain and heart. The combination of a glomerulus and a renal tubule forms a unit called a nephron (Figure 7-4B). Each kidney contains about 1 million nephrons. All of the collecting ducts lead to the renal pelvis, a bowl-like area in the middle of the kidney. Small cup-shaped regions of the renal pelvis are

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called chalices or chalices (singular: goblet or goblet). Figure 7-5 is an X-ray image of a kidney showing the renal pelvis, calyces, and ureter.

FIGURE 7-5 Renal pelvis, calyces, and ureter viewed on CT urography (intravenous dye used).

The renal pelvis narrows into the ureter, which carries urine to the urinary bladder. The bladder, a muscular sac, temporarily stores urine. The sphincter muscles control the area where the bladder exits into the urethra. As the bladder fills and pressure at its base increases, the individual becomes aware of the need to urinate and voluntarily relaxes the sphincter muscles. Study the diagram in Figure 7-6 that describes the process of urine formation and excretion.

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FIGURE 7-6 Flow chart illustrating the process of urine formation and expulsion.

Vocabulary

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arteriola calciferol caliz (plural: calyces or calyces) catheter

small artery Active form of vitamin D, secreted by the kidney. Cup-shaped collecting region of the renal pelvis. The term comes from the Greek, kalux, which means a cup or box that encloses a flower bud.

Tube to inject or extract fluids. A bladder catheter drains urine from the bladder. cortex Outer region of an organ; the renal cortex is the outer region of the kidney (cortical media belonging to the cortex). creatinine Nitrogenous waste excreted in the urine. Creatinine is a product of muscle metabolism. Creatinine clearance is a measure of the efficiency of the kidneys in removing (cleaning) creatinine from the blood. electrolyte A chemical element that carries an electrical charge when dissolved in water. Electrolytes are necessary for muscle and nerve function. The kidneys maintain the proper balance of electrolytes and water in the blood. Potassium (K+) and sodium (Na+) are electrolytes. erythropoietin A hormone secreted by the kidneys to stimulate the production of red blood cells. (EPO) Poietin means a substance that is formed. EPO stimulates the production of red blood cells in the bone marrow and therefore increases the amount of oxygen that reaches the muscles. This increases athletic endurance. However, the use of EPO is a form of blood doping and is prohibited by the World Anti-Doping Authority (WADA). filtration Process by which some, but not all, substances pass through a filter. glomerular Enveloping structure that surrounds each glomerulus. The glomerular capsule is also known as Bowman's capsule and collects material that leaks from the blood through the walls of the glomerulus. glomerulus A small ball of capillaries (microscopic blood vessels) in the kidney. (plural: glomeruli) hilum A depression in the kidney where blood vessels and nerves enter and exit. Hilum comes from Latin and means small thing. It is also used in the respiratory system to mark the depression in the lung where blood vessels, bronchi, and lymphatic vessels enter and exit. kidney One of two bean-shaped organs on each side of the spinal column in the lower back. Filters nitrogenous waste from the bloodstream to form urine. Opening or canal of the meatus. medulla Internal region of an organ. The renal medulla is the inner region of the kidney. Medullary means pertaining to the medulla. The term comes from the Latin medulla, which means marrow (internal part). nephron Functional unit of the kidney. It is the combination of glomerulus and renal tubule where filtration, reabsorption, and secretion take place in the kidney. Each nephron is capable of making urine on its own. There are about 1 million nephrons in a kidney. nitrogenous A substance that contains nitrogen and is excreted in the urine. Examples of nitrogenous wastes are urea, uric acid, and creatinine. potassium An electrolyte regulated by the kidney so that an adequate concentration is maintained in the blood. Potassium is essential to allow muscle contraction and conduction (K+) of nerve impulses. reabsorption The process by which the renal tubules return materials needed by the body to the bloodstream. renal artery A blood vessel that carries blood to the kidney. Renal pelvis Central collecting region in the kidney. renal tubule A microscopic tube in the kidney where urine is formed after filtration. renal vein A blood vessel that carries blood from the kidneys to the heart. renin An enzyme secreted by the kidney. Increases blood pressure by influencing vasoconstriction (narrowing of blood vessels). sodium (Na+) Electrolyte regulated in blood and urine by the kidneys. It is necessary for the correct transmission of nerve impulses, cardiac activity and other metabolic functions. A common form of sodium is sodium chloride (table salt).

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trigone urea ureter urethra uric acid urinary bladder urination (urination)

Triangular area in the urinary bladder. The main nitrogenous wastes are excreted in the urine. One of the two tubes that connect the kidneys to the urinary bladder. A tube leading from the urinary bladder to the outside of the body. Nitrogenous waste excreted in the urine. Hollow muscular sac that retains and stores urine. Process of expelling urine; also called urination.

Filtration of blood by the kidney

This process is maintained by cardiac output (25% of cardiac output goes to the kidneys) and adequate blood pressure to drive blood through the glomeruli (filter). About 200 quarts (189 L) of fluid are filtered each day, but 98% to 99% of the water and salts are returned to the blood. Only about 2 quarts (1500 ml) of urine are excreted per day.

Terminology Structures, Substances, and Urinary Signs and Symptoms Write the meanings of the medical terms in the spaces provided.

structures

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MATCHING MEANING TERMINOLOGY MEANING SHAPE cal/o, calic/o calyx calyx caliectasia ________________________________________calyceal (calyx); cup-shaped cyst/urinary cystitis _____________________________________________ bladder Bacterial infections usually cause acute or chronic cystitis. In acute cystitis, the bladder contains blood as a result of mucosal hemorrhage (Figure 7-7). A catheter is placed in the bladder for drainage. glomerulus/the glomerulus glomerulus glomerular capsule ________________________________ flesh/meatal stenosis ____________________________________ nephr/the paranephric kidney __________________________________________ nephropathy _____________________________________ (neh-FROP-ah-the) nephroptosis ______________________________________ A downward displacement or drooping of a kidney when its anatomical supports are weakened. Nephropexy (-pexi means fixation) is an operation to put a “floating” kidney into place. nephrolithotomy __________________________________ An incision (percutaneous) into the kidney to remove a stone. hydronephrosis _____________________________________ Urinary flow obstruction may be due to kidney stones (Fig. 7-8), tumor compression of the ureter, or prostatic hyperplasia at the base of the bladder in men. nephrostomy __________________________________________ Surgical opening to the outside of the body (from the renal pelvis). This is necessary when a ureter becomes blocked and the obstruction cannot be easily removed. The renal pelvis becomes distended with urine (hydronephrosis), necessitating nephrostomy. skin/pyelolithotomy of the renal pelvis ____________________________________ Removal of a large calculus (stone) that contributes to the blockage of urine flow and the development of an infection. The renal pelvis is surgically opened. kidney/kidney renal ischemia __________________________________________ renal colic __________________________________________ Colic is a spasm of intermittent pain caused by inflammation and distension of an organ. In renal colic, pain is due to stones in the kidney or ureter. trigon/or trigonitis trigonitis ____________________________________ (bladder region) ureter/or ureter ureteroplasty ______________________________________ureteroileostomy __________________________________ After cystectomy, the urologic surgeon forms a pouch from a segment of the ileum, which is used instead of the bladder to transport urine from the ureters outside the body (Figure 7-9). It is illegal conduct. urethra/or urethritis of the urethra ____________________________________________urethroplasty _____________________________________urethral stricture _________________________________ A stricture is an abnormal narrowing of an opening or passage.

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MATCH MEANING TERMINOLOGY MEANING SHAPE bladder/or urinary intravesical _________________________________________ bladder Do not confuse the term bladder with the term vesicle, which is a small blister on the skin.vesicoureteral reflux ________________________________

FIGURE 7-7 Acute cystitis. Note that the bladder mucosa is red and swollen. Bladder and urinary tract infections are more common in women because the urethra is shorter, which facilitates bacterial colonization of the urinary bladder. They often occur with no known cause, but can be acquired during sexual intercourse ("honeymoon cystitis") or after surgical procedures and urinary catheterization.

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FIGURE 7-8 A. Hydronephrosis caused by a calculus (obstruction) in the proximal part of a ureter. Note the accumulation of excess fluid in the kidney. B. Hydroureter with hydronephrosis caused by calculus in the distal ureter.

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FIGURE 7-9 Ileostomy and ileal conduit after cystectomy.

Urinary substances and signs and symptoms

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SUFFIX COMBINATION OF FORM OR MEANING albumin/or albumin (a protein in the blood)

TERMINOLOGY

SENSE

albuminuria ____________________________________ The suffix -uria means urinary condition. This finding may indicate a malfunction of the kidneys as protein is leaked from the damaged glomeruli. Microalbuminuria is the leakage of very small amounts of albumin through the glomeruli. Nitrogenous azemia ____________________________________ This toxic condition is characteristic of uremia. It is indicated by an elevated BUN (blood urea nitrogen) test. bacteria bacteriuria _________________________________ Usually a sign of urinary tract infection (UTI). The bacteria in the urine are cultured (grown in a special nutrient environment) and then tested with antibiotics to determine which one will inhibit growth. This is known as a culture and susceptibility (C&S) test. falls/thirst polydipsia __________________________________________ Commonly a sign of diabetes mellitus or diabetes insipidus. Polydipsia occurs when excessive urination (polyuria) signals the brain to cause thirst. kal/i potassium hyperkalemia ____________________________________ Because potassium (K+) is normally excreted by the kidneys, it accumulates in the blood when the kidneys fail. keto/o, ketone/or ketone ketosis _____________________________________ bodies Often called ketoacidosis because acids build up in the blood (ketoacids and tissues). The breath of a ketosis patient has a sweet or “fruity” odor. This is produced by acetone (a ketone body) released from the blood into the lungs and exhaled through the mouth. ketonuria ____________________________________ calculus calculi calculi nephrolithiasis ________________________________________ natr/o sodium hyponatremia ____________________________________ This condition can occur when water intake is excessive - primary polydipsia or when athletes drink too much water in high endurance events. Nocturia nocturia _________________________________ Frequent and excessive urination at night. scant olig/o oliguria ____________________________________ -poietin substance that erythropoietin __________________________________________ forms pi/o pus pyuria _____________________________________ -overwhelming trip lithotripsy ______________________________ ur/o urine (urea) uremia ________________________________________ This toxic state results when nitrogenous wastes accumulate abnormally in the blood. enuresis ____________________________________ Literally, a condition (-esis) of being “in the urine”; bed-us. diuresis ____________________________________ Di- (of the day-) means complete. Caffeine and alcohol are well known diuretics: they induce an increase in urine production (diuresis). antidiuretic hormone ____________________________________ This hormone from the pituitary gland normally acts on the renal tubules to promote water reabsorption. It is also called vasopressin and is abbreviated ADH.

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COMBINATION FORM OR MEANING SUFFIX urine/or urine

- urine

urination; urine condition

TERMINOLOGY

SENSE

urinary incontinence ________________________________ Incontinence literally means not (in-) able to hold (tin) together (with-). This is the loss of control of the passage of urine from the bladder. Stress incontinence occurs when you strain to open your bladder when you cough or sneeze. Urge incontinence occurs with the inability to hold back urination when the urge to urinate is felt. Urinary retention ________________________________ This symptom occurs when the outflow of urine from the bladder is blocked. dysuria _________________________________ anuria ____________________________________ Commonly caused by kidney failure or urinary tract obstruction. hematuria _____________________________________ Microhematuria is hematuria visible only under a microscope, as opposed to gross hematuria, which can be seen with the naked eye. Glycosuria ____________________________________ A sign of diabetes mellitus. symptom of diabetes insipidus and diabetes mellitus.

Enuresis/Nicturia

Don't confuse bedwetting, which is involuntary, with nocturia, which is frequent urination at night.

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Urinalysis Urinalysis is an examination of urine to determine the presence of abnormal elements that may indicate various pathological conditions. It is an inexpensive and non-invasive test that provides valuable information not only about the urine content, but also about diseases that affect the body as a whole. Urine tests can be done in the office with almost instant results. See Figure 7-10.

FIGURE 7-10 Dipstick test and urinalysis.

The following are some of the tests included in a urinalysis: 1. Color: The normal color of urine is yellow (amber) or straw-colored. A pale, colorless urine indicates a large amount of water in the urine, while a smoky red or brown color indicates the presence of large amounts of blood. Foods such as beets and certain medications can also cause a red color in the urine. 2. Appearance: Urine should normally be clear. Cloudy or cloudy urine indicates a urinary tract infection with pus (pyuria) and bacteria (bacteriuria). 3. pH—The determination of pH reveals the chemical nature of the urine. It indicates the degree to which a solution is acidic or alkaline (basic) (Figure 7-11). Normal urine has a slightly acidic pH of 6.5. However, in some bladder infections, the pH of the urine can be alkaline, due to the action of bacteria in the urine that break down the urea and release ammonia (an alkaline substance).

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FIGURE 7-11

The pH scale. Pure water has a neutral pH.

4. Protein: Small amounts of protein are normally found in the urine, but not enough to produce a positive result with common test methods. When urine protein tests come back positive, albumin is usually to blame. Albumin is the main protein in blood plasma. If detected in the urine (albuminuria), it may indicate a leak in the glomerular membrane, which allows albumin to enter the renal tubule and pass into the urine. Through more sensitive tests, smaller amounts of abnormal albumin can be detected, revealing microalbuminuria when standard tests are negative. Microalbuminuria is recognized as the first sign of renal involvement in diabetes mellitus. 5. Glucose—Sugar is not normally found in the urine. In most cases, when it appears (glycosuria), it indicates diabetes mellitus. In diabetes mellitus, there is too much sugar in the bloodstream (hyperglycemia), causing sugar to "spill" into the urine. The renal tubules cannot reabsorb all the sugar that is filtered by the glomerular membrane. 6. Specific Gravity: The specific gravity of urine reflects the amounts of waste, minerals, and solids in the urine. It is a comparison of the density of urine with that of water. The urine of patients with diabetes mellitus has a specific gravity higher than normal due to the presence of sugar. 7. Ketone Bodies: Ketones (or ketones, a type of ketone body) are formed when fatty acids are broken down in the liver. Ketones build up in the blood and urine when the body breaks down fat instead of sugar for fuel. Ketonuria occurs in diabetes mellitus when cells deprived of sugar must use available fat for energy. In starvation, when sugar is not available, ketonuria and ketosis (blood ketones) occur as fat is abnormally catabolized. Ketones in the blood are dangerous because they increase the acidity of the blood (ketoacidosis). If severe, it can lead to coma (loss of consciousness) and death. 8. Sediments and casts: The presence of abnormal particles in the urine is a sign of a pathological condition. These particles, which can settle to the bottom of a urine sample as sediment, can include cells (epithelial, white, or red cells), bacteria, crystals, and casts (cylindrical protein structures that usually contain cellular elements). 9. Phenylketonuria (PKU): This is a rare condition in which a baby is born unable to break down an amino acid, phenylalanine. resulting

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Elevated levels of phenylalanine in the blood (phenylketones are detected in the urine) can cause mental retardation. While the PKU test was originally done on urine samples, it is now done by pricking the newborn's heel to obtain a small blood sample. If phenylalanine is detected, the child is fed a diet that excludes phenylalanine. Affected children remain on this diet well into adulthood. 10. Bilirubin: A small amount of this pigmented substance is present in urine and gives it its characteristic yellow color. Bilirubin is a breakdown product of red blood cells, and patients with liver disease have elevated levels in the urine (bilirubinuria).

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Pathologic Terminology: Kidney, Bladder, and Associated Renal Conditions

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glomerulonephritis

interstitial nephritis

nephrolithiasis

nephrotic syndrome (nephrosis)

polycystic kidney disease (PKD)

pyelonephritis

Renal cell carcinoma

renal insufficiency

renal hypertension

Inflammation of the glomeruli within the kidney. This condition may follow a strep infection or may be associated with an autoimmune disease. It results in leaky glomeruli, hematuria, red blood cell casts, albuminuria, and, when severe, renal failure and uremia. Medications can be helpful in controlling inflammation, and dialysis or a kidney transplant may be needed if uremia develops. Inflammation of the connective tissue found between the kidney tubules. The supporting connective tissue between the renal tubules is formed by renal interstitial cells. The interstitial cells of any organ are found in addition to the essential, principal, and functional cells that constitute the parenchyma. The renal parenchyma is made up of the glomeruli and renal tubules (nephrons). Acute interstitial nephritis, an increasingly common disorder, can develop after the use of NSAIDs (non-steroidal anti-inflammatory drugs such as aspirin and ibuprofen) and other medications. It may be marked by fever, rash, and eosinophils in the blood and urine. Kidney stones (kidney stones). Kidney stones are usually made up of uric acid or calcium salts. Stones often lodge in the ureter or bladder, as well as in the renal pelvis, and may need to be removed by lithotripsy (see page 222) or surgery. Set of clinical signs and symptoms caused by excessive loss of protein in the urine. Nephrotic syndrome can occur after glomerulonephritis or exposure to toxins or certain drugs, immune disorders, and other pathological conditions such as diabetes mellitus and cancer. Two important signs of nephrotic syndrome are edema (swelling caused by fluid in tissue spaces) and hypoalbuminemia. Both changes are caused by the massive leakage of protein into the urine. Multiple fluid-filled sacs (cysts) in and on the kidney. There are two types of hereditary PKD. One type is usually asymptomatic (without symptoms) until middle age and then is characterized by hematuria, urinary tract infections, nephrolithiasis, and renal failure. The other type of PKD occurs in infants or children and results in kidney failure. Figure 7-12A shows polycystic kidney disease. Inflammation of the lining of the renal pelvis and renal parenchyma. The parenchyma of an organ is its essential and distinctive tissue. The nephrons form the renal parenchyma. Bacterial infection in the urinary tract causes collections of pus to form in the kidneys, usually associated with the spread of bacteria in the bloodstream. Urinalysis reveals pyuria. Treatment consists of antibiotics and surgical correction of any obstruction to urinary flow. Cancerous tumor of the kidney in adulthood. This tumor (see Figure 7-12B) accounts for 2% of all adult cancers. Hematuria is the primary abnormal finding, and the tumor often metastasizes to the bones and lungs. Nephrectomy or partial nephrectomy is the primary treatment. Decreased waste excretion results from impaired filtration function. A large number of conditions, such as high blood pressure, infections, and diabetes, can lead to kidney failure, which can be acute (ARI) or chronic (CRI), reversible or progressive, mild or severe. A more recent classification of chronic kidney disease (CKD) classifies its severity based on creatinine clearance level and glomerular filtration rate (GFR), ranging from normal (stage 1) to end-stage renal failure, or ESRF (stage 1). 5). CKD Stages on page 225. High blood pressure as a result of kidney disease. Renal hypertension is a type of secondary hypertension (high blood pressure caused by an abnormal condition such as glomerulonephritis). However, the most common type of high blood pressure is essential

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tumor de Wilms

hypertension or primary hypertension. In essential hypertension, there is no obvious underlying medical condition. Chronic essential hypertension can damage blood vessels, which could lead to a stroke, myocardial infarction (heart attack), heart failure, or kidney failure. Malignant tumor of the kidney that occurs in childhood. This tumor can be treated with surgery, radiation therapy, and chemotherapy.

FIGURE 7-12 A. Polycystic kidney disease. The kidneys contain masses of cysts. Polycystic kidneys normally weigh 20 times their normal weight (150 to 200 grams). B, Renal cell carcinoma.

urinary bladder

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bladder cancer

Malignant tumor of the urinary bladder. Bladder cancer occurs most often in men (often smokers) and in people over the age of 50, especially in industrial workers exposed to dyes and leather tanning. Signs and symptoms include macroscopic (visible to the naked eye) or microscopic hematuria and dysuria. Cystoscopy with biopsy is the most common diagnostic procedure. Tumor staging is based on the depth to which the tumor invades the bladder wall and the presence of metastases. Superficial tumors are removed by electrocautery (burning). Cystectomy, chemotherapy, and radiation therapy are treatments for disease that has spread deep within the bladder wall, to regional lymph nodes, or to distant organs.

Conditions Associated with Diabetes Insipidus (DI)

diabetes mellitus (DM)

Antidiuretic hormone (ADH) is not secreted or there is renal resistance to ADH. In DI, the kidney produces large amounts of dilute urine (polyuria). The lack of ADH prevents water from being reabsorbed into the blood through the renal tubules. Insipid means tasteless, reflecting very dilute and watery urine, not sweet as in diabetes mellitus. The term diabetes comes from the Greek diabainein, which means to pass. Both types of diabetes (mellitus and insipidus) are characterized by polyuria and polydipsia. Insulin is not secreted properly or the tissues are resistant to its effects. The main signs and symptoms of diabetes mellitus are glycosuria, hyperglycemia, polyuria, and polydipsia. Without insulin, sugar cannot leave the bloodstream and is not available to the body's cells as energy. The sugar stays in the blood (hyperglycemia) and spreads into the urine (glycosuria). Mellitus means sweet, reflecting the content of the urine. The term diabetes, when used alone, refers to diabetes mellitus. See Chapter 18 for more information on diabetes mellitus.

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Laboratory tests and clinical procedures Laboratory tests BUN (blood urea nitrogen) Creatinine clearance

Measurement of blood urea levels. Normally, the BUN (pronounced be-u-n) level is low because urea is continuously excreted in the urine. However, when the kidney is diseased or failing, the BUN can be very high. Urea builds up in the blood (uremia), leading to unconsciousness and death. A measurement of the rate at which the kidney removes creatinine from the blood. This is an important test to assess kidney function. A blood sample is collected and the concentration of creatinine in the blood is compared with the amount of creatinine excreted in the urine over a fixed period of time. If the kidney is not doing its job of removing creatinine from the blood, the amount of creatinine in the blood will be high relative to the amount in the urine. Creatinine clearance is a useful indicator of glomerular filtration rate (GFR), which is usually 90 to 120 mL/min.

Clinical procedures X-ray examinations Computed tomography Urography

KUB (kidneys, ureters, and bladder) renal angiography retrograde pyelography (RP) voiding cystourethrography (VCUG)

X-ray images obtained by computed tomography (CT) show multiple cross sections and other views of the kidney. CT scans show multiple views of the kidney, taken with or without contrast material. Two main indications are the detection of kidney stones and the evaluation of patients with hematuria (Fig. 7.13A). X-ray examination (without contrast) of the kidneys, ureters, and bladder. A KUB (pronounced k-u-be) study demonstrates the size and location of the kidneys in relation to other organs in the abdominopelvic region. It can also show kidney stones. X-ray examination (with contrast) of the blood vessels in the kidney. This procedure helps diagnose blockage or constriction of the blood vessels leading to the kidney. The same changes can be seen on CT and MR urography. X-ray image of the renal pelvis and ureters after contrast injection through a urinary catheter into the ureters of the bladder. This technique is useful for locating urinary calculi and obstructions. Radiographic image (with contrast) of the urinary bladder and urethra obtained while the patient is urinating. See Figure 7-13B. The bladder is filled with contrast material, followed by fluoroscopy (real-time X-ray). Contrast backflow into the ureters is abnormal and can occur with recurrent urinary tract infections.

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FIGURE 7-13 A. Contrast-enhanced CT urography (axial view) demonstrates a benign cyst in the kidney. It does not take away from the contrast and is soft and round. B, Voiding cystourethrogram showing a normal female urethra. (Courtesy of William H. Bush, Jr., MD, University of Washington, Seattle.)

ultrasound ultrasound examination

Imaging of urinary tract structures using high-frequency sound waves. Kidney size, tumors, hydronephrosis, polycystic kidney disease, and ureteral and bladder obstruction can be diagnosed using ultrasound techniques.

Radioactive study radioisotope scan

A picture of the kidney obtained after a radioactive substance (radioisotope) is injected into the bloodstream. Pictures show the size and shape of the kidney (renal scan) and how it works (renogram). These studies can indicate narrowing of blood vessels, diagnose obstruction, and determine individual kidney function.

magnetic resonance urography

The changing magnetic field produces images of the kidney and surrounding structures in three planes of the body. The patient lies inside a cylindrical MRI machine and images of the pelvic and retroperitoneal regions are taken using magnetic waves. The test shows tumor invasion of blood vessels, lymph nodes, and adjacent tissues.

Other Procedures

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cistoscopia

Direct visualization of the urethra and urinary bladder with an endoscope (cystoscope). The procedure can be performed in two ways. Flexible cystoscopy uses a thin fiberoptic cystoscope and is used for diagnosis and examination of the urinary bladder. Rigid cystoscopy uses a hollow metal tube that is passed through the urethra and into the bladder. It is used to collect biopsy samples, remove polyps, or perform laser treatments. Both tests can be done in the doctor's office or in the operating room. See Figure 7-14A and B. dialysis The process of separating nitrogenous wastes from the blood. Dialysis is used to treat acute or chronic kidney failure and some cases of drug use. There are two methods: 1. Hemodialysis (HD) uses an artificial kidney machine that takes residual blood from the patient's bloodstream, filters it through an artificial porous membrane (dialyzer), and returns the dialyzed blood to the patient's body ( Figure 7-15A). ). An arteriovenous fistula (a communication between an artery and a vein) is surgically created, usually in the patient's arm, to facilitate access for hemodialysis (Fig. 7.15B). 2. Peritoneal dialysis (PD) uses a catheter to introduce fluid into the peritoneal (abdominal) cavity. Waste products, such as urea, in the capillaries of the peritoneum leave the bloodstream and enter the fluid. The fluid (with debris) is then removed through a catheter. When used to treat patients with chronic kidney disease, PD can be performed continuously by the patient without mechanical support (CAPD - Continuous Ambulatory PD; Figure 7-16) or with the aid of a mechanical device worn at night while sleep. lithotripsy Urinary tract stones are crushed. The out-of-body method uses shock waves directed at the stone from outside the body (extra = exterior, corpo/o = body). The patient receives light sedation or anesthesia. The stones leave the body in the urine after the procedure. The abbreviation is ESWL (extracorporeal shock wave lithotripsy). renal Enlargement of narrowed areas in the renal arteries. angioplasty A balloon attached to a catheter is inserted into the artery and then inflated to increase the diameter of the vessel. Later, stents (mesh tubes) can be inserted to keep the vessel open. This procedure is used to treat renal hypertension and preserve kidney function. kidney biopsy Removal of kidney tissue for microscopic examination. The biopsy can be taken at the time of surgery (open) or through the skin (percutaneous or closed). When the latter technique is used, the patient is in the prone position; Then, after applying a local anesthetic to the skin and muscles of the back, the doctor inserts a biopsy needle into the kidney. Several samples are obtained for examination by a pathologist. renal Surgical transfer of a kidney from a donor to a recipient. Transplantation Patients with kidney failure may receive a kidney from a living donor, such as an identical twin (isograft) or another person (allograft), or from a patient at the time of death (cadaveric transplant). The best results are obtained when the donor is a close relative of the recipient: 98% of transplanted kidneys survive 1 year or more (Figure 7.17). See In Person: Kidney Transplantation on page 228. urinary Passage of a flexible tubular instrument through the urethra into the urinary bladder for catheterization. Catheters are primarily used for short- or long-term drainage of urine. A Foley catheter is an indwelling catheter (left in the bladder) supported by a fluid-inflated balloon (Figure 7-18).

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FIGURE 7-14 Cystoscopy. A. Rigid cystoscope placed within the urethra. B. Flexible cystoscope.

FIGURE 7-15 Hemodialysis (HD). A. Patient on HD. Conventional HD involves 3 to 4 hours of dialysis three times a week. Newer alternative modalities include longer, slower dialysis, overnight HD, and brief daily HD. B. Arteriovenous fistula for hemodialysis.

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FIGURE 7-16 Continuous ambulatory peritoneal dialysis (CAPD). A, Dialysis solution (dialysate) flows from a collapsible plastic bag through a catheter (Tenckhoff peritoneal catheter) into the patient's peritoneal cavity. The empty bag is then folded and inserted into the underwear. B, After 4 to 8 hours, the bag is opened and the fluid is drained by gravity. The full bag is discarded and a new bag of fresh dialysate is attached.

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FIGURE 7-17 Renal (kidney) transplantation. A, The donor's left kidney is removed for transplantation. B, The kidney is transplanted into the right pelvis (iliac fossa) of the recipient. The renal artery and vein from the donor kidney are attached to the artery and vein from the recipient kidney, and the end of the donor ureter is connected to the recipient's bladder (ureteroneocystostomy). The donor's health is not affected by the loss of a kidney. In fact, the remaining kidney can take over full function.

FIGURE 7-18 Foley catheter placed in the urinary bladder. The three-way catheter has three separate lumens: for draining urine, for inflating balloons in the bladder, and for introducing irrigation solutions into the bladder.

abbreviations

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ADH AKI GOOD CAPD ERC

antidiuretic hormone: vasopressin acute renal (kidney) injury blood urea nitrogen continuous ambulatory peritoneal dialysis chronic kidney disease: a condition during which the serum levels of creatinine and BUN rise, which can lead to deterioration of all body systems − chloride: an electrolyte excreted by the kidney Cl CrCl creatinine clearance CKD chronic renal failure — progressive loss of kidney function; same as CKD C&S culture and susceptibility testing: to determine the efficacy of antibiotics against bacteria cultured from a patient's urine specimen cystoscopic examination eGFR estimated glomerular filtration rate ESRD end-stage renal disease ESWL extracorporeal wave lithotripsy shock HCO3-bicarbonate: an electrolyte conserved by the kidney HD hemodialysis IC interstitial cystitis – chronic inflammation of the bladder wall; not caused by bacterial infection and unresponsive to conventional antibiotic therapy PVI intravenous pyelography + potassium—an electrolyte K KUB kidney, ureters, and bladder + sodium—an electrolyte Na PD peritoneal dialysis potential pH hydrogen; scale to indicate the degree of acidity or alkalinity PKD polycystic kidney disease PUL percutaneous ultrasound lithotripsy PR retrograde pyelography sp gr specific gravity UA urinalysis UTI urinary tract infection VCUG voiding cystourethrography

CKD stages

The five stages of CKD reflect increasing severity of kidney disease: Stage 1: eGFR >90 Stage 2: eGFR 60-90 Stage 3: eGFR 30-60 Stage 4: eGFR 15-30 Stage 5: eGFR 100 rods ) leukocyte casts

NORMAL FINDINGS clear amber-yellow 1.003-1.030 6.5 (range, 4.6-8.0) neg neg neg neg 0 0 none

What is the most likely diagnosis? a. Diabetes mellitus with glycosuria b. Glomerulonephritis with staphylococcal infection c. Nephrotic syndrome with albuminuria d. Urinary tract infection with pyelonephritis

Personal Kidney Transplant

This first-person narrative was written by a kidney donor. When my 64-year-old father-in-law announced to my wife and me that his kidney function was failing, it really didn't cross our minds that one of us might have a role to play in his survival. Five years later, dialysis was taking its toll on his organ systems and there was no success in obtaining a cadaveric kidney. Things got to the point where he needed a kidney in a short time, before his health deteriorated to the point where he was no longer a candidate for a transplant. My wife's blood type ruled out her being a direct donor, so I volunteered to get tested. Turns out her dad and I were the same.

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in 5 of 7 key features - very good choice! The next round of tests, blood work and my kidney function, could be done locally. I remember carrying a sample container (on ice) and having to deliver a full liter of urine in 24 hours! The results of those tests were favorable, and two weeks later I drove an hour to the University of Virginia transplant center in Charlo Esville. Although a transplant is really a team of two, donor and recipient, the entire process at UVA was very individualized. A transplant coordinator (an experienced RN) was specifically assigned to our case, and I had a team of physicians and support staff dedicated solely to me, the donor. Likewise, there was a team that only served my father-in-law as a recipient. My visit involved some more in-depth blood work and cardiac studies largely to determine if he was healthy enough for major surgery. My transplant team and I spent an entire afternoon discussing the implications of being a donor: the risk inherent in any surgery, the potential implications for me and my family, the likely recovery time, and the possibility that, despite all the evidence, initials, the transplant cannot be performed. succeed. The discussions that afternoon only reaffirmed that he was making the right decision. I had the opportunity to make a positive impact on another person's life with relatively little risk to my own health. The events surrounding the surgery itself were pretty straightforward. Surgery is a more complicated procedure for the donor than the recipient, so they took me in first. A nurse started an IV and injected him with a mild sedative. From that moment on, my only memory is one last hug with my wife and children, and then being transferred from the gurney to the operating table. When I woke up in recovery, the news was good. My surgery went well: four laparoscopic incisions through which the surgeons did most of their work, and a lateral incision in my lower abdomen through which the kidney was removed. Just as important, my father-in-law had great surgery and his kidney started working right away! I was released from the hospital on Sunday and released to go home the following Friday, 8 days post-op. As is typical after major surgery, it took about 6 weeks for me to feel "normal" again. During those 6 weeks, I had weekly blood tests to record the progress of my kidney function. I returned to UVA for a routine follow-up appointment at 6 weeks. I was recovering as expected, and my remaining kidney was growing in size and capacity. Blood tests continued monthly until I was officially "discharged" from the transplant center 6 months after surgery. Now, 8 years after the transplant, my father-in-law and I are still doing well. As my mother-in-law likes to say, I donated a “rock star” kidney which has allowed our family to enjoy many visits and create many cherished memories to last a lifetime. My two sons, now 20 and 17, enjoyed the love and guidance of their grandfather during some very important years of their lives. This is especially meaningful to me because I lost my father.

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before my wife and I started our family, and our children missed out on knowing and loving a wonderful man. John Melson lives in Greensboro, North Carolina. He is pictured with his mother-in-law, Rod Beckwith.

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Exercises Remember to check your answers carefully with the Answers to the exercises, pages 234 and 235.

A Using the terms below, follow the path of urine from the renal arterioles (bloodstream) to the point where urine leaves the body. The first response is provided. glomerular capsule glomerulus renal pelvis renal tubule ureter urethra urinary bladder urinary meatus 1. glomerulus________________________________ 2. ____________________________________ 3. ____________________________________ 4. ____________________________________ 5. __________________________________ 6. ___________________________________ 7. ___________________________________ 8. _________________________________________ B Match the term in Column I with its definition or with its definition a term of similar meaning in column II. Write the correct letter in the spaces provided.

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COLUNA I

_______ 1. urination _______ 2. trigone _______ 3. renal cortex 4. renal medulla _______ _______ 5. urea 6. erythropoietin _______ _______ 7. renin _______ 8. electrolyte _______ 9. hilum _______ 10. calyx (chalice)

COLUMN II A. Hormone secreted by the kidney that stimulates the formation of red blood cells B. Notch in the surface of the kidney where blood vessels and nerves enter C. Urination; urination D. Nitrogenous waste E. Cup-shaped collecting region of the renal pelvis F. Small molecule that carries an electrical charge in solution G. Internal region of the kidney H. Enzyme produced by the kidney; increases blood pressure I. Triangular area in bladder J. Outer section of kidney

C Give the meaning of the following medical terms. 1. calyx ________________________________________________ ______________ 2. uric acid ________________________________________________ _______________ 3. meatal stenosis ________________________________________________ _____ 4. cystocele ________________________________________________ _________________ 5. pyelolithotomy ________________________________________________ ____________ 6. trigonitis __________________________________________ _________________ 7. ureteroileostomy __________________________________________________________ ___________ 8. urethrostenosis __________________________________________ ______________

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9. vesicoureteral reflux ________________________________________________ _________ 10. creatinine ________________________________________________ __________________ 11. medullary ________________________________________________ _________________ 12. cortical ________________________________________________ ___________________ 13. calciferol ________________________________________________ __________________ D All of the following terms contain the suffix -uria, meaning urination. Write their meanings in the spaces provided. 1. nocturia ________________________________________________ _________________ 2. dysuria ________________________________________________ ____________________ 3. oliguria ________________________________________________ __________________ 4. polyuria ________________________________________________ _________________ 5. anuria ________________________________________________ _____________________

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E In the following terms, -uria means urinary condition (substance in urine). What is in the urine? 1. pyuria _________________________ 2. albuminuria ___________________ 3. hematuria _________________ 4. glycosuria _________________ 5. ketonuria _____________________ 6. bacteriuria ______________________ F State the meaning of the following terms related to urinary signs and symptoms. 1. azotemia ________________________________________________ ______________________ 2. polydipsia ________________________________________________ ____________ 3. urinary incontinence ________________________________________________ _______ 4. enuresis ________________________________________________ ___________ 5. urinary retention ________________________________________________ _______ 6. ketosis ________________________________________________ _______ G Give brief answers to the following. 1. What is the difference between hematuria and uremia? __________________________

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2. What is diuresis? _____________________________________ 3. What is a diuretic? _____________________________________ 4. What is antidiuretic hormone? ________________________________ 5. What is hyponatremia? _____________________________________ 6. What is hyperkalemia? ___________________________________ 7. What is PKU? _________________________________ H Match the listed terms related to urinalysis with their meanings/descriptions below. Albuminuria Bilirubinuria Glycosuria Hematuria Ketonuria pH Pyuria Specific Gravity of Sediment 1. Abnormal Particles Present in Urine: Cells, Bacteria, Casts and Crystals ____________________ 2. Smoky Red Color of Urine Caused by Presence of Blood __________________ 3. Turbid (Cloudy) Urine caused by the presence of polymorphonuclear leukocytes and pus _______________________ 4. Sugar in the urine; a sign of diabetes mellitus and a result of hyperglycemia _____________________________

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5. Urine test that reflects the acidity or alkalinity of the urine _____________________ 6. High levels of acids and ketones accumulate in the urine as a result of the abnormal breakdown of fats _____________________ 7. Dark pigment that accumulates in the urine as a result of disease or gallbladder __________________________ 8. Urine test reflecting urine concentration _______________________ 9. Leaky glomeruli can cause protein buildup in the urine _________________ I Describe the following abnormal conditions that affect the kidney. 1. renal insufficiency _________________________ 2. polycystic kidney _____________________________ 3. interstitial nephritis _____________________________ 4. glomerulonephritis _________________________ 5. nephrolithiasis _________________________ 6. renal cell carcinoma ___________________ 7. pyelonephritis ___________________ 8. Wilms tumor _________________________ 9. nephrotic syndrome ______________________________ 10. renal hypertension ___________________ J Match the terms listed with their meanings/descriptions below. catheter abscess diabetes insipidus diabetes mellitus edema

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essential hypertension nephroptosis renal colic secondary hypertension stenosis 1. idiopathic high blood pressure ________________________________ 2. swelling, fluid in tissues ________________________________________ 3. narrowed area in a tube __________________________________________ 4. accumulation of pus __________________________________________ 5. inappropriate insulin secretion or inappropriate insulin utilization leads to this condition ________________________________________________ 6. High blood pressure caused by kidney disease or other disease ________________________________________________ 7. Tube for removing or giving fluids __________________________________________ 8. Inadequate secretion or resistance of the kidney to the action of antidiuretic hormone __________________________________________ 9. Prolapsed kidney _____________________________________ 10 Severe discharge resulting in pain from a stone that is blocking a ureter or kidney __________________________________ K Admi List the m meanings of the abbreviations in Column I. Then select the letter of the phrase in Column II that best corresponds to each.

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COLUNA I 1. CAPD __________________________ 2. BUN __________________________ 3. RP __________________________ 4. cisto __________________________ 5. UA __________________________ 6. UTI __________________________ 7. CKD __________________________ 8. K+ __________________________ 9. VCUG __________________________ 10. HD __________________________

_______ _______ _______ _______ _______ _______ _______ _______ _______ _______

COLUMN II A. Bacterial invasion leads to this condition; Acute cystitis is an example. B. This electrolyte is secreted by the renal tubules into the urine. C. A machine removes nitrogenous wastes from the patient's blood. D. Elevated levels measured in this test raise suspicion of kidney disease. E. This endoscopic procedure is used to examine the inside of the urinary bladder. F. The dialysate (liquid) is injected into the peritoneal cavity and then drained. G. Contrast is injected into the urinary bladder and ureters, and radiographs of the urinary tract are taken. H. X-ray images of the urinary bladder and urethra are taken while the patient urinates. I. Parts of this test include specific gravity, color, protein, glucose, and pH. J. This condition includes mild to severe renal failure.

L Match the procedures listed with their definitions/meanings below. cystectomy cystoscopy cystostomy lithotripsy nephrectomy nephrolithotomy nephrostomy ureterolithotomy urethroplasty ureteroileostomy 1. Excision of a kidney ________________________________________ 2. Surgical incision in the kidney to remove a stone ________________________ 3. Visual examination of the bladder through an endoscope ________________________ 4. Crushing of stones ______________________________________

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5. Reopening of the ureters into a segment of the ileum (instead of the bladder) ________________________________________ 6. Surgical repair of the urethra ________________________________________ 7. Creating an artificial opening into the kidney (via a catheter) from outside the body ________________________________________ 8 Surgical training of a bladder opening to the outside of the body _____________________________________ 9. Removal of the urinary bladder _____________________________________ 10. Incision of a ureter to remove a stone _____________________________________ M Circle the correct term to complete the following sentences. 1. After diagnosing renal cell carcinoma (performed by renal biopsy), Dr. Davis advised Donna that (nephrostomy, meatotomy, nephrectomy) would be necessary. 2. Since Bill's gout condition was diagnosed, he has been warned that uric acid crystals can accumulate in his blood and tissues, which he can cause (pyuria, kidney stones, cystocele). 3. Voiding cystourethrography showed blockage of urinary flow from Jim's bladder and (hydronephrosis, renal ischemia, azotemia). 4. Narrow arterioles in the kidneys increase blood pressure, therefore (urinary incontinence, urinary retention, nephrosclerosis) is often associated with hypertension. 5. Eight-year-old Willy continually wets the bed at night while sleeping. His pediatrician told his mother

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limit Willy's fluid intake at night to discourage him (nocturia, oliguria, enuresis). 6. David's chronic type 1 diabetes eventually resulted in (kidney disease, meatal stenosis, urolithiasis) leading to kidney failure. 7. After Sue's bilateral renal failure, her doctor advised dialysis and possible dialysis (cystostomy, nephrolithotomy, kidney transplant). 8. When Maria's left kidney stopped working, her contralateral kidney overdeveloped or (metastasized, atrophied, hypertrophied) to cope with the increased workload. 9. A popular diet program recommends eating foods high in fat and protein. People who follow this diet check for the presence of (ketones, glucose, amino acids) in their urine. 10. Andrea's urinalysis revealed proteinuria and her ankles began to swell, demonstrating pitting, a condition known as (ascites, edema, stenosis). She (gastroenterologist, urologist, nephrologist) diagnosed Andrea's condition as (polycystic kidneys, nephrotic syndrome, bladder carcinoma) and recommended medication to heal the leaky glomeruli and diuretics to reduce swelling.

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Answers to exercises A 1. glomerulus 2. glomerular capsule 3. renal tubule 4. renal pelvis 5. ureter 6. urinary bladder 7. urethra 8. urinary meatus B 1. C 2. I 3. J 4. G 5. D 6 . A 7. H 8. F 9. B 10. E C 1. belonging to a calyx (renal pelvis collector)

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2. Nitrogenous residues excreted in the urine; high uric acid levels in the blood are associated with gouty arthritis 3. narrowing of the urinary meatus 4. herniation of the urinary bladder 5. incision to remove a stone from the renal pelvis 6. inflammation of the trigone (triangular area in the bladder where ureters enter and urethra exits) 7. new opening between ureter and ileum (an anastomosis); the urine then leaves the body through an ileostomy; this surgery (ileal conduit) is performed when the bladder has been removed 8. narrowing (narrowing) of the urethra 9. reflux of urine from the bladder into the ureter 10. nitrogenous wastes produced as a result of muscle metabolism and excreted in the urine 11 Pertaining to the inner and middle section (of the kidney) 12. Pertaining to the outer section (of the kidney) 13. Active form of vitamin D secreted by the kidneys D 1. Frequent urination at night 2. Painful urination 3. scanty urination 4. excessive urination 5. no urination E 1. pus

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2. protein 3. blood 4. sugar 5. ketones or ketones 6. F bacteria 1. excess nitrogenous waste in the bloodstream 2. condition of great thirst 3. inability to hold urine in the bladder 4. urinary incontinence 5. inability to expel urine from the bladder 6. abnormal condition of ketone bodies (acids and ketones) in the blood and body tissues G 1. Hematuria is the presence of blood in the urine and uremia is a toxic condition of the excess urea (nitrogenous waste) in the bloodstream blood . Hematuria is a symptomatic condition of the urine (-uria) and uremia is an abnormal condition of the blood (-emia). 2. Diuresis is the excessive production of urine (polyuria). 3. A diuretic is a drug or chemical (caffeine or alcohol) that causes diuresis. 4. Antidiuretic hormone is a hormone produced by the pituitary gland that normally helps the kidney tubules to reabsorb water into the bloodstream. It acts against diuresis to help retain water in the blood.

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5. Hyponatremia is abnormally low levels of sodium in the bloodstream. 6. Hyperkalemia is an abnormally high concentration of potassium in the blood. The main cause is chronic renal failure. 7. PKU is phenylketonuria. This occurs when there are high levels of phenylketones in the urine and phenylalanine in the blood. The condition causes mental retardation in babies. H 1. sediment 2. hematuria (blood in the urine) 3. pyuria (pus in the urine) 4. glycosuria (sugar in the urine) 5. pH 6. ketonuria (ketones in the urine) 7. bilirubinuria (elevated levels of bilirubin in the urine) 8. specific gravity 9. albuminuria I 1. the kidney does not excrete waste 2. multiple fluid-filled sacs form in and on the kidney 3. inflammation of the connective tissue (interstitium) between the tubules kidney stones 4 .inflammation of the glomerulus of the kidney (may be a complication after strep infection) 5. kidney stone (kidney stone) condition

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6. Malignant tumor of the kidney in adults 7. Inflammation of the renal pelvis and renal parenchyma (caused by a bacterial infection, such as Escherichia coli, which spreads to the urinary tract from the gastrointestinal tract) 8. Malignant tumor of the kidney in children 9 .group of symptoms (proteinuria, edema, hypoalbuminemia) that appear when the kidney is damaged by a disease; also called nephrosis 10. hypertension caused by kidney disease J 1. essential hypertension 2. edema 3. stricture 4. abscess 5. diabetes mellitus 6. secondary hypertension 7. catheter 8. diabetes insipidus 9. nephroptosis 10. renal colic K 1 . continuous ambulatory peritoneal dialysis: F 2. blood urea nitrogen: D 3. retrograde pyelography: G 4. cystoscopy: E

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5. urinalysis: I 6. urinary tract infection: A 7. chronic kidney disease: J 8. potassium: B 9. voiding cystourethrography: H 10. hemodialysis: C L 1. nephrectomy 2. nephrolithotomy 3. cystoscopy 4. lithotripsy 5. ureteroileostomy 6. urethroplasty 7. nephrostomy 8. cystostomy 9. cystectomy 10. M ureterolithotomy 1. nephrectomy 2. kidney stones: do not confuse calculus (stone) with dental calculus, which is an accumulation of hardened dental plaque 3. hydronephrosis 4. nephrosclerosis 5 enuresis

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6. nephropathy 7. kidney transplant 8. hypertrophied 9. ketones 10. edema, nephrologist, nephrotic syndrome Answers to practical applications Urological case report

1. c 2. c 3. a 4. b 5. a 6. b Urinalysis results

1. glucose 2. bilirubin 3. color 4. protein 5. sediment 6. pH 7. specific gravity 8. ketones 9. appearance Urology case study

The correct diagnosis is d.

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Pronunciation of Terms

The terms you learned in this chapter are presented here with their pronunciations. The meanings of all the terms are found in the Mini Dictionary starting on page 897. You can also listen to the pronunciation of each term on the Evolve website (h p://evolve.elsevier.com/Chabner/language/).

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TERM acetone albuminuria antidiuretic hormone anuria arteriole azotemia bacteriuria BUN calciferol calyx calicectasis calyx; please calyces catheter cortical cortex creatinine creatinine clearance CT urography cystitis cystoscopy cystostomy diabetes insipidus diabetes mellitus diuresis dysuria electrolyte edema enuresis erythropoietin essential hypertension filtration glomerular capsule glomerulonephritis glomerulus; please glomerulus glycosuria hematuria hemodialysis hilum hydronephrosis hyperkalemia interstitial hypernatremia intravesical nephritis ketonuria ketosis kidney KUB medullary lithotripsy mechanistic stenosis medullary magnetic resonance imaging urography nephrolithiasis

PRONUNCIATION AS-eh-tohn al-bu-min-U-re-ah an-tih-di-u-RET-ik HOR-mohn an-U-re-ah ar-TE-re-ohl az-o-TE -me-ah bak-te-re-U-re-ah B-U-N kal-SIF-er-ol ka-lih-SE-al ka-le-EK-tah-sis KA-liks; KA-lih-seez KATH-et-er KOR-text KOR-tik-al cre-AH-do-neen cre-AH-do-neen KLE-ranz CT u-ROG-rah-fe sis-TEK-to-me sis-TI-tis sis-TOS-ko-pe sis-TOS-for-me di-ah-BE-teez in-SIP-ih-dus di-ah-BE-teez MEL-ih-tus di-u-RE -sis dis-U-re-a eh-DE-mah eh-LEK-tro-lite en-u-RE-sis eh-rith-ro-PO-eh-tin e-SEN-shul hi-per-TEN- shun fil-TRA-shun glo-MER-u-lar KAP-sul glo-mer-u-lo-nef-RI-tis glo-MER-u-lus; glo-MER-u-li gli-kohs-U-re-ah hem-ah-TU-re-ah he-mo-di-AL-ih-sis HI-lum hi-dro-neh-FRO-sis hi- per-my-LE-me-ah hi-per-na-TRE-me-ah in-ter-STIH-shul neh-FRI-tis in-trah-VES-ih-go foot-to-NU-re-ah ke-TO-sis KID-ne K-U-B LITH-o-trip-see me-A-number stone-O-sis me-A-tus meh-DU-lah MED-u-lah-re MRI u-ROG-raf- e neh-fro-lih-THI-ah-sis

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TERM nephrolithotomy nephron nephropathy nephroptosis nphrostomy nephrotic syndrome nitrogenous waste nocturia oliguria paranephric parenchyma peritoneal dialysis phenylketonuria polycystic kidney disease polydipsia polyuria pyelolithotomy potassium pyelonephritis pyuria renal angiography renal artery renal calculus renal carcinoma colic renal failure renal hypertension renal ischemia renal tubule renal pelvis renal transplantation retrograde vein renin pyelography secondary hypertension sodium stenosis trigonitis trigone urea uremia ureter ureteroileostomy ureteroneocystostomy ureteroplasty urethral stricture urethral urethritis urethroplasty uric acid urinalysis urinary bladder urinary catheterization

PRONUNCIATION neh-fro-lih-THOT-o-me NEH-fron neh-FROP-ah-the neh-FROP-to-sis neh-FROS-to-me neh-FROT-ik sin-drome ni-TROJ-en- us waste nok-TU-re-ah ol-ig-U-re-ah par-ah-NEF-rik pah-RENK-ih-mah per-it-o-NE-al di-AL-ih-sis fe- nil-ke-to-NU-re-ah pol-e-SIS-tik KID-ne dih-ZEEZ pol-e-DIP-se-ah pol-e-U-re-ah po-TAS-e-um pi-el -o-lith-OT-o-me pi-el-o-neh-FRI-tis pi-U-re-ah re-ab-SORP-shun RE-nal an-je-OG-rah-fe RE-nal RE of AN-je-o-plas RE of AR-teh-re RE of KAL-ku-li RE of sel kar-sih-NO-mah RE of KOL-ik RE of FA-lyur RE- nal hi-per - TEN-shun RE-nal is-KE-me-ah RE-nal PEL-vis RE-nal trans-plan-TA-shun RE-nal TU-bule RE-nal vine RE-nin RET-ro -grade PI- el -o-gram SEK-on-dah-re hi-per-TEN-shun SO-de-um STRIK-shur TRI-gohn tri-go-NI-tis u-RE-in u-RE- me-in U - reh-ter u-re-ter-o-il-OS-to-me u-re-ter-o-ne-o-sis-TOS-to-me u-re-ter-o- PLAS-o u - RE-thrah u-RE-thral STRIK-shur u-re-THRI-tis u-re-thro-PLAS-o acid U-ric u-rin-AL-ih-sis U-rin-ar -e BLAD- er U-rin-ar-e kath-et-er-ih-ZA-shun

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TERM urinary incontinence urinary retention urination vesicoureteral reflux urination cystourethrogram Wilms tumor

PRONUNCIATE U-rin-ar-e in-KON-tin-en U-rin-ar-e re-TEN-shun u-rin-A-shun ves-ik-o-u-RE-ter-al RE-flux VOY- em PE VOY-ding sis-to-u-RE-thro-gram wilmz TU-pared

revision sheet

Write the meanings of the combined forms, suffixes, and prefixes in the spaces provided. Check your answers with the information in the chapter or in the Glossary (Parts of Medical Words—English) at the end of this book.

Combined forms COMBINATION FORM albumin/angi/nitrogen/bacteria/cali/calico/cyst/immersions/glomerulus/glycos/hydr/isch/kal/i ket/ketone/ the lith

MEANING COMBINED FORM ____________________ carne/o ____________________ natr/o ____________________ necr/o ____________________ nefr/o ____________________ noct/o ____________________ olig/o ____________________ py/o ____________________ pyel/o ____________________ ren/o ____________________ trigon/o ____________________ ur/o ____________________ ureter/ la ____________________ urethra/la ____________________ orina/la ____________________ gallbladder/la ____________________

Suffixes SUFFIX -ectasia -ectomy -emia -esis -gram -lithiasis -lithotomy -lyse -megalia -ole -ose

SUFFIX -pathy -plasty -poietin -ptosis -rea -sclerosis -stenosis -stomy -tomy -virus -uria

prefixes

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PREFIX a-, anantidiadysen-

SENSE ____________________ ____________________ ____________________ ____________________ ____________________

PREFIX hipoperipoliretro-

SENSE ____________________ ____________________ ____________________ ____________________

Anatomical Terms Match the locations/functions in Column I with the structures of the urinary system in Column II. Write the correct frame number in the blank spaces provided. COLUMN I Tiny structure that surrounds each glomerulus; receives filtered materials from the blood. Tubes that carry urine from the kidney to the urinary bladder. Tubules leaving the glomerular capsule. Urine is formed there as water, sugar, and salts are reabsorbed into the bloodstream. Inner (middle) region of the kidney. Muscular sac that serves as a urine reservoir. Cup-shaped divisions of the renal pelvis that receive urine from the renal tubules. The tube that carries urine from the bladder to the outside of the body. Central urine collection vessel in the kidney that tapers into the ureter. Set of capillaries through which materials from the blood are filtered into the glomerular capsule. External region of the kidney.

COLUMN II ______ 1. urethra 2. cortex ______ 3. glomerular capsule ______ 4. calyces 5. renal ______ pelvis ______ 6. ______ glomerulus ______ 7. medulla 8. renal ______ tubules ______ 9. urinary bladder ______ 10. ureters

Provide the medical terms for the following conditions related to urine or substances in the urine. 1. sugar in the urine __________________________________________________ 2. protein in the urine __________________________________________________ 3. painful urination _________________________________________________ 4. little urination _____________________________________________ 5. bacteria in the urine _____________________________________________ 6. excessive urination ________________________________________________________ 7. blood in the urine _____________________________________________ 8. ketones in the urine urine _________________________________________________ 9. no urination ______________________________________ 10. pus in urine _________________________________________________ 11. excessive urination at night ________________________________

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CHAPTER 8

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Female Reproductive System CHAPTER SECTIONS: Introduction 242 Organs of the Female Reproductive System 242 Menstruation and Pregnancy 246 Vocabulary 250 Terminology 252 Pathology: Gynecologic, Mammary, Pregnancy, and Neonatal 258 Clinical Tests and Procedures 266 Abbreviations 272 Practical Applications 273 Face-to-Face: Prophylactic Mastectomy 2765 Exercises a exercises 284 Pronunciation of terms 286 Review sheet 289

CHAPTER OBJECTIVES • Name and locate the female reproductive organs and learn their combined forms. • Explain how these organs and their hormones work in the normal processes of ovulation, menstruation, and pregnancy. • Identify abnormal conditions of the female and newborn reproductive system.

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• Describe important laboratory tests and clinical procedures used in obstetrics and gynecology and recognize related abbreviations. • Apply your new knowledge to understand medical terms in their proper contexts, such as medical reports and records.

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Introduction Sexual reproduction is the union of the ovum (female sex cell) with the sperm (male sex cell). Each sex cell, known as a gamete, has half the number of chromosomes needed to create a new organism. At fertilization, the nuclei of the two gametes unite to form a single nucleus with half the chromosomes and the genetic code of each parent. Special organs called gonads in both males and females produce eggs and sperm. The female gonads are the ovaries and the male gonads are the testicles. After an egg leaves the ovary during ovulation, it travels down one of the two fallopian tubes to the uterus (womb). If intercourse (copulation, sexual intercourse) has occurred, millions of sperm travel to the fallopian tubes, but only one sperm can enter the egg. This is fertilization. The fertilized egg is then known as a zygote. After many cell divisions, a ball of cells is formed and the zygote is called an embryo (2 to 8 weeks) and finally a fetus (8 to 38 or 40 weeks). The period of development inside the uterus is gestation or pregnancy. The female reproductive system consists of organs that produce eggs (singular, ovum) and provide a place for the embryo to grow. In addition, the female reproductive organs supply important hormones that contribute to the development of female secondary sexual characteristics (body hair, breast development, structural changes in bone and fat). The ova, or ova, are present from birth in the female ovary, but begin to mature and are released from the ovary in a 21-28 day cycle, when the secondary sexual characteristics develop. The onset of the first cycle is called menarche. Menstrual cycles continue until menopause, when all the eggs have been released, hormone production slows, and menstruation ends. If fertilization occurs during the years between menarche and menopause, the fertilized egg can grow and develop inside the uterus. A new organ rich in blood vessels called the placenta (connected to the embryo by the umbilical cord) develops to nourish the embryo, which implants itself in the lining of the uterus. The ovary and placenta secrete various hormones to stimulate placental expansion. If fertilization does not occur, hormonal changes cause the lining of the uterus to shed and bleeding or menstruation. The ovarian hormones, estrogen and progesterone, play important roles in the processes of menstruation and pregnancy and in the development of secondary sexual characteristics. the pituitary gland,

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Located at the base of the brain, it secretes other hormones that govern the reproductive functions of the ovaries, breasts, and uterus. Gynecology is the study of the female reproductive system (organs, hormones, and diseases); obstetrics (from the Latin obstetrix means midwife) is a specialty that deals with pregnancy and fetal delivery; and neonatology is the study of the care and treatment of the newborn.

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Organs of the Female Reproductive System Uterus, Ovaries, and Associated Organs Refer to Figures 8-1 and 8-3 as you read the following description of the female reproductive system.

FIGURE 8-1 Female reproductive organs, lateral view.

Figure 8-1 shows a side view of the female reproductive organs and their relationship to other organs in the pelvic cavity. The ovaries [1] (only one ovary is shown in this side view) are a pair of small, almond-shaped organs located in the pelvis. The fallopian tubes [2] (only one is shown in this image) run from each ovary to the uterus [3], which is a fibromuscular organ located between the urinary bladder and the rectum. The uterus is normally the size and shape of a pear and is 3 to 4 inches long in a non-pregnant woman. Halfway between the uterus and the rectum is a region in the abdominal cavity known as the cul-de-sac [4]. The vagina [5], a tubular structure, extends from the uterus to the outside of the body. Bartholin's glands [6] are two small, rounded glands located on either side of the vaginal opening. These glands produce

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Mucous discharge that lubricates the vagina. The clitoris [7] is an organ of sensitive erectile tissue located anterior to the vaginal orifice (opening) and in front of the urethral orifice. The region between the vaginal opening and the anus is the perineum [8]. The external genitalia of a woman are collectively called the vulva. Figure 8-2 shows the various structures that make up the vulva. The labia majora, the outer lips of the vagina, surround the inner labia minora, the labia minora. The hymen, a thin membrane that partially covers the entrance to the vagina, tears during the first episode of sexual intercourse. The clitoris and Bartholin's glands are also part of the vulva.

FIGURE 8-2 Female external genitalia (vulva). The mount of Venus (from the Latin mons, mountain) is a cloth pad that covers the symphysis pubis. After puberty, it becomes covered in pubic hair.

Figure 8-3 shows an anterior view of the female reproductive system. Each ovary [1] is held in place on either side of the uterus by a utero-ovarian ligament [2].

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FIGURE 8-3 Female reproductive organs, anterior view.

Inside each ovary there are thousands of small sacs: the ovarian follicles [3]. Each follicle contains an ovum [4]. During ovulation, an egg cell matures; its follicle breaks the surface and releases the egg from the ovary. A ruptured follicle fills with a yellow, fat-like material. Then it is called the corpus luteum [5], which means yellow body. The corpus luteum secretes hormones (estrogen and progesterone) that maintain the early stages of pregnancy. A fallopian tube [6] is about an inch long and is located near each ovary. Together, the fallopian tubes, ovaries, and supporting ligaments are the appendages (accessory structures) of the uterus. The finger-like ends of the fallopian tube are the fimbriae [7]. They collect the egg after it is released from the ovary. The cilia (small hairs) line the fallopian tube and, through their movement, drag the egg towards the uterus. It usually takes 2-3 days for the egg to pass through the fallopian tube. If there are sperm in the fallopian tube, fertilization can occur (Figure 8-4). If there are no sperm, the egg remains unfertilized and eventually disintegrates.

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FIGURE 8-4 Fertilization. A. Once a single sperm has entered the egg, others are prevented from entering. B, Electron micrograph showing a sperm penetrating an egg.

The fallopian tubes, one on each side, lead to the uterus [8], a pear-shaped organ with muscular walls and a mucous membrane lining filled with abundant supply of blood vessels. The rounded top of the uterus is the fundus and the larger central section is the body (body of the organ). The inner layer, a specialized epithelial mucosa of the uterus, is the endometrium [9]; the middle muscular layer of the uterine wall is the myometrium [10]; and the outer layer of membranous tissue is the perimetrium (uterine serosa) [11], a lining that produces a watery, serum-like secretion. The outermost layer of an organ in the abdomen or chest is also known as the serosa. The lowest and narrowest portion of the uterus is the cervix [12] (from the Latin cervix meaning neck). The cervical opening leads to a 3-inch mucosa-lined muscular canal called the vagina [13], which opens to the outside of the body.

The label of the breast (accessory reproductive organ) Figure 8-5 as you read the following description of the structures of the breast.

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FIGURE 8-5 Views of the breast. Ah, sagittal. B, front. Note the numerous lymph nodes.

The breasts, located in the upper anterior region of the thorax, are composed mostly of mammary glands. Glandular tissue [1] contains mammary glands that develop in response to hormones from the ovaries during puberty. The breasts also contain fibrous and phallic tissue [2], special milk ducts (milk carriers) [3] and sinuses (cavities) [4] that carry milk to the nipple, which has small openings for the ducts to release their milk. Milk. The nipple is the mammary papilla [5], and the area of dark pigmentation around the mammary papilla is the areola [6]. During pregnancy, hormones from the ovaries and placenta stimulate the glandular and other tissues in the breasts to fully develop. After childbirth (giving birth), hormones from the pituitary gland stimulate the normal secretion of milk (lactation).

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Menstruation and Pregnancy Menstrual Cycle (Figure 8-6) Menarche, or the onset of menstruation with the first menstrual cycle, occurs around puberty. An average menstrual cycle lasts 28 days, but it can be shorter or longer, and cycles can be irregular in length. These days can be divided into four time periods, useful for describing the events of the cycle. The approximate deadlines are the following:

FIGURE 8-6 The menstrual cycle. Hint: don't try to memorize this figure. Just get the big picture! In the ovary, as the egg matures, hormone levels rise, culminating in ovulation (days 13 and 14). At the same time, in the uterus, the endometrium is forming in anticipation of pregnancy. If pregnancy does not occur, hormone levels drop and menstruation begins.

Days 1-5 (menstrual period) Discharge of bloody fluid containing disintegrated endometrial cells, glandular secretions, and blood cells. Days 6 to 12 After the bleeding stops, the endometrium begins to repair itself. The maturing follicle in the ovary releases estrogen, which aids in repair. The egg grows in the follicle during this period. Days 13 and 14 (ovulation period) Around day 14 of the cycle, the follicle ruptures and the egg leaves the ovary (ovulation) and travels down the fallopian tube.

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Days 15 to 28 The empty follicle that has just released the ovum becomes a corpus luteum (Latin for yellow body due to its color). The corpus luteum functions as an endocrine organ, continuing to produce estrogen and now secreting the hormone progesterone into the bloodstream. Progesterone stimulates the buildup of the endometrium prior to fertilization of the egg and pregnancy. If fertilization does not occur, the corpus luteum in the ovary stops producing progesterone and regresses. At this time, reduced levels of progesterone and estrogen are likely to be responsible for symptoms of depression, breast tenderness, and irritability before menstruation in some women. The combination of these symptoms is known as premenstrual syndrome (PMS). After 2 days of decreased hormones, the uterine lining breaks down and the menstrual period begins (days 1 to 5). Note: Cycles vary in length, from 21 to 42 days or longer. Ovulation usually occurs 14 days before the end of the cycle. A woman with a 42-day cycle ovulates on day 28, while a woman with a 21-day cycle ovulates on day 7.

Pregnancy If fertilization occurs in the fallopian tube, the fertilized egg travels to the uterus and implants in the uterine lining. The corpus luteum in the ovary continues to produce progesterone and estrogen. These hormones support the vascular and glandular development of the uterine lining. The placenta, a vascular organ, is now formed, attached to the uterine wall. The placenta is derived from the maternal endometrium and the chorion, the outermost membrane that surrounds the developing embryo. The amnion, the innermost of the embryonic membranes, holds the fetus suspended in an amniotic cavity surrounded by a fluid called amniotic fluid. The amnion with its fluid is also known as the “water sac” or amniotic sac, which ruptures (ruptures) during childbirth. Maternal blood and fetal blood never mix during pregnancy, but important nutrients, oxygen, and wastes are exchanged when the fetal blood vessels (from the umbilical cord) meet the mother's blood vessels in the placenta. Figures 8-7A and B show implantation in the uterus and the relationship of the embryo to the placenta and surrounding membranes (chorion and amnion).

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FIGURE 8-7 A. Embryo implantation in the endometrium. B, The placenta, with the membranes of the chorion and amnion.

As the placenta develops, it produces its own hormone, human chorionic gonadotropin (hCG). When women test their urine with a pregnancy test kit, the presence or absence of hCG confirms or rules out that they are pregnant. This hormone stimulates the corpus luteum to continue producing hormones until about the third month of pregnancy, when the placenta takes over endocrine function and releases estrogen and progesterone. Progesterone maintains the development of the placenta. Low progesterone levels can cause miscarriage in pregnant women and menstrual irregularities in women who are not pregnant. The uterus is normally located within the pelvis. During pregnancy, the uterus expands as the fetus grows, and the upper part emerges from the pelvic cavity to become an abdominal organ. Between 28 and 30 weeks it occupies much of the abdominopelvic cavity and reaches the epigastric region (Fig. 8.8).

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FIGURE 8-8 The enlarging uterus alters the pelvic anatomy during pregnancy, as shown here in a sagittal section: A, nonpregnant woman, B, 20 weeks pregnant, C, 30 weeks pregnant.

The beginning of true labor is marked by rhythmic contractions, dilation and thinning (effacement) of the cervix, and discharge of bloody mucus from the cervix and vagina (the “show”). In a normal birthing position, the baby's head appears first (cephalic presentation). After the baby is delivered vaginally, the umbilical cord is cut and the placenta follows (Figure 8-9). Figures 8-10A and B show photographs of a newborn and a placenta with a tender cord minutes after birth. The expelled placenta is the placenta.

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FIGURE 8-9 A, Cephalic presentation ("crown") of the fetus during labor through the birth canal (delivery). B, Usually 15 minutes after labor (birth), the placenta separates from the uterine wall. The strong contractions expel the placenta and attached membranes, now called the placenta. The three stages of labor are (1) dilation of the cervix, (2) delivery or delivery of the baby, and (3) delivery of the placenta.

FIGURE 8-10 A, My newborn granddaughter, Beatrix Bess (Bebe) Thompson, and her mother, Dr. Elizabeth Chabner Thompson, minutes after Bebe was born. Note that Bebe's skin is covered in vernix caseosa, a mixture of fatty secretions from the fetal sebaceous glands (oil) and dead skin. The vernix protects the delicate skin of the fetus from chafing, cracking and hardening as a result of being bathed in amniotic fluid. B, The placenta and umbilical cord just after delivery of the uterus.

hormonal interactions

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The events of menstruation and pregnancy depend on hormones not only from the ovaries (estrogens and progesterone) but also from the pituitary gland. The pituitary gland secretes follicle-stimulating hormone (FSH) and luteinizing hormone (LH) after the onset of menstruation. As their levels increase in the bloodstream, FSH and LH stimulate egg maturation and ovulation. The spike in LH levels is called the LH surge. This triggers ovulation and the development of the corpus luteum. The flare can last a few hours or a few days, and ovulation usually occurs within 24 hours of its onset. Home ovulation kits track LH levels in urine. After ovulation, LH influences the maintenance of the corpus luteum and its production of estrogen and progesterone. During pregnancy, high levels of estrogen and progesterone in the ovary and placenta cause the pituitary gland to stop producing FSH and LH. Therefore, while a woman is pregnant, the extra eggs do not mature and ovulation cannot occur. Oral contraceptives (birth control pills) work in the same way. Another female contraceptive method is the IUD (intrauterine device). A health professional inserts the IUD, a small device designed to stay inside the uterus. It works by preventing the implantation of the embryo. Birth control pills and IUDs do not protect a woman against sexually transmitted infections, such as those caused by HIV. See page 274 for a chart of contraceptive options and their characteristics.

How do birth control pills work?

Birth control pills contain a combination of estrogen and progesterone or only progesterone. When taken as directed, the levels of these hormones in a woman's bloodstream are increased. High levels of estrogen and progesterone send a signal to the pituitary gland to stop the secretion of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). When these hormones are blocked, the ovaries do not release eggs and pregnancy cannot occur. During pregnancy, estrogen and progesterone levels are also high, and the ovaries do not release eggs either! Thus, birth control pills effectively trick the body into "thinking" that the woman is pregnant and that her ovaries stop producing eggs. When all the eggs are released and estrogen secretion from the ovaries decreases, menopause begins. Menopause marks the gradual end of menstrual cycles. Premature menopause occurs before the age of 40, while late menopause occurs after the age of 55. artificial menopause

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It occurs if the ovaries are removed by surgery or become nonfunctional as a result of radiation therapy or some forms of chemotherapy. During menopause, when estrogen levels drop, the most common signs and symptoms are hot flashes (temperature regulation in the brain is disturbed), insomnia, and vaginal atrophy (the lining of the vagina dries out and thins, which predisposes the affected woman to irritation and discomfort during menstruation). intercourse). Hormone replacement therapy (HRT), given by mouth or as a transdermal patch or vaginal ring, relieves these menopausal symptoms and slows the development of weak bones (osteoporosis). HRT use may be associated with an increased risk of breast cancer, endometrial cancer, stroke, or heart attack. This therapy should be used only after careful consideration of the possible risks and benefits. Table 8-1 reviews the various female hormones, including where they are produced, their target organs, and their effects on the body. TABLE 8-1 SITES OF FEMALE HORMONE PRODUCTION FSH Pituitary gland LH Pituitary gland Estrogen Ovary Placenta (during pregnancy) Progesterone Ovary (corpus luteum) Placenta (during pregnancy) hCG Placenta HORMONE

TARGET ORGAN Ovary Ovary Uterus Uterus

EFFECT Stimulates ovum maturation Stimulates ovulation Builds the endometrial lining Maintains the uterine lining and placenta during pregnancy

Ovary (body that supports the luteal pregnancy)

FSH, follicle stimulating hormone; hCG, human chorionic gonadotropin; LH, luteinizing hormone.

Vocabulary

The following list reviews many of the new terms introduced in the text. Short definitions reinforce your understanding of the terms.

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appendages uterus amnion areola Bartholin's glands

Fallopian tubes, ovaries, and supporting ligaments. Innermost membrane that surrounds the embryo and fetus. Dark pigmented area around the nipple. Small mucus-secreting exocrine glands in the vaginal orifice (opening to the outside of the body). Caspar Bartholin was a Danish anatomist who described the glands in 1637. cervix The lower part of the uterus, similar to a neck. chorion Outermost membrane that surrounds the embryo and fetus; forms the fetal part of the placenta. clitoris A sensitive erectile tissue organ anterior to the opening of the female urethra. coitus Coitus; copulation. The pronunciation is KO-ih-tus. body Empty ovarian follicle that secretes progesterone after ovum is released; luteo literally means yellow body (luteus). dead end Region in the lower abdomen, halfway between the rectum and the uterus. embryo Stage in prenatal development from 2 to 8 weeks. endometrium The inner lining of the mucous membrane of the uterus. estrogen A hormone produced by the ovaries; promotes female secondary sexual characteristics. Fallopian tube One of a pair of tubes through which the egg travels to the uterus; also a tube called oviduct. The tubes are named after Gabriello Fallopia, an Italian anatomist. fertilization Union of the spermatozoon and the ovum from which the embryo develops. fetus Stage in prenatal development from 8 weeks to birth. Fimbriae Finger-like projections or stripes at the end of the fallopian tubes. (singular: fimbria) follicle Secreted by the pituitary gland to stimulate the maturation of the ovum (ovum). hormone gamete (FSH) Male or female sexual reproductive cell; sperm or egg. genitalia Reproductive organs; Also called genitalia. gestation Period of time from fertilization of the ovum to birth; the pregnancy. gonad Female or male reproductive organ that produces sex cells and hormones; ovary or testis. gynecology The study of the female reproductive organs, including the breasts. A human hormone produced by the placenta to maintain pregnancy by stimulating (chorionic trophin) the ovaries to produce estrogen and progesterone. gonadotropin (hCG) hymen Mucous membrane that partially or completely covers the opening of the vagina. labia labia of the vagina; the labia majora are the outermost and largest lips, and the labia minora are the innermost and smallest lips. Milk ducts that carry milk from the mammary glands to the nipple. Luteinizing ducts Secreted by the pituitary gland to promote ovulation. mammary hormone (LH) Mammary nipple. A papilla is any small nipple-like projection. Papilla menarche Beginning of the first menstrual period and ability to reproduce. menopause Gradual end of menstruation.

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menstruation Monthly shedding of the uterine lining. The flow of blood and tissue that is normally discharged during menstruation is called menstruation (from the Latin mensis meaning month). myometrium Muscular layer of the uterus. neonatology The study of the medical care of the newborn (neonatal). obstetrics The branch of medicine and surgery concerned with pregnancy and childbirth. hole An opening. ovary The developing sac that surrounds each ovum within the ovary. Only about 400 follicles from these sacs mature in a woman's lifetime. ovary One of a pair of female organs (gonads) on each side of the pelvis. The ovaries are almond-shaped, about the size of large walnuts, and produce ova (ova) and hormones. ovulation Release of an egg from the ovary. egg (plural: mature ovum (female gamete). Egg cells develop from immature ova) called oocytes. childbirth Act of giving birth. perimetrium Outermost layer of uterus; uterine serosa. perineum In women, the area between the anus and the vagina. pituitary gland Endocrine gland at the base of the brain. It produces hormones that stimulate the ovaries. The pituitary gland also regulates other endocrine organs. placenta A painful vascular organ in the uterine wall during pregnancy. It allows the exchange of oxygen, nutrients and fetal waste between the mother and the fetus. Pregnancy Pregnancy. progesterone Hormone produced by the corpus luteum in the ovary and placenta of pregnant women. puberty Period of adolescent development in which secondary sexual characteristics appear and gametes are produced. uterus A pear-shaped, hollow, muscular female organ in which the embryo and fetus develop and from which menstruation occurs. The top is the bottom; the middle portion is the corpus; and the lower, cervix-like portion is the cervix (see Figure 8-3, page 244). vagina Muscular canal lined with mucus that extends from the uterus to the outside of the body. vulva External female genitalia; includes the labia, hymen, clitoris, and vaginal opening. zygote Stage in prenatal development from fertilization and implantation to 2 weeks.

Terminology

Write the meanings of the medical terms in the spaces provided.

match shapes

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COMBINATION OF MEANINGS amnion bartholin

Bartholin's gland

cervico/o chori/o, chorion/o colp/o culd/o

cervix, chorion of the neck

episode

vulva

galacto/o

leite

gynecologist

women

ayer

uterus, uterus

milk/or

leite

madre

otherwise

mast

otherwise

asshole vagina

TERMINOLOGY

SENSE

amniocentesis __________________________________ amniotic fluid ___________________________________ Produced by fetal membranes and the fetus. bartholinitis __________________________________ A Bartholin cyst is a fluid-filled sac caused by obstruction of a duct of the Bartholin gland. If a bacterial infection occurs, an abscess may form. endocervicitis __________________________________ chorionic __________________________________ colposcopy ___________________________________ culdocentesis ___________________________________ A needle is placed through the posterior wall of the vagina and fluid is withdrawn for diagnostic purposes. episiotomy __________________________________ An incision in the skin of the perineum enlarges the vaginal opening for delivery. The incision is repaired by perineorrhaphy. Galactorrhea __________________________________ Abnormal and persistent secretion of milk, commonly seen in tumors of the pituitary gland. Gynecomastia __________________________________ Breast enlargement in a man. It usually occurs with puberty or aging, or the condition may be drug related. hysterectomy __________________________________ Total abdominal hysterectomy (TAH) is the removal of the entire uterus (including the cervix) through an abdominal incision (Fig. 8-11). Vaginal hysterectomy (VH) is removal through the vagina. Laparoscopic supracervical hysterectomy (see Figure 8-11) is a partial hysterectomy that preserves the cervix. hysteroscopy ___________________________________ A gynecologist uses an endoscope (passed through the vagina and cervix) to view the uterine cavity. lactation __________________________________ The normal secretion of milk. Inframammary __________________________________ Infra- means below. mammoplasty __________________________________ Includes reduction and augmentation (enlargement) operations. mastitis __________________________________ Usually caused by a strep or staphylococcal infection. mastectomy __________________________________ Mastectomy procedures are discussed in Breast Cancer (see page 262).

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CORRESPONDENCE MEANING TERMINOLOGY MEANING FORM menstruation, amenorrhea __________________________________ menstruation Absence of menstruation for 6 months or more than three of the patient's normal menstrual cycles. dysmenorrhea __________________________________ oligomenorrhea ___________________________________ Infrequent menstrual periods or scanty menstrual periods. menorrhagia __________________________________ Abnormally heavy or prolonged menstrual periods. Fibroids (see page 260) are one of the main causes of menorrhagia. metro/o, uterine metrorrhagia __________________________________ metro/o Bleeding between menses. Possible causes of metrorrhagia include ectopic pregnancy, cervical polyps, and ovarian and uterine tumors. menometrorrhagia __________________________________ Excessive uterine bleeding during and between menstrual periods. myom/o muscle, myom/o, myometrium ___________________________________ muscle myomectomy ___________________________________ tumor Removal of fibroids (fibroids) from the uterus. nat/i neonatal birth ___________________________________ obstetrics/o pregnancy obstetrics ___________________________________ e From the Latin obstetrix, midwife. childbirth ovum oogenesis ___________________________________ oocyte __________________________________ immature ovum. oophor/o ovarian oophorectomy ___________________________________ Oophor/o means to produce (phor/o) ovules (o/o). In a bilateral oophorectomy, both ovaries are removed. ov/the egg ovule ___________________________________ Ripe egg. ovary ovary __________________________________ anovulatory ovum/ovum ___________________________________ perine/or perineum perineorrhaphy ___________________________________ to/or have oophoritis ___________________________________ salping/or fallopian salpingectomy _________________________________ tubs Figure 8-12 shows a total hysterectomy with bilateral salpingo-oophorectomy (BSO). uterus/uterus uterine prolapse ___________________________________ vagina/vaginal opening Vaginal opening ___________________________________ An orifice is an opening. vaginitis __________________________________ Bacteria and yeast (usually Candida) often cause this infection. The use of antibiotic therapy can cause the loss of normal vaginal bacteria, resulting in an environment that allows yeast to grow. vulv/or vulva vulvovaginitis __________________________________ vulvodynia ___________________________________ Chronic pain (without identifiable cause) affecting the vulvar area (labia, clitoris, and vaginal opening).

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FIGURE 8-11 Normal uterus and hysterectomies. A total hysterectomy is the removal of the entire uterus: fundus, body, and cervix. This can be done through an abdominal or vaginal incision. Laparoscopic supracervical hysterectomy is the removal of the upper part of the uterus (above the cervix), leaving the cervix intact. Three to five small incisions are made in the abdomen, and the uterus is removed using a laparoscope. Robotic hysterectomy (da Vinci surgery) is another option that uses small incisions, three-dimensional vision, and a magnified view of the surgical site.

FIGURE 8-12 Total hysterectomy with bilateral salpingo-oophorectomy.

suffixes

485

SUFFIX MEANING TERMINOLOGY MEANING -arc onset of menarche _____________________________________ -cyesis pregnancy pseudocyesis _________________________________ Pseudo- means false. There is no pregnancy, but physical changes do occur, such as weight gain and amenorrhea. pregnant primiparous ________________________________ pregnant A woman during her first pregnancy (primi- means first). Gravida is also used to designate a pregnant woman, usually followed by a number to indicate the number of pregnancies (pregnant 1, 2, 3). -delivery, primiparous __________________________________ que brings Adjective that describes a woman who has given birth to at least a fourth child. Pará is also used as a noun, usually followed by a number to indicate the number of births after the 20th week of gestation (paragraph 1, paragraph 2, paragraph 3). When a woman arrives in the delivery room, her pregnancy and delivery are important facts to include in the medical and surgical history. For example, G2P2 is a medical abbreviation for a woman who has had 2 pregnancies and 2 deliveries. -rhea leucorrhea discharge ___________________________________ This vaginal discharge is normal or becomes more yellow (purulent or with pus) as a sign of infection. menorrhoea __________________________________ fallopian pyosalpinx ___________________________________ salpinx (uterine) tube -tocia labor, birth dystocia ___________________________________ oxytocia __________________________________ Oxy- means sharp or rapid. The pituitary gland releases oxytocin, which stimulates the contraction of the pregnant uterus (labour begins). It also stimulates the secretion of milk from the mammary glands. act of cephalic version __________________________________ turning version The fetus turns so that the head is the part of the body closest to the cervix (version can occur spontaneously or can be performed by the obstetrician). Fetal presentation is the way the fetus appears to the examiner during delivery. A breech presentation is the buttocks first, or feet first in a small breech presentation; a cephalic presentation is head first.

prefixes

486

PREFIX MEANING TERMINOLOGY MEANING Dyspareunia dyspain ___________________________________ (dis-pah-RU-ne-ah) Pareunia means coitus. endometritis endointerior _________________________________ Usually caused by a bacterial infection. involution of the uterus ________________________________ Vol- means to turn around. The uterus returns to its normal size before pregnancy. intrauterine intrauterine device _____________________________________ Figure 8-13A shows an IUD. multi- many multiparous ____________________________________ multipregnant _____________________________________ A woman who has been pregnant more than once. nullino, no, nulligravida _________________________________________ not nulliparous _____________________________________ Paragraph 0. Figure 8-13B shows the cervix of a nulliparous woman and the cervix of a multiparous woman (who delivered vaginally). pre-before prenatal ____________________________________ primi-first primiparous ___________________________________ retroverse retroversion ____________________________________ The uterus is abnormally tilted backwards. This occurs in 30% of women.

FIGURE 8-13 A. Intrauterine device (IUD) placed to prevent implantation of a fertilized egg. B, The cervix of a nulliparous woman (the os, or opening, is small and perfectly round) and the cervix of a multiparous woman (the os is wide and irregular). These views would be visible on colposcopic examination.

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Pathology: gynecological cancer, breast, pregnancy and neonatal gynecological uterus cervical cancer (carcinoma of the cervix)

Malignant cells in the cervix. The human papillomavirus (HPV) is both a cause and a risk factor for the development of cancer. Other factors that can work together with HPV to increase the risk of developing cervical cancer include smoking and smoking, having multiple sexual partners, and having a weakened immune system (for example, AIDS patients). The human papillomavirus is the most widespread sexually transmitted infection in the world. In countries with high rates of HPV infection, cervical cancer may become the most common cancer in adult women. There are more than 200 types of HPV. Some cause genital warts (benign growths on the vulva, cervix, vagina, or anus), while others can cause cancer, most commonly on the cervix, vagina, vulva, anus, penis, or head. and parts. Most HPV infections are cleared by a person's immune system. A persistent infection can lead to precancerous changes called cervical intraepithelial neoplasia (CIN). See Figure 8-14 which shows the progression of the NIC. CIN is also known as cervical dysplasia (abnormal cell growth). Carcinoma in situ (CIS) is considered an early, localized, and precancerous form of cervical cancer, and local resection (conization) of the CIS may be necessary to prevent the development of invasive cancer. Figure 8-15 shows a normal cervix and one with cervical cancer. Surgical treatment of cervical cancer requires a radical hysterectomy, in which the entire uterus is removed with ligaments, supporting tissues, and the upper third of the vagina. Radiation therapy and cisplatin chemotherapy are used to treat disease that has spread beyond the cervix to nearby pelvic tissues and distant organs. Brachytherapy (radioactive seeds implanted in the cervix) can also be an effective treatment.

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FIGURE 8-14 Precancerous neoplastic lesions are called cervical intraepithelial neoplasia (CIN). Pathologists diagnose such lesions from a Pap smear (microscopic examination of cells scraped from the cervical epithelium) and classify them as CIN-1 to CIN-3. Cervical carcinoma in situ (CIS) is equivalent to CIN-3. These are precancerous lesions that have not yet invaded the substance of the cervix.

FIGURE 8-15 Normal cervix (A) and cervix with cervical cancer (B) seen on colposcopy.

HPV vaccine

HPV vaccines are given as a series of three shots over 6 months to protect women and men against HPV infection. Girls can get this vaccine to prevent cervical, vulvar, and vaginal cancer, and

489

Genital warts. Children receive the vaccine to prevent anal cancer and genital warts. The names of these vaccines are Cervarix, Gardasil, and Gardasil 9. cervicitis

endometrial cancer (endometrial carcinoma)

endometriosis

fibroids

Inflammation of the cervix. Bacteria such as Chlamydia trachomatis and Neisseria gonorrhoeae commonly cause cervicitis. In acute cervicitis, the cervix becomes red and may show exudate (discharge) or even ulcerations. After ruling out the presence of malignancy (by Pap smear or biopsy), cryocautery (destroy tissue by freezing) of the affected area and treatment with antibiotics may be indicated. Malignant tumor of the lining of the uterus (adenocarcinoma). The most common sign of endometrial cancer is postmenopausal bleeding. This malignancy most often occurs in women exposed to high levels of estrogen, either through estrogen replacement therapy, estrogen-producing tumors, or obesity (fat tissue produces estrogen). Doctors perform endometrial biopsy, hysteroscopy and dilation (enlargement of the cervical canal) and age cure (scraping of the inner lining of the uterus) for diagnosis. When the cancer is confined to the uterus, surgery (hysterectomy and bilateral salpingo-oophorectomy) is curative. Radiation oncologists administer radiation therapy as additional treatment. Endometrial tissue located outside the uterus. In endometriosis, endometrial tissue can be found in the ovaries, fallopian tubes, supporting ligaments, or small intestine, leading to inflammation and scar tissue. When the endometrium sheds and bleeds in your monthly cycle, it can cause dysmenorrhea, or pelvic pain. Infertility (inability to become pregnant) and dyspareunia may also occur. Most cases are the result of the growth of pieces of menstrual endometrium that have passed backward through the lumen (opening) of the fallopian tube and into the peritoneal cavity. When endometriosis affects the ovaries, large cysts filled with menstrual blood ("chocolate cysts") develop. Symptoms may not correlate with the amount of endometriosis. Women may have extensive disease but no symptoms, while others may have minimal endometriosis but severe symptoms. Treatment ranges from symptomatic pain relief and hormonal medications that suppress the menstrual cycle to surgical removal of ectopic endometrial tissue and hysterectomy. Benign tumors in the uterus. Fibroids, also called leiomyomas or leiomyomas (lei/o = smooth, my/o = muscle, and -oma = tumor), are composed of fibrous tissue and muscle. If the fibroids grow and cause symptoms such as metrorrhagia (irregular periods), pelvic pain, or menorrhagia (heavy periods), a myomectomy or hysterectomy is indicated. Ablation (destruction) of fibroids without surgery can be done by uterine artery embolization (UAE), in which small pellets (acting like emboli) are injected into a uterine artery, blocking the blood supply to the fibroids and causes them to shrink. Figures 8-16A and B show the location of uterine fibroids.

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FIGURE 8-16 A. Location of uterine fibroids (leiomyomas). Pedunculated growths protrude from the stems. A subserous mass is found under the serous (outermost) layer of the uterus. A submucosal leiomyoma grows under the mucosal (innermost) layer. Intramural masses (mural means wall) arise within the muscular uterine wall. B, Fibroids are shown after hysterectectomy.

ovaries

491

ovarian cancer

ovarian cysts

Malignant tumor of the ovary (adenocarcinoma). Each year, approximately 22,000 women in the United States are diagnosed with ovarian cancer. Two types of ovarian cancer are the most common: serous (clear fluid) and mucinous (thick, pasty fluid) cystadenocarcinomas. The tumor is usually discovered at an advanced stage as an abdominal mass and may produce few symptoms in its early stages. When the disease metastasizes beyond the ovary before diagnosis, ascites (fluid accumulation in the abdominal cavity) is often present. Treatment consists of surgery to remove as much of the tumor as possible (tumor excision). This may include hysterectomy, bilateral salpingo-oophorectomy, and removal of the omentum (membranous tissue that covers abdominal organs and often contains tumor deposits). Surgery is followed by systemic drug treatment, which depends on the type of ovarian cancer. A protein marker produced by tumor cells, CA 125, can be measured in the bloodstream to assess the effectiveness of treatment. Inherited mutations (changes) in genes greatly increase the risk of developing ovarian and breast cancer. These mutations are BRCA1 and BRCA2 (short for breast cancer 1 and breast cancer 2). Women with a strong family history of ovarian cancer (with multiple family members affected) may seek genetic counseling to determine if they should be tested for these inherited defects. Prophylactic (preventive) oophorectomy significantly reduces the chances of developing ovarian cancer if a woman is at high risk. Fluid-filled sacs within the ovary. Some cysts are benign and are lined with typical ovarian cells. These cysts originate from unruptured ovarian follicles (follicular cysts) or from follicles that ruptured and were immediately sealed (luteal cysts). Other cysts are malignant and lined with tumor cells (cystadenocarcinomas). Doctors decide to remove these cysts to distinguish between benign and malignant tumors. Other benign ovarian cysts are dermoid cysts. They contain a variety of cell types, including skin, hair, teeth, and cartilage, and arise from immature eggs in the ovary. Due to the unusual variety of tissue types in the tumor (Fig. 8.17), this tumor is often referred to as a benign cystic teratoma (terat/o = monster) or mature teratoma. Surgical removal of the cyst cures the condition.

FIGURE 8-17 Dermoid ovarian cyst with hair, skin, and teeth. (Courtesy of Dr. Elizabeth Chabner Thompson).

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Pelvic inflammatory disease of the fallopian tubes (PID)

Inflammation and infection of organs in the pelvis and abdomen; salpingitis, oophoritis, endometritis, endocervicitis. PID is caused by sexually transmitted infections. Repeated episodes of these infections lead to the formation of adhesions and scarring in the fallopian tubes. After PID, women are at increased risk of ectopic pregnancy and infertility. Signs and symptoms include fever, vaginal discharge, abdominal pain in the left and right lower quadrants (LLQ and RLQ), and tenderness of the cervix. Antibiotics treat PID.

Sexually transmitted infections (STIs)

Examples of bacterial and viral sexually transmitted diseases in women are:

• gonorrhea (gonococcal bacteria) • chlamydia (chlamydial bacteria) • syphilis (spirochetal bacteria) • genital herpes (herpes simplex virus, HSV) • HPV infection and genital warts (human papillomavirus) More information on STDs in women and men on page 302 .

otherwise

493

breast cancer

Malignant tumor of the breast (derived from the mammary glands and ducts). The most common type of breast cancer is invasive ductal carcinoma (IDC). Invasive means that the tumor has spread to surrounding breast tissue. Figure 8-18A shows the tumor on a mammogram. Figure 8-18B shows a section through an invasive ductal carcinoma. Other histopathologic (tissue tissue) types include lobular and medullary breast carcinomas. Ductal carcinoma in situ (DCIS) is a non-invasive breast cancer. It begins in the lactiferous ducts and does not spread beyond its original location (in situ). DCIS can increase the risk of developing invasive breast cancer and is treated with mastectomy. Breast cancer spreads first to the lymph nodes in the armpit (armpit) closest to the affected breast and then to the skin and chest wall. From the lymph nodes, it can also metastasize to other organs in the body, including the bones, liver, lungs, and brain. Diagnosis is initially established by biopsy, core needle aspiration, or surgical removal of the specimen (solid mass or area of microcalcification). A stereotactic core needle biopsy is performed with the aid of a mammogram as a guide. For small primary tumors, the lump with surrounding tissue may be removed immediately (lumpectomy). To find out if the tumor has spread to the lymph nodes, a sentinel lymph node (SLN) biopsy is done. For this procedure, a blue dye or radioisotope is injected into the tumor site and travels to the axillary (under the arm) lymph nodes. See Figure 8-19. After lumpectomy, radiation therapy to the breast and all involved lymph nodes is followed to destroy any remaining tumor cells. An alternative surgical procedure is a mastectomy (Figure 8-20A), which involves removal of the entire breast. After a lumpectomy or mastectomy, if the lymph nodes are involved or if the primary tumor is large, adjuvant (adjuvant) chemotherapy is given to prevent tumor recurrence. Breast reconstruction is an option after mastectomy. See Figure 8-20B. In patients with large primary tumors, neoadjuvant chemotherapy (added before surgery) may be given to shrink the tumor and allow complete surgical removal of the tumor. After surgery, additional treatment may be indicated to prevent recurrence. To determine which treatment is best, it is important to test the breast cancer tumor for the presence of estrogen receptors (ERs). Two thirds of breast cancers are ER-positive (ER+). These receptor proteins indicate that the tumor will respond to therapy that blocks estrogen stimulation. If metastases later develop, this information will be valuable in selecting further treatment. There are two types of drugs that block the effects of estrogen and therefore kill ER-positive breast cancer cells. Drugs of the first type directly block ER reception. An example is tamoxifen. Drugs of the second type block estrogen production by inhibiting the aromatase enzyme. These aromatase inhibitors are particularly useful in the treatment of postmenopausal women. Examples are anastrozole (Arimidex) and letrozole (Femara). A second receptor protein, HER2, is found in some types of breast cancer and signals a high risk of tumor recurrence. Herceptin, an antibody that binds to and blocks HER2, is effective at stopping growth when used with chemotherapy. A new drug, pertuzumab, also targets HER2 and, combined with Herceptin, is effective in the treatment of HER2-positive advanced breast cancer. Triple-negative tumors lack estrogen, progesterone, and HER2 and grow rapidly but respond well to chemotherapy. Testing for heritable BRCA1, BRCA2, and PALB2 mutations (BRCA1 and BRCA2 associate and localizer) is recommended for women with a strong family history of breast cancer. Some women who test positive on the breast test

494

fibrocystic breast disease

Cancer genes opt for prophylactic (preventive) bilateral mastectomy with reconstruction to eliminate the risk of developing a new breast cancer. See Personal History: Prophylactic Mastectomy on page 275. Numerous small sacs of fluid surrounded by dense strands of fibrous tissue in the breast. Women with this common benign condition notice a nodular consistency (lump) in the breast, often associated with premenstrual tenderness and fullness. Mammography and surgical biopsy are often indicated to differentiate fibrocystic changes from breast cancer.

FIGURE 8-18 A, Arrows on mammogram point to invasive breast cancer. A dense white calcium spot is seen at 2 o'clock in the mass; Calcifications like this are often a sign of cancer. B, Cross section of invasive ductal carcinoma of the breast.

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FIGURE 8-19 Sentinel lymph node biopsy. After injection of dye or radioisotope, its course is visualized and the sentinel lymph node (first) is identified. It is more likely to contain a tumor if the cells have left the breast. The sentinel lymph node is removed and biopsied. If it is negative for tumor cells, the breast cancer has not spread.

FIGURE 8-20 A. Surgical scar, mastectomy, right breast. A modified radical mastectomy removes the breast and underarm lymph nodes (usually 20 to 30 nodes). B, Reconstruction of the right breast after a skin-sparing mastectomy. A silicone gel implant was used. In a second operation, local tissue was manipulated to create the appearance of a nipple-areola complex. The procedure was completed with the colored tattoo around the nipple. In this patient, the right breast tissue was removed prophylactically and a silicone implant was inserted through an inframammary incision. (A, Courtesy of Dr. Elizabeth Chabner Thompson.)

The pregnancy

496

placental abruption

choriocarcinoma

Ectopic pregnancy

multiple pregnancies

previous placenta

preeclampsia

Premature separation of the normally implanted placenta. Placental abruption (from Latin ab, away from; ruptus, broken) occurs due to trauma, such as a fall, or it may be secondary to vascular insufficiency resulting from hypertension or preeclampsia (see page 265). Signs and symptoms of an acute abruption include sudden severe abdominal pain (burning) and bleeding. It's an obstetric emergency. Malignant tumor of the placenta. This extremely rare cancerous tumor comes from cells that were part of the placenta in a normal pregnancy. Treatment of metastatic choriocarcinoma may include chemotherapy and radiation therapy to distant sites of the cancer. Implantation of the fertilized egg outside the uterus. The condition occurs in 1-2% of all pregnancies, with most of them occurring in the fallopian tubes (tubal pregnancy). Rupture of the ectopic implant within the fallopian tube can lead to massive abdominal bleeding and death. Surgeons can remove the implant, or drug treatment (methotrexate) can destroy it, thus preserving the fallopian tube before it ruptures. Other ectopic pregnancy sites include the ovaries and abdominal cavity; Whatever the location, an ectopic pregnancy often constitutes a surgical emergency. Presence of more than one embryo developing in the uterus during pregnancy. Multiple births are on the rise in the United States. This is due to assisted reproductive technology (ART), such as ovulation induction followed by intrauterine insemination (IUI) or in vitro fertilization (IVF). These pregnancies are at increased risk of preterm birth, fetal growth restriction, high blood pressure, and diabetes. Implantation of the placenta over the cervical opening or in the lower region of the uterus (Figure 8-21). Maternal signs and symptoms include painless bleeding, hemorrhage, and preterm labor. Usually, a cesarean section is recommended. Abnormal condition associated with pregnancy, characterized by high blood pressure, proteinuria, edema, and headache. Mild preeclampsia can be treated with bed rest and close control of blood pressure. Women with severe preeclampsia need treatment with medications such as magnesium sulfate to prevent seizures, and the baby is delivered as soon as possible. The Greek word eklampein means to shine, referring to seizures and hypertension, often with visual symptoms of flashing lights, accompanying the condition. Eclampsia is the final and most serious stage of untreated preeclampsia. It often causes seizures and even death in both mother and baby.

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Previous placenta. Previous means before or in front of. Three forms of this abnormal placental implantation are: placenta accreta (in the wall but not in the muscle), placenta increta (in the uterine muscle), and placenta percreta (attached to another organ). FIGURE 8-21

Neonatal The following terms describe conditions or symptoms that may affect the newborn. The Apgar score (Figure 8-22) is a system for rating a baby's physical condition at one minute and again at 5 minutes after birth. Heart rate, respiration, color, muscle tone, and response to stimuli are scored as 0, 1, or 2. The maximum total score is 10. Babies with an Apgar score less than 7 require immediate medical attention, such as airway suction or oxygen to help with breathing.

Apgar score table. This test is named after anesthesiologist Virginia Apgar (1909-1974), who developed it in 1953. Dr. Joseph Butterfield, in 1963, introduced an acronym "APGAR" as a mnemonic (memory device): Appearance (color) , Pulse (heart rate), Grimaces (response to catheter in the nostril), Activity (muscle tone), and Respiration (breathing). effort). FIGURE 8-22

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Down syndrome Hemolytic disease of the newborn (HDN) Infant respiratory distress syndrome (IRDS) Hydrocephalus

meconium aspiration syndrome

pyloric stenosis

The chromosomal abnormality (trisomy 21) causes mental retardation, growth retardation, and a flat face with a short nose, low-set ears, and slanted eyes. Destruction of red blood cells in the newborn caused by a blood group incompatibility (Rh factor) between the mother and the fetus. See explanation in Chapter 4, page 115. Acute lung disease commonly seen in preterm infants. This condition is caused by a deficiency of surfactant, a protein necessary for proper lung function. Surfactant may be given to the newborn to cure the condition. This condition was formerly called hyaline membrane disease. Accumulation of fluid in the spaces of the brain. In a child with this condition, the entire head may become enlarged because the skull bones are not fully fused at birth. Babies usually have a soft spot or fontanel between the bones of the skull that allows them to swell a little during the baby's birth. Hydrocephalus occurs due to a problem with the circulation of fluids in the brain and spinal cord, resulting in the accumulation of fluids. Abnormal inhalation of meconium produced by a fetus or newborn. Meconium, a thick, sticky, greenish to black substance, is the first intestinal discharge (feces) of newborns. Intrauterine suffering can cause it to pass into the amniotic fluid. Once the meconium has passed into the surrounding amniotic fluid, the fetus can inhale meconium into the lungs. It can cause breathing problems due to inflammation of the baby's lungs after birth. Narrowing of the opening of the stomach to the duodenum. This condition can be present at birth and is often associated with Down syndrome. Surgical repair of the pyloric opening may be necessary.

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Clinical Tests and Procedures Clinical Tests Papanicolaou (Pap smear)

Microscopic examination of stained cells taken from the vagina and cervix. After inserting a vaginal speculum (instrument to separate the vaginal walls), the doctor uses a small spatula to remove exfoliated cells (scaling and scaling) from the cervix and vagina (Figure 8-23). Microscopic analysis of the cell smear detects abnormalities in cervical or vaginal cells. pregnancy Blood or urine tests to detect the presence of hCG. Test

FIGURE 8-23 Method of obtaining a sample for a Pap smear. The test is 95% accurate in diagnosing cervical cancer early. It was invented and named after a Greek doctor, Georgios Papanicolaou.

Procedures X-ray studies

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hysterosalpingography (HSG) mammography

X-ray images of the uterus and fallopian tubes after injection of contrast material. This radiological procedure is used to evaluate the patency of the tubes (adequate opening) and abnormalities of the uterine cavity. X-ray image of the breast. Women are recommended to have a baseline mammogram between the ages of 40 and 44 for later comparison, if needed. The most recent method of mammography is digital tomosynthesis. See Figure 8-24. In this procedure, an x-ray tube is moved in an arc around the breast while several images are taken. These images are sent to a computer and produce clear, highly focused three-dimensional images. This procedure makes breast cancer easier to find in dense breast tissue; also called 3D mammography.

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FIGURE 8-24 A, Mammogram. The machine compresses the breast and x-rays are taken (top down and from the side). B, Comparison of mammography and digital tomosynthesis images.

Ultrasound examination and nuclear magnetic resonance (NMR)

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breast ultrasound and breast magnetic resonance imaging

pelvic ultrasound

Technologies that use sound waves and a magnetic field to create images of breast tissue. These imaging techniques confirm the presence of a mass and can distinguish a cystic mass from a solid mass. MRI is very useful for detecting masses in young women with dense breasts or in women with a strong family history of breast cancer and at high risk for this condition. Breast ultrasound is useful for evaluating a specific area of cancer on a mammogram. Recording images of sound waves as they bounce off organs in the pelvic region. This technique can assess the size and anatomy of the fetus, as well as fetal and placental position. Uterine tumors and other pelvic masses, including abscesses, are also diagnosed by ultrasound. Transvaginal ultrasound allows the radiologist a closer and clearer view of the organs within the pelvis. The sound probe is placed in the vagina instead of over the pelvis or abdomen; this method is best used to evaluate fluid-filled cysts.

Gynecological Procedures

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cauterization

colposcopy

conization

culdocentesis cryosurgery

dilation (dilation) and age of healing (D&C)

fine needle aspiration exenteroscopy laparoscopy

tubal ligation

Tissue destruction by burn. Destruction of abnormal tissue with chemicals (silver nitrate) or an electrically heated instrument. Cauterization is used to treat cervical dysplasia or cervical erosion. The loop electrocautery excision procedure (LEEP) (see Figure 8-26A) is used to further evaluate and often treat abnormal cervical tissue. Visual examination of the vagina and cervix with a colposcope. A colposcope is an illuminated magnifying instrument that resembles a small pair of mounted binoculars. Gynecologists prefer colposcopy for pelvic examination for cervical dysplasia because it identifies specific areas of abnormal cells. A biopsy sample can then be obtained for a more accurate diagnosis (Figure 8-25). Removal of a cone-shaped section (cone biopsy) of the cervix. The doctor resects the tissue with a LEEP (loop electrocautery excision procedure) or with a carbon dioxide laser or scalpel (scalpel). Figure 8-26A shows the LEEP cone biopsy and Figure 8-26B shows the surgically removed cone biopsy specimen. Use of cold temperatures to destroy tissue. A liquid nitrogen probe produces the freezing temperature (cry/o means cold). Also called cryocautery. Needle aspiration of fluid from the fornix. The doctor inserts a needle through the vagina into the dead end. The presence of blood can indicate a ruptured ectopic pregnancy or a ruptured ovarian cyst. Enlargement of the cervix and scraping of the endometrial lining of the uterus. Dilation is performed by inserting a series of dilators of increasing diameter. A curette (a metal handle at the end of a long, thin handle) is then used to collect samples of the uterine lining. This procedure helps diagnose uterine diseases and can temporarily stop heavy or prolonged uterine bleeding. When necessary, a dilator and curettage is used to remove tissue during a miscarriage or therapeutic abortion (Figure 8-27). Removal of internal organs within a cavity. Pelvic exenteration is the removal of organs and adjacent structures of the pelvis. Removal of fluid or tissue from a cyst or solid mass by suction with a needle. FNAB is a valuable diagnostic technique in the evaluation of breast lumps. Visual examination of the abdominal cavity with an endoscope (laparoscope). In this procedure, a form of minimally invasive surgery (MIS), small incisions (5 to 10 mm long) are made near the woman's belly button to insert the laparoscope and other instruments. Uses for laparoscopy include inspection and removal of the ovaries and fallopian tubes, diagnosis and treatment of endometriosis, and removal of fibroids. Laparoscopy is also used to perform subtotal (the cervix is left in place) and total hysterectomies (Fig. 8.28). Morcellation (removal of uterine tissue in the abdomen) is commonly performed when the uterus or fibroids are removed laparoscopically. It is contraindicated in situations of suspicion or premalignancy. Block the fallopian tubes to prevent fertilization from occurring. This sterilization procedure (rendering an individual unable to reproduce) is done laparoscopically or through a hysteroscope inserted through the cervical os (opening). binding means

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tying, and it doesn't just refer to the fallopian tubes: they can be "tied off" with clips or bands, or by surgically cutting or burning the tissue.

FIGURE 8-25 Colposcopy is used to evaluate a patient with an abnormal Pap test result. For this exam, the woman is in the dorsal lithotomy position. This is the same position that is used to remove a stone from the urinary tract (lithotomy means incision to remove a stone).

FIGURE 8-26 A, Ansa cervicalis electrocautery excision procedure (LEEP) for cone biopsy. B, Surgical removal of a cone biopsy specimen. (A, courtesy of Dr. A.K. Goodman, Massachusetts General Hospital, Boston.)

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FIGURE 8-27 Dilation and curettage (D&C) of the uterus. A, The uterine cavity is explored with a uterine sound (a thin instrument used to measure the depth of the uterus) to avoid perforation during dilation. B, Uterine dilators (Hanks or Hagar) of graduated sizes are used to gradually dilate the cervix. C, The uterus is gently scraped and samples are taken.

FIGURE 8-28 Laparoscopic oophorectomy. A, Note the ovary placed in a plastic bag. The bag was inserted through the laparoscope and then opened and the ovary placed inside. B, Both are removed through the laparoscope, leaving the uterus and the cut end of the fallopian tube. (Courtesy of Dr. A.K. Goodman, Massachusetts General Hospital, Boston.)

Procedures related to pregnancy

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abortion (AB)

Termination of pregnancy before the embryo or fetus can exist on its own. Abortions are spontaneous or induced. Miscarriages, commonly known as "miscarriages," occur for no apparent reason. Induced abortions can be therapeutic or elective. Therapeutic abortion is performed when the health of the pregnant woman is in danger. At the woman's request, an elective abortion is performed. The main methods of abortion include vaginal evacuation by dilation and curettage or vacuum aspiration (suction) and stimulation of uterine contractions by injection of saline (saline solution) into the amniotic cavity (in second-trimester pregnancies). amniocentesis Needle puncture of the amniotic sac to remove amniotic fluid for analysis (Fig. 8.29). Fetal cells found in the fluid are cultured (cultured), and cytology and biochemical studies are performed to check fetal chromosomes, protein and bilirubin levels, and fetal maturation. Cesarean section Surgical incision of the abdominal wall and uterus for the delivery of a fetus. Caesarean section Indications for cesarean section include cephalopelvic disproportion (baby's head is too large for the mother's birth canal), placental abruption or placenta previa, fetal distress (fetal hypoxia), and breech or shoulder presentation. The name comes from a law from the time of Julius Caesar that required the removal of the fetus before a deceased pregnant woman could be buried. chorionic Sampling of placental tissues (chorionic villi) for prenatal diagnosis. villus The tissue sample is removed with a sampling catheter inserted into the uterus. The procedure can be performed before amniocentesis, at (CVS) 10 or more weeks of gestation. Continuous fetal recording of fetal heart rate and monitoring of maternal uterine contractions to assess fetal status and progress of labor. in vitro Eggs and sperm are combined outside the body in a laboratory (in vitro) fertilization dish to facilitate fertilization. (IVF) After an incubation period of 3 to 5 days, the fertilized eggs are injected into the uterus through the cervix. (Latin in vitro means in glass, used for laboratory vessels.) 30% to 50% of all IVF procedures are now associated with intracytoplasmic sperm injection (ICSI). This is the direct injection of sperm into the harvested eggs.

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FIGURE 8-29 Amniocentesis. The obstetrician inserts a long needle through the pregnant woman's abdominal wall into the amniotic cavity. Needle placement (avoiding the fetus and placenta) is guided by simultaneous ultrasound images performed with the transducer in the radiologist's hand. The yellow amniotic fluid is drawn into the syringe attached to the needle. This procedure was carried out in the 16th week of pregnancy. The indication for amniocentesis was a low level of alpha-fetoprotein (AFP). This finding suggests an increased risk of Down syndrome in the baby. Karyotype analysis (received 10 days later) showed a normal chromosome configuration.

abbreviations

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AB AFP

Alpha-fetoprotein miscarriage: Elevated levels in fetal amniotic fluid or maternal serum indicate an increased risk of neurologic congenital abnormalities in the infant. ART Assisted reproductive techniques, including IVF and sperm donation BRCA1 breast cancer 1 and 2: Gene mutations associated with increased risk of breast cancer BRCA2 breast self-exam BSE breast self-exam protein marker CA-125 elevated in ovarian cancer C-cesarean section CS CIN cervical intraepithelial neoplasia CIS carcinoma in situ CVS chorionic villus sampling Cx D&C dilation of the cervix (dilatation) and age at healing DCIS ductal carcinoma in situ; a precancerous breast lesion indicating an increased risk of invasive ductal breast cancer DUB dysfunctional uterine bleeding FHR fetal heart rate FNA fine needle aspiration FSH follicle-stimulating hormone G pregnant (pregnant) gonadotropin-releasing hormone GnRH: secreted by the hypothalamus to stimulate the release of FSH and LH from the pituitary gland GYN gynecology hCG or human chorionic gonadotropin HCG HDN hemolytic disease of the newborn HPV human papillomavirus HRT hormone replacement therapy HSG hysterosalpingography IUD intrauterine device; contraceptive IDC invasive ductal carcinoma IRDS infantile respiratory distress syndrome IVF in vitro fertilization LEEP electrocautery excision procedure LH luteinizing hormone DUM last menstrual period multiparous multiparous; multiparous obstetrics obstetrics for 2-0-1- woman's reproductive history: 2 full-term, 0 preterm, 1 miscarriage, and 2 live infants Pap smear for cervical or vaginal cancer PID pelvic inflammatory disease PMS prenatal syndrome primipara menstrual period ; sentinel lymph node biopsy SLN in primiparous women: blue dye or a radioisotope (or both) identifies the biopsy or the first lymph node draining the lymphatics from the breast SNB TAH-BSO total abdominal hysterectomy with bilateral salpingo-oophorectomy UAE artery embolization uterine Vaginal HV hysterectomy

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Practical applications

This section contains an actual operating report and brief extracts from other medical records using words you have studied in this and previous chapters. Explanations of more difficult terms are added in square brackets.

Operative report Preoperative diagnosis: Menorrhagia, leiomyomas Anesthetic: General Material sent to the laboratory for examination: A. Endocervical healing B. Endometrial healing Operation performed: Dilation and healing of the uterus With the patient in the dorsal lithotomy position [legs flexed on the thighs, thighs flexed at the abdomen and abducted] and prepared and draped sterile, manual examination of the uterus revealed it to be 6 to 8 weeks in size, retroflex; no adnexal masses were observed. The anterior lip of the cervix was then attached with a tenaculum [a hook-like surgical instrument for grasping and holding parts]. The cervix was dilated with a Hank #20 dilator. The uterus was sounded [measured depth] to 4 inches. A marked healing age of the endocervix showed only a scant amount of tissue. With a sharp curette, the uterus was healed clockwise with an irregularity noted on the posterior floor. A large amount of endometrial tissue has been removed. The patient tolerated the procedure well. Operative diagnosis: uterine leiomyoma Recommendation: hysterectomy for myomectomy

Phrases using medical terminology 1. Mammography report: The breast parenchyma [essential tissue] is bilaterally symmetric. There are no abnormal masses or calcifications in either breast. The armpits are normal. 2. This is a 43-year-old pregnant woman 3, paragraph 2, with premature ovarian failure and now on HRT. She has a history of endocervical atypia [the cells are not normal or typical] secondary to a chlamydial infection, which is now being treated.

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3. The patient is a 40-year-old pregnant woman 3, by 2, admitted for exploratory laparotomy to remove and evaluate a 10-cm left adnexal mass. Discharge diagnosis: (1) endometriosis, left ovary; (2) benign cystic teratoma [dermoid cyst], left ovary. 4. History: G3 P3 51 years; SMOK early 40's; on HRT until the age of 49 when they are diagnosed with breast carcinoma; treated with mastectomy and tamoxifen. Followed by ultrasound showing a 9-10mm slightly thickened endometrium. No bleeding Surgical findings: office endometrial biopsy, scant tissue Clinical diagnosis: rule out hyperplasia

Operating Room Schedule The operating room schedule for one day at a large general hospital listed six different gynecologic procedures. It relates the surgical procedures of column I with the indications for surgery of column II. Write the letter of the nomination in the blank spaces provided. Answers are on page 286. COLUMN I 1. Left oophorectomy 2. Vaginal hysterectomy with colporrhaphy 3. TAH-BSO, pelvic and periaortic lymphadenectomy 4. Exploratory laparotomy for uterine myomectomy 5. Cervical conization 6. Lumpectomy with SLN biopsy

COLUMN II _______ A. Pain in LLQ; Ovarian mass on _______ pelvic ultrasound _______ B. Fibroids C. Endometrial cancer _______ D. Small invasive ductal carcinoma of the breast E. Suspected cervical cancer _______ F. Uterine prolapse _______

Contraceptive Options Review and compare the various birth control options available today.

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METHOD 1. Abstinence: no sexual intercourse 2. Cervical cap: applied by a doctor or nurse 3. Condom: male 4. Condom: female 5. Diaphragm (with spermicide) 6. Film and foam (with spermicide) 7. Implant: inserted in the upper part of the arm; releases hormones; effective for 3 years 8. Injectable: Depo-Provera given every 3 months 9. Intrauterine device (IUD) 10. Oral contraceptives (birth control pills) 11. Patch: applied to the skin weekly 12. Ring: inserted into the vagina; effective for 1 month 13. Sponge - used by women who have never given birth 14. Suppositories - inserted into the vagina (with spermicide) 15. Interruption

UNINTENDED PREGNANCY RATES: TYPICAL USE / PERFECT USE 0% / 0% 16% / 9% 15% / 2% 21% / 5% 16% / 6% 29% / 18% 0.05% / 0.05% 3% / 3% less than 1% 8% / 3% 8% / 3% 8% / less than 1% 16% / 9% 29% / 15% 27% / 4%

Personal Prophylactic Mastectomy

Every time May rolls around, I think about my surgery and the decision I made many years ago to have prophylactic mastectomies. I grew up in a family of strong women. They were determined to work, play sports,

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and raise their families, except they all had breast cancer. It was a bump in the road for each of them, and at 36, I had 4 children, a wonderful career, a husband, and abnormal mammograms. I had friends, vacations, and biopsies, and as a physician (radiation oncologist) and the daughter of an oncologist, I was concerned about my own health. When my mother tested negative for the BRCA gene, she did not ease my anxiety. She just escalated it. What was causing breast cancer in my family? Genetic counselors have explained that only about 15% of breast cancers can be attributed to BRCA genes; the rest are caused by other "defective genes" or simply changes in the breast cells. I heard about a new procedure doctors were beginning: direct implant breast reconstruction after mastectomy. One step and surgery would reduce my risk from 40% to about 2-3%. I could preserve my anatomy and get rid of those breast cells that could one day kill me. It had a lot to do with my family and my career. I didn't want to have breast cancer. So I decided, after much research and discussion, to have prophylactic mastectomies with reconstruction. One Tuesday in the first week of May 2006 they operated on me. My mom was there when I woke up from the anesthesia and I have never seen her so relieved. My husband took care of the kids, locked the car doors for me, and mowed the lawn for a while. I didn't talk about my surgery, especially not with the freedom Angelina Jolie had in 2013. In 2006, no one had heard of my surgery; They couldn't even pronounce her name. But he was convinced that this meant he could also "dodge a bullet." Nine years later, I smile when I watch morning TV shows about the “Angelina Effect”: breast implants and reconstruction, nipples and risk reduction, all in the same story. It's wonderful that women can talk about their "flawed parts" without feeling ashamed. It's a great example for our daughters too. In March 2015, Angelina wrote another op-ed, discussing her oophorectomy and salpingectomy (removal of both ovaries and both fallopian tubes) surgery. Women with BRCA genes are at increased risk of not only breast cancer, but also ovarian cancer. And that was the disease that took the life of Angelina's mother. Ovarian cancer, unlike breast cancer, is usually diagnosed at a very late stage. Most breast cancers are diagnosed at stage 1 or 2 or even a “precancerous” stage of DCIS [ductal carcinoma in situ]. Ovarian cancer, on the other hand, is usually diagnosed after the cancer has already spread. Angelina also addressed another “taboo” topic: the removal of ovaries and fallopian tubes in a premenopausal woman (Angelina was 39 years old at the time).

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time of her surgery) sends her into an early menopause. Hot flashes, skin changes, dryness (you know where) are difficult topics to discuss in public. She put it front and center to destigmatize the issue for all women. There is no family history of ovarian cancer and we are BRCA negative, so my genetic counselor did not recommend removing my ovaries and fallopian tubes. Instead, I get a pelvic ultrasound once a year and a blood test (CA-125) to make sure nothing is abnormal. Because of my decision to have prophylactic mastectomies, I know my life has been changed forever. I am not afraid of having breast cancer. I also decided to dedicate my life to the work of helping women recover with comfort, dignity and grace after being overcome by illness. Angelina Jolie says that knowledge is power! It is up to us to learn all we can to prevent disease and proactively care for the fragile and precious thing we call health. Elizabeth Chabner Thompson is CEO/Founder of Masthead, a company dedicated to bringing innovative products to breast cancer patients. She is a doctor, swimmer, cross-country skier, and proud mother of four children, ages 16-21.

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Exercises Remember to check your answers carefully with the Answers to the exercises, page 284.

A Match the following terms for structures or tissues with their meanings below. amnion areola cervix chorion clitoris endometrium fallopian tubes fibrias labia mammary papilla ovaries perineum placenta perimetrium vagina vulva 1. inner lining of the uterus _____________________________________ 2. area between the anus and vagina in females _____________________________________ 3. area of dark pigmentation around the nipple _____________________________________

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4. finger-like ends of the fallopian tube _____________________________________ 5. tubes through which the egg travels from the ovary to the uterus _____________________________________ 6. sensitive erectile tissue organ in females; anterior to the urethral orifice __________________________________________ 7. nipple of the breast _____________________________________ 8. painful vascular organ in the uterine wall during pregnancy _________________________ 9. lower cervix-like portion of the uterus __________________________________________ 10. innermost membrane around the developing embryo ________________________________________ 11. layer outermost layer of membranes that surround the developing embryo and are part of the placenta _____________________________________ 12. outermost layer that surrounds the uterus _____________________________________ 13. lips of the vulva __________________________________________ 14. female gonads; egg production and hormones _____________________________________ 15. includes the perineum, labia, clitoris, and hymen; external genitalia _____________________ 16. mucous-lined muscular canal that extends from the uterus to the outside of the body ________________________________

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B Identify the following terms. 1. fetus ________________________________________ 2. milk ducts _____________________________________ 3. gametes _____________________________________ 4. gonads _____________________________________ 5. uterine adnexa __________________________________________ 6. cul-de-sac __________________________________________ 7. genitalia _____________________________________ 8. Bartholin glands _____________________________________ 9. ovarian follicle _____________________________________ 10. corpus luteum _____________________________________ C Combine the terms listed with the descriptions/definitions below. coitus estrogen fertilization follicle stimulating hormone human chorionic gonadotropin luteinizing hormone prenatal menarche myometrium

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progesterone 1. hormone produced by the ovaries; promotes female secondary sexual characteristics_____________ 2. hormone secreted by the pituitary gland to stimulate the maturation of the ovum (ovum) _____________________________________ 3. sexual intercourse _____________________________________ 4. before birth _____________________________________ 5. onset of the first menstrual period _____________________________________ 6. hormone produced by the placenta to maintain pregnancy by stimulating the ovaries to produce estrogen and progesterone _____________________________________ 7. muscular layer of the uterus _____________________________________ 8. hormone produced by the corpus luteum in the ovary and placenta of a pregnant woman _____________________________________ 9. hormone produced by the pituitary gland to promote ovulation ___________________________ 10. Union of sperm and egg from which the embryo develops _______________________ D Give definitions tions to complete the following sentences. 1. galact/o and lact/o mean ______________________________.

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2. colp/o and vagin/o both mean ______________________________. 3. mamm/o and mast/o both mean _____________________________. 4. metro/o, utero/o and hystero/o mean _________________________. 5. oophor/o and ovari/o both mean ____________________________. 6. o/o, ov/o and egg/o mean ______________________________. 7. in- and endo- both mean __________________________________. 8. -ciesis and -pregnant mean _____________________________. 9. salping/or and -salpinx both mean ___________________________. 10. epi/o and vulv/o both mean _____________________________. And Match the terms listed with the meanings/descriptions below. bilateral salpingophorectomy cervicitis chorion culdocentesis lactation neonatology obstetrics oxytocin total hysterectomy

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vulvovaginitis 1. examination of the newborn ______________________________ 2. hormone that stimulates the contraction of the pregnant uterus ______________________________ 3. secretion of milk ______________________________ 4. removal of the entire uterus ______________________________ 5. inflammation of the cervix ______________________________ 6. pregnancy-related branch of medicine and childbirth __________________________ 7. Outer membrane surrounding the fetus ______________________________ 8. Removal of both fallopian tubes and both ovaries ______________________________ 9. Inflammation of the external female genitalia and vagina ____________________________________ 10. Needle puncture to remove fluid from the fornix ____________________________________ F Manage the meaning of the following signs and symptoms. 1. amenorrhea __________________________________________ ______________________ 2. dysmenorrhea __________________________________________ ______________________ 3. leucorrhea _____________________________________________

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________________________ 4. metrorrhagia _____________________________________________ _____________________________ 5. galactorrhea _________________________________________________ ________________________ 6. menorrhagia ________________________________________________ ________________________ 7. pyosalpinx ____________________________________________ ________________________ 8. dyspareunia _____________________________________________ ___________________ 9. menometrorrhagia _____________________________________________ _________________ 10. oligomenorrhea _____________________________________________ ______________ G Indicate whether the following statements are true or false . 1. After a total (complete) hysterectomy, a woman still has regular menstrual periods. ________________________________________________ ________________ 2. After a total hysterectomy, a woman can still produce estrogen and progesterone.

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________________________________________ 3. Birth control pills prevent pregnancy by keeping estrogen and progesterone levels high. ________________________________________________ ___________________ 4. After a total hysterectomy with bilateral salpingo-oophorectomy, your doctor may recommend hormone replacement therapy. ________________________________________________ ______ 5. Human papillomavirus can cause genital warts and ovarian cancer. ________________________________________________ _________________ 6. A Pap smear can detect cervical dysplasia. ______________________________________ 7. Human chorionic gonadotropin is produced by the ovaries during pregnancy. ________________________________________________ ________________________ 8. Gynecomastia is a common condition in pregnant women. ________________________________________________ ________________________ 9. The treatment for endometriosis is uterine myomectomy. ________________________________________________ ________________________ 10. A 3 to 2 pregnant woman is a woman who has given birth 3 times.

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________________________________________________ _____________________ 11. A non-pregnant woman is a woman who has had multiple pregnancies. ________________________________________________ __________________________ 12. Pseudocyesis is the same condition as a tubal pregnancy. ________________________________________________ ________________________ 13. Fibrocystic breast changes are a malignant condition. ________________________________________________ ________________________ 14. Cystadenomas occur in the ovaries. ________________________________________________ _____________________ 15. FSH and LH are ovarian hormones. ________________________________________________ ____________________ H Give the meaning of the following terms. 1. childbirth _____________________________________________ __ 2. menopause ___________________________________________ __ 3. menarche ___________________________________________________

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4. ovulation __________________________________________________ __ 5. gestation __________________________________________________ __ 6. anovulation __________________________________________________ __ 7. dilation _________________________________________________ __ 8. lactation _____________________________________________ __ 9. nulliparous women _____________________________________________ __ 10. oophoritis ________________________________________________ _______ 11. bartholinitis ________________________________________________________ __ 12. vulvodynia _____________________________________________ __ Combine the terms listed with the following meanings/descriptions. placental abruption cervical cancer

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cervicitis cystadenocarcinoma endometrial cancer endometriosis leiomyoma multiple pregnancies placenta previa preeclampsia 1. malignant tumor of the ovary ___________________________ 2. neck-like inflammation of the lower part of the uterus ___________________________ 3. condition during or shortly after pregnancy marked by hypertension, proteinuria, and swelling __________________________ 4. Uterine tissue located outside the uterus, for example, in the ovaries, fornix, fallopian tubes, or peritoneum ___________________________ 5. Premature separation of a normally implanted placenta ___________________________ 6. Placenta implantation over the cervical opening ___________________________ 7 more than a fetus inside the uterus ___________________________ 8. malignant condition of the lower part of the uterus ___________________________ 9. malignant condition of the inner lining of the uterus ___________________________ 10. benign muscular tumor in the uterus __________ ____ _____________

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J Name the appropriate test or procedure for each of the following descriptions. 1. Burning abnormal tissue with chemicals or an electrically heated instrument: ________________________________________ 2. Contrast material is injected into the uterus and fallopian tubes and X-ray images are obtained: _____________________________________ 3. Cold temperature is used to destroy the tissue: _______________________________ 4. Visual examination of the vagina and cervix: _____________________________________ 5. Enlargement of the opening of the cervix and scraping of the uterine lining: _____________________________________ 6. Removal of fluid or tissue from a cyst or solid mass by suction with a needle : ________________________________________ 7. X-ray imaging of the breast: _____________________________________ 8. Removal of a cone-shaped section of the cervix for diagnosis or treatment of cervical dysplasia: _____________________________________ 9. Surgical puncture to remove fornix fluid: ____________________ _______ 10. Echoes from sound waves create an image of structures in the pelvic area: ______________________________________ 11. Blockage of the fallopian tubes to prevent fertilization from occurring: ________________________________________

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12. Visual examination of the abdominal cavity with an endoscope:______________________________________ 13. hCG is measured in urine or blood:_____________________________________ 14. Cells are scraped from the cervix or vagina for microscopic analysis:__________________________________________ 15. Removal of internal gynecological organs and adjacent structures in the pelvis:______________________________________ K Provide medical terms for the following definitions. Pay attention to the spelling. 1. Benign muscular tumors in the uterus _____________________________________ 2. Absence of menstruation _____________________________________ 3. Removal of an ovary _____________________________________ 4. Condition of the female (male) breasts _____________________________________ 5. Ovarian hormone that maintains pregnancy _____________________________________ 6. Nipple-like elevation in the breast _________________________________ L Match the terms obstetric and neonatal with the descriptions below. • miscarriage • Apgar score

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• cephalic version • cesarean section • fetal monitoring • fetal presentation • fontanel • infantile respiratory distress syndrome • hemolytic disease of the newborn • hydrocephalus • in vitro fertilization • meconium aspiration syndrome • pyloric stenosis 1. Turn the fetus so that the head is facing present during delivery _________________________________ 2. The soft spot between the bones of the newborn's skull _____________________________________ 3. Assessment of the physical condition of the newborn _____________________________________ 4. Premature termination of pregnancy _____________________________________ 5. Removal of the fetus through an abdominal incision from the uterus ___________________________ 6. Acute lung disease in the preterm newborn: surfactant deficiency ____________________ 7. Use of a machine to electronically record the fetal heart rate during labor ____________________ 8. Narrowing of the opening urea from the stomach into the small intestine in the baby ___________ 9. Rh factor incompatibility between the mother and the fetus _____________________________________

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10. Fluid buildup in the brain spaces of a newborn _________________________ 11. How the fetus appears to the examiner during labor _________________________ 12. A thick, sticky, dark green substance is discharged into the amniotic fluid, causing fetal lung problems _______________________ 13 Union of sperm and ovum in a laboratory dish __________________________________________ M Indicate the meaning of the abbreviations in Column I. Then select the letter of the correct description in Column II. COLUMN I 1. CIS __________________________ 2. FSH __________________________ 3. D&C __________________________ 4. multip ___________________ 5. C-section __________________ 6. IVF __________________________ 7. Cx __________________________ 8. TAH-BSO _______________ 9. Primip ___________________ 10. OB ___________________

_______ _______ _______ _______ _______ _______ _______ _______ _______ _______

COLUMN II A. This woman gave birth to more than one baby. B. Eggs and sperm combine outside the body. C. This woman gave birth for the first time. D. Secretion from the pituitary gland stimulates the ovaries. E. This procedure helps diagnose uterine diseases. F. Localized growth of cancer. G. Surgical procedure to remove the uterus, fallopian tubes, and ovaries. H. Surgical delivery of a child through an abdominal incision. I. Branch of medicine dealing with pregnancy and childbirth. J. Lower cervix-like region of the uterus.

N Match the following abbreviations from Column I with the best description from Column II.

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COLUNA I 1. Papanicolau 2. HSG 3. AB 4. HPV 5. CDIS 6. TRH

_______ _______ _______ _______ _______ _______

COLUMN II A. Precancerous lesion in the breast B. Radiographic record of the uterus and fallopian tubes C. Hormones administered to menopausal women D. Diagnosis of cervical and vaginal cancer E. Termination of pregnancy; spontaneous or induced F. Cause of cervical cancer

OR Circle the term in parentheses that best completes the meaning of each sentence. 1. Dr. Hanson felt it was important to do a (culdocentesis, Pap smear, amniocentesis) once a year on each of her gynecologic patients to check for abnormal cells. 2. When Doris missed her period, her doctor checked Doris's urine for (LH, IUD, hCG) to see if she was pregnant. 3. Ellen was 34 weeks pregnant and experiencing severe headaches and blurred vision, with a weight gain of 10 pounds in 2 days. Murphy's doctor told her to go to the emergency obstetrics department because she suspected it (preeclampsia, pelvic inflammatory disease, fibroids). 4. Sally, 52, noted increased pain, fullness, and swelling in her abdomen. She had a history of ovarian cancer for which her doctor recommended (sentinel node biopsy, pelvic ultrasound, colposcopy). 5. Clara she knew she shouldn't ignore her fevers, yellow vaginal discharge and back pain. She had previous episodes of (PMS, PID, HRT) treated with IV antibiotics. She feared that she might have a recurrence. 6. After years of trying to get pregnant, Jill decided to talk to her (hematologist,

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gynecologist, urologist) on in vitro (pregnancy, childbirth, fertilization). 7. To collect her eggs, Jill's doctor prescribed hormones to stimulate the maturation of the eggs and (intercourse, lactation, ovulation). Eggs were surgically removed and fertilized with sperm in a petri dish. 8. Several embryos were then implanted in Jill's uterus (fallopian tubes, vagina, uterus) and she was given hormones to ensure the survival of at least one embryo. 9. IVF was successful and later (abdominal CT scan, ultrasound) Jill was told she was having twins in a few months. 10. At 37 weeks, Jill went into labor. Under continuous (chorionic villus sampling, culdocentesis, fetal monitoring), two healthy infants were delivered vaginally. 11. At age 41, Carol underwent an exam (hysterosalpingogram, mammogram, conization) of her breasts. Her results showed small calcium deposits, or calcifications, behind her (areola, chorion, uterine adnexa). A core needle (laparoscopy, colposcopy, biopsy) was done and it showed cells that were an early sign of cancer called (CIN, DCIS, DUB). Her surgical oncologist recommended (lumpectomy, TAH-BSO, chorionic villus sampling) to remove the calcifications and surrounding tissue as treatment.

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Answers to exercises A 1. endometrium 2. perineum 3. areola 4. fimbriae 5. fallopian tubes 6. clitoris 7. mammary papilla 8. placenta 9. cervix 10. amnion 11. chorion 12. perimetrium 13. labia 14. ovaries 15. vulva 16. vagina B 1. embryo from the third month (after 8 weeks) until birth 2. tubes that carry milk into the breast 3. sex cells; eggs and sperm

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4. organs (ovaries and testicles) in females and males that produce gametes 5. ovaries, fallopian tubes, and supporting ligaments (accessory parts of the uterus) 6. region of the abdomen between the rectum and uterus 7. reproductive (genital) organs 8. small exocrine glands at the vaginal orifice that secrete a lubricating fluid 9. developing sac in the ovary that surrounds the ovum 10. empty follicle that secretes progesterone after ovulation C 1. estrogen 2. follicle-stimulating hormone 3. relationships sexual 4. prenatal 5. menarche 6. human chorionic gonadotropin 7. myometrium 8. progesterone 9. luteinizing hormone 10. fertilization D

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1. milk 2. vagina 3. breast 4. uterus 5. ovary 6. ovum 7. inside, inside 8. pregnancy 9. fallopian tube 10. vulva (external female genitalia) Y 1. neonatology 2. oxytocin 3. lactation 4 Total hysterectomy 5. Cervicitis 6. Obstetrics 7. Chorion 8. Bilateral salpingo-oophorectomy 9. Vulvovaginitis 10. Culdocentesis F 1. Absence of menstrual flow

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2. Painful menstrual discharge 3. White discharge (usually from the vagina and also associated with cervicitis) 4. Bleeding from the uterus at irregular intervals 5. Abnormal flow of milk from the breasts 6. Heavy or prolonged menstrual periods occurring at regular intervals 7 pus in the fallopian (uterine) tubes 8. painful intercourse 9. heavy bleeding during and between menstrual periods 10. scanty menstrual flow G 1. False. A total hysterectomy means removing the entire uterus so that menstruation does not occur. 2. True. A total hysterectomy does not mean that the ovaries have been removed. 3. True. Birth control pills contain estrogen and progesterone; high levels prevent ovulation and pregnancy. 4. True. This may be necessary to treat the symptoms of estrogen loss (vaginal atrophy, hot flashes) and to prevent bone deterioration (osteoporosis). 5. False. HPV causes genital warts, but not ovarian cancer. In some cases, HPV infection can lead to cervical cancer.

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6. True. A Pap smear can detect abnormal changes in the cervix, from cervical dysplasia to cervical intraepithelial neoplasia (CIN) and CIS (carcinoma in situ). 7. False. The hCG hormone is produced by the placenta during pregnancy. 8. False. Gynecomastia is a condition of increased breast development in men. 9. False. Myomectomy means the removal of muscle growths (fibroids). Endometriosis is the abnormal location of uterine tissue outside the uterine lining. 10. False. A pregnant woman from 3 to 2 is a woman who has had two children and three pregnancies. 11. False. A nulliparous woman has not had a pregnancy. A multi-pregnant woman has had many pregnancies. 12. False. A pseudocyesis is a false pregnancy (no pregnancy occurs) and a tubal pregnancy is an example of an ectopic pregnancy (the pregnancy occurs in the fallopian tube, not the uterus). 13. False. Fibrocystic breast changes are a benign condition. 14. Truth. Cystadenomas are glandular sacs lined with tumor cells; They occur in the ovaries. 15. False. FSH and LH are hormones from the pituitary gland. Estrogen and progesterone are secreted by the ovaries. H 1. act of giving birth

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2. gradual end of menstrual function 3. onset of first menstrual period at puberty 4. release of ovum from ovary 5. pregnancy 6. related to non-ovulation (ovum is not released from ovary) 7. enlargement 8. natural secretion of milk 9. woman who has never given birth 10. inflammation of the ovaries 11. inflammation of Bartholin's glands 12. pain in the vulva I 1. cystadenocarcinoma 2. cervicitis 3. preeclampsia 4. endometriosis 5. detachment of placenta 6. placenta anterior 7. multiple pregnancies 8. cervical cancer 9. endometrial cancer 10. leiomyoma

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J 1. cauterization 2. hysterosalpingography 3. cryosurgery or cryocautery 4. colposcopy 5. dilation (dilation) and age of healing 6. fine needle aspiration 7. mammography 8. conization 9. culdocentesis 10. pelvic ultrasound 11. tubal ligation 12 laparoscopy 13 pregnancy test 14. pap smear 15. pelvic exenteration K 1. fibromas or leiomyomas 2. amenorrhea 3. ovariectomy 4. gynecomastia 5. progesterone 6. mammary papilla

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L 1. Cephalic version 2. Fontanelle 3. Apgar score 4. Abortion 5. Cesarean section 6. Infant respiratory distress syndrome 7. Fetal monitoring 8. Pyloric stenosis 9. Hemolytic disease of the newborn 10. Hydrocephalus 11. Fetal presentation 12 Aspiration meconium syndrome 13. in vitro fertilization M 1. carcinoma in situ: F 2. follicle-stimulating hormone: D 3. age of dilation (dilation) and healing: E 4. multiparous: A 5. caesarean section: H 6. in vitro fertilization : B 7. cervix: J

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8. Total abdominal hysterectomy with bilateral salpingo-oophorectomy: G 9. Primiparous: C 10. Obstetrics: I N 1. D 2. B 3. E 4. F 5. A 6. CO 1. Pap smear 2. hCG 3. preeclampsia 4. ultrasound pelvic 5. PID 6. gynecologist; fertilization 7. ovulation 8. uterus 9. ultrasound 10. fetal monitoring 11. mammography; areola; biopsy; DCIS; mastectomy

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Answers to practical applications Operating room hours

1. A 2. F 3. C 4. B 5. E 6. D Pronunciation of terms

Vocabulary and Terminology

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TERM uterine adnexa amenorrhea amniotic amniocentesis anovulatory amniotic fluid areola Bartholin's glands bartholinitis cephalic version chorionic cervix chorionic clitoris coitus colposcopy corpus luteum fornix cul-de-sac culdocentesis dysmenorrhea dyspareunia dystocia embryo endocervicitis endometritis endometrium episiotomy estrogen cul-de-sac cul-de-sac culdocentesis dysmenorrhea dyspareunia embryonic dystocia endocervicitis endometritis endometrium episiotomy estrogens genital tubopioculdolescent folligynous tubing gynecomastia human chorionic gonadotropin hymen hysterectomy hysteroscopy intrauterine device involution inframammary lips lips lactation milk ducts leucorrhea

PRONUNCIATION ad-NEK-sah U-ter-i a-but-o-RE-ah am-ne-o-late-TE-sis AM-ne-on am-ne-OT-ik FLU-id an-OV- u-lah-tor-e ah-re-O-lah BAR-tho-lin gland bar-tho-lih-NI-tis seh-FAL-ik VER-zhun SER-viks KOR-e-on kor-e-ON -ik KLIH-tor-is KO-it-us col-POS-ko-pe KOR-pus LU-te-um KUL-deh-sak kul-do-sen-TE-sis dis-men-o-RE-ah dis-pah-RU-ne-ah dis-TO-se-ah EM-bre-o en-do-ser-vih-SI-tis en-do-meh-TRI-tis en-do-ME-tre-um eh-pe-ze-OT-o-me ES-tro-jen fah-LO-pe-an toob fer-tih-lih-ZA-shun FE-tal pres-en-TA-shun FE-tus FIM-bre- e FOL-lik-il STIM-u-la-thing HOR-mone gah-lak-to-RE-ah GAM-eet jeh-nih-TA-le-ah jes-TA-shun GO-nad gi-neh-KOL -o-je gi-neh-ko-MAS-te-ah HU-man ko-re-ON- ik go-nad-o-TRO-pin HI-men his-ter-EK-to-me his-ter- OS-ko-pe in-frah-MAM-ar-e in-trah-U-ter-in de-VISE in-vo-LU-shun LA-be-ah lak-TA-shun lak-TIH-fer-us Duties in front of the RE

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TERM luteinizing hormone mammary papilla mammoplasty mastectomy mastitis menarche menometrorrhagia menopause menorrhagia menstruation menstruation metrorrhagia multigestation multipara myomectomy myometrium neonatal neonatology nulliparous nulliparous obstetrics oligomenorrhea oocyte oogenesis oophorectomy oophoritis orifice ovary ovary follicle ovary ovulation ovum; please ovules oxytocia oxytocin labor perimetrium perineorrhaphy perineum pituitary placenta prenatal pregnancy primiparous primiparous primiparous progesterone pseudocyesis puberty pyosalpinx retroversion salpingectomy salpingitis

PRONUNCIATION LU-teh-dia-manhã HOR-mone MAH-meh-re pah-PIL-ah MAH-mo-plas-te mah-STEK-to-me mah-STI-tis meh-NAR-foot meh-no-meh -tro-RA-jah MEN-o-pawz men-o-RA-jah men-o-RE-ah men-stru-A-shun met-ro-RA-jah mul-tih-GRAV-ih-dah mul- TIH-pah-rah mi-o-MEK-to-me mi-o-ME-tre-um ne-o-NA-tal ne-o-na-TOL-o-je nul-leh-GRAV-ih-dah nul-LIH-pah-rah ob-STET-riks ol-ig-o-men-o-RE-ah o-o-SITE o-o-JEN-eh-sis oo-fo-REK-para-me oo-fo-RI- tis OR-ih-fis o-VAH-re-an o-VAH-re-an FOL-ih-kil O-vah-re ov-u-LA-shun O-vum; O-va ox-e-TO-se-ah ox-se-TO-sin par-tu-RIH-shun peh-rih-ME-tre-um peh-rih-ne-OR-ah-fe peh-rih- NE-um pih-TU-ih-tah-re glandular plah-SEN-tah PREG-nan-se pré-NA-tal prih-mih-GRAV-ih-dah prih-MIP-ah-rah prih-MIP-pah- russia pro-JES-teh-rone su-do-si-E-sis PU-ber-te pi-o-SAL-pinks retro-VER-zhun hall-pin-JEK-to-me hall-pin-JI -tis

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TERM uterine prolapse uterus vagina vaginal orifice vaginitis vulva vulvodynia vulvovaginitis zygote

PRONUNCIATION U-teh-rin PRO-laps U-ter-us vah-JI-nah VAH-jih-nal OR-ih-fis vah-jih-NI-tis VUL-vah vul-vo-DIH-ne-ah vul- ;vo-vah-jih-NI-tis ZI-gote

Pathological Conditions, Clinical Tests and Procedures

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TERM abortion placental abruption Apgar score breast cancer in situ cesarean cauterization cervical cancer cervical dysplasia cervicitis choriocarcinoma chorionic villus sampling colposcopy conization cryosurgery culdocentesis dermoid cysts dilation dilation and healing age Down syndrome ectopic pregnancy endometrial cancer endometriosis exenteration control fetal fibrocystic breast disease fibroids fine needle aspiration hemolytic disease of the newborn hydrocephalus hysterosalpingography in vitro fertilization infantile respiratory distress syndrome laparoscopy leiomyomas mammography meconium aspiration syndrome multiple pregnancy ovarian cancer ovarian cysts palpation Pap smear pelvic inflammatory disease pelvic ultrasound placenta previous eclampsia pregnancy test pyloric stenosis tubal ligation

PRONUNCIATION ah-BOR-shun ah-BRUP-se-o plah-SEN-ta Score AP-gar brest KAN-ser kar-sih-NO-mah in SI-tu kaw-ter-ih-ZA-shun seh-ZAH- re-an SEK-shun SER-vih-kul KAN-ser SER-vih-kul dis-PLA-ze-ah ser-vih-SI-tis ko-re-o-kar-sih-NO-mah ko-re- ON-ik WILL-us SAMP-ling call-POS-co-pe ko-nih-ZA-shun kri-o-SUR-jer-e kul-do-sen-TE-sis THERE-moyd sists dih-lah-TA -shun di-LA-shun & kur-eh-TAZH Down SIN-drohm ek-TOP-ik PREG-nan-ver y-make-ME-three-al CAN-ver y-make-me-three-O-sis ex-en-teh-RA-shun FE-number MON-it-or-ing fi-bro-SIS-tik mama dih-ZEEZ FI-broydz thin NE-heart as-pih-RA-shun he-mo-LIH- tic dih-ZEEZ of his mother hi-dro-SEF-ah-lus his-ter-o-sal-ping-OG-rah-fe in VE-through fer-til-ih-ZA-shun IN-fant RES -pih - rah-tor-e dis-TRES SIN-drohm lap-ah-ROS-ko-pe li-o-mi-O-maz mah-MOG-rah-fe meh-KO-ne-um as-pih- RA- shun SIN-drohm MUL-that-beyond he-TA-shun o-VAH-re-an CAN-ser o-VAH-re-an sists pal-PA-shun teste the father PEL-vik in-FLAM-mah- tor - e dih-ZEEZ PEL-vic ul-trah-son-OG-rah-fe plah-s en-tah PREH-ve-ah pre-e-CLAMP-se -ah PREG-n an-se test pi-LOR-ik steh-NO-sis TOOB-al li-GA-shun

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revision sheet

Write the meanings of the word parts in the spaces provided and test yourself. Check your answers with the information in the chapter or in the Glossary (Parts of Medical Words—English) at the end of the book.

Combined forms COMBINANT FORM amni/o bartholin/o cephal/o cervic/o chori/o, chorion/o colp/o culd/o episi/o galact/o gynec/o hyster/o lact/o mamm/o, mast/ o men/o metr/o, metri/o my/o, myom/o nat/i obstetric/o olig/o o/o, ov/o, ovul/o oophor/o, ovari/o perine/o phor/o py/el salping/el uterino/la vagina/la vulva/la

prefixes

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PREFIX bidysendoinintramultinullioxyperipreprimipseudoretrouni-

Suffixes SUFFIX -arch -ciesis -dynia -ectomy -bending -genesis -pregnancy -itis -pareunia -parous -plasia -plasty -rrhagia -rraphia -rhea -salpinge -scopy -stenosis -stomy -tocy, -tocyn -tomy -version

Diagnostic Procedures Match the diagnostic procedures in column I with their descriptions in column II. Compare your answers with the information in the chapter.

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COLUMN I 1. Fine needle aspiration 2. Colposcopy 3. Culdocentesis 4. Hysterosalpingography 5. Mammography 6. Papanicolaou 7. Pregnancy test 8. Pelvic ultrasound

_______ _______ _______ _______ _______ _______ _______ _______

COLUMN II A. Images of the uterus and fallopian tubes are obtained (x-ray procedure). B. hCG is measured. C. X-ray images of the breast are taken. D. Procedure for biopsy of breast tissue. E. Extraction of cervical and vaginal cells for analysis. F. Fluid is obtained from the region between the rectum and the uterus. G. Imaging of the hip region is obtained using sound waves. H. Visual microscopic examination of the vagina and cervix.

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CHAPTER 9

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Male Reproductive System CHAPTER SECTIONS: Introduction 292 Anatomy 293 Vocabulary 295 Terminology 297 Pathological conditions; Sexually Transmitted Diseases 299 Laboratory Tests and Clinical Procedures 304 Abbreviations 306 Practical Applications 307 Face to Face: Prostate Cancer 309 Exercises 310 Answers to Exercises 316 Pronunciation of Terms 318 Review Sheet 320

CHAPTER OBJECTIVES • Name, locate, and describe the functions of the organs of the male reproductive system. • Define abnormal conditions and infectious diseases that affect the male reproductive system. • Differentiate between the different types of sexually transmitted infections. • Define forms of combination used to describe the structures of this system. • Describe various laboratory tests and clinical procedures relevant to disorders of the male reproductive system and recognize related abbreviations.

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• Apply your new knowledge to understand medical terms in their proper contexts, such as medical reports and records.

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Introduction The male sex cell, the spermatozoon (sperm cell), is microscopic: by volume, only one-third the size of a red blood cell and less than 1/100,000 the size of a female egg. A relatively simple cell, the sperm cell is made up of a head region, which contains hereditary nuclear material (chromosomes), and a tail region, which consists of a flagellum (hair-like process). The flagellum makes the sperm motile and makes it look like a tadpole. The sperm contains relatively little food and cytoplasm because it lives long enough (3 to 5 days) to travel from its point of release in the male to where the egg is found within the female reproductive tract (fallopian tube). Only one sperm out of approximately 300 million sperm released during a single ejaculation (expulsion of sperm and fluid from the male urethra) can penetrate a single egg and result in fertilization of the egg. Figure 9-1 shows a diagram of a sperm cell and a photograph of sperm cells.

FIGURE 9-1 A, Sperm. B, Photograph of spermatozoa.

If more than one egg passes through the fallopian tube when sperm are present, multiple fertilizations are possible, with twins, triplets, quadruplets, etc. Twins that result from the fertilization of separate eggs by separate sperm are called fraternal twins. Fraternal twins, which develop with separate placentas, can be of the same or different sexes and are no more similar than common brothers and sisters. Fraternal twinning is hereditary; daughters of mothers of twins can carry the gene.

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Identical twins result from the fertilization of a single egg by a single sperm. As the fertilized egg divides and forms many cells, it somehow divides, with each separated part continuing to undergo further divisions, each producing an embryo. The division usually occurs between the third and fifth day of embryonic development. Most identical twins have one placenta and two amniotic sacs. Identical twins have the same DNA and are therefore the same sex and very similar in shape and characteristics. The organs of the male reproductive system are designed to produce and release billions of sperm during a man's lifetime from puberty onwards. Also, the male reproductive system secretes a hormone called testosterone. Testosterone is responsible for producing masculine bodily characteristics (such as a beard, pubic hair, and a deeper voice) and for the proper development of the male gonads (testicles) and accessory organs (prostate gland and seminal vesicles) that secrete fluids to ensure lubrication and the feasibility. of the sperm

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Anatomy Label Figure 9-2 as you study the following description of the anatomy of the male reproductive system.

FIGURE 9-2 Male reproductive system, sagittal view.

Each male gonad is a testicle [1]. There are two testicles (plural) or testicles that develop in the abdomen near the level of the kidneys before descending during embryonic development into the scrotum [2], a sac that surrounds the testicles on the outside of the body. The scrotum, located between the thighs, exposes the testicles to a lower temperature than the rest of the body. This lower temperature is necessary for the proper maturation and development of sperm (spermatogenesis). Located between the anus and the scrotum, on the floor of the pelvic cavity in men, the perineum [3] is analogous to the perineal region in women. The interior of a testicle is made up of a large mass of narrow, coiled tubules called the seminiferous tubules [4]. These tubules contain cells that make sperm. The seminiferous tubules are the parenchymal tissue of the testicle, that is, they carry out the essential work of the organ (sperm formation). Other cells in the testis,

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adjacent to the seminiferous tubules are the interstitial cells. They make an important male hormone, testosterone. All organs in the body contain parenchyma, which performs the essential functions of the organ. Organs also contain supportive, connective, and structural tissue, such as blood vessels, connective tissues, and sometimes also muscle. This supporting tissue is called the stroma (stromal tissue). After formation, spermatozoa move through the seminiferous tubules and accumulate in ducts that lead to a large tube, the epididymis [5], at the top of each testis. Sperm mature, become motile in the epididymis, and are temporarily stored there. An epididymis runs the length of each testicle (the coiled tube is about 16 feet long) and then goes back up and becomes a narrow, straight tube called the vas deferens [6] or vas deferens. Figure 9-3 shows the internal structure of a testicle and the epididymis. The vas deferens is about 60 cm long and carries sperm to the pelvic region, at the level of the urinary bladder, fusing with the ducts of the seminal vesicles [7] to form the ejaculatory duct [8] which leads to the urethra. . During a vasectomy or sterilization procedure, the urologist cuts and ties off each vas deferens by making an incision in the scrotum.

FIGURE 9-3 Internal structure of a testis and epididymis.

The seminal vesicles, two glands (only one is shown in Figure 9-2) located at the base of the bladder, open into the ejaculatory duct as it joins the urethra [9]. They secrete a thick, sugary, yellowish substance that nourishes the sperm and forms part of the ejaculated semen. Semen,

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a combination of fluid (seminal fluid) and sperm (sperm make up less than 1% of the volume of semen) is expelled from the body through the urethra. In men, unlike women, the genital opening is combined with the urinary (urethral) opening. The prostate [10] is located in the region where the vas deferens enters the urethra, almost encircling the upper end of the urethra. It secretes a milky white fluid that is a mixture of sugars, enzymes, and alkaline chemicals. As part of the semen, this fluid nourishes the sperm, and after ejaculation into the vagina, the alkaline chemicals promote sperm survival in the acidic environment of the vagina. The muscle tissue of the prostate helps expel fluid during ejaculation. The bulbourethral glands [11], located below the prostate, also secrete fluid into the urethra during ejaculation. The urethra passes through the penis [12] and exits the body. The penis is composed of erectile tissue and at its tip it expands to form a soft and sensitive region called the glans [13]. Normally, a fold of skin called the prepuce [14] covers the glans. The foreskin is a painful area on the glans penis in uncircumcised babies. Between the ages of 2 and 10, the foreskin falls off naturally and can be removed from the head of the penis. If a boy is circumcised, the foreskin is removed, leaving the glans visible at all times. Erectile dysfunction (impotence) is the inability of an adult man to achieve an erection. Viagra (sildenafil), Cialis (tadalafil) and Stendra (avanafil) are medications that increase blood flow to the penis, increasing the ability to have an erection. Male infertility is any problem in a man that decreases his partner's chances of getting pregnant. The flowchart in Figure 9-4 traces the path of sperm from its formation in the seminiferous tubules of the testes to outside the body.

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FIGURE 9-4 Passage of sperm from the seminiferous tubules of the testes to the outside of the body.

Vocabulary

This list reviews new terms introduced in the text. Brief definitions reinforce your understanding.

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bulbourethral Pair of exocrine glands near the male urethra. They secrete fluid into the urethra from the glands. Also called Cowper's glands. circumcision Removal of the foreskin (foreskin). It is a common elective procedure that is performed shortly after birth. ejaculation Ejection of sperm and fluid from the male urethra. Ejaculatory tube through which semen enters the male urethra. Epididymal duct One of a pair of long, tightly coiled tubes over each testis. Stores and (plural: carries sperm from the seminiferous tubules to the vas deferens. epididymis) erectile The inability of an adult male to obtain an erection; impotence. flagellum dysfunction A hair-like projection on a sperm that makes it motile (able to move). prepuce Fold of skin that covers the head of the penis; foreskin. fraternal Two babies resulting from the fertilization of two separate eggs by two separate twin sperm (Figure 9-5). glans penis Sensitive tip of penis; comparable to the clitoris in women. Two identical babies resulting from the division of a fertilized egg. Conjoined twins ("Siamese") are identical twins who are not completely separated. infertility In a man, any problem that reduces the chances that his partner will get pregnant. Interstitial specialized cells adjacent to the seminiferous tubules in the testes. These cells produce testosterone and are also called Leydig cells. Parenchymal testicles Essential cells to distinguish an organ. In the testes, the tissue of the seminiferous tubules that produce sperm is parenchymal. penis Male external reproductive organ. perineum External region between the anus and the scrotum in men. foreskin foreskin; fold of skin that covers the tip of the penis. prostate An exocrine gland at the base of the male urinary bladder. The prostate secretes a fluid that contributes to semen during ejaculation. TIP: Don't confuse prostate with prostrate, which means lying down. scrotum Outer sac that contains the testicles. semen Sperm (sperm cells) and seminal fluid (secretions from the seminal and prostatic vesicles), discharged through the urethra during ejaculation. Seminal Paired sac-shaped exocrine glands that secrete fluid (a major component of semen vesicles) into the vas deferens. narrow, coiled seminiferous tubules that produce sperm in the testicles. sperm tubules. (plural: sperm) sterilization A procedure that removes a person's ability to produce or release reproductive cells; Testicular removal, vasectomy, and oophorectomy are sterilization procedures. Stromal tissue Connective tissue that supports an organ, as distinct from its parenchyma. Also called stroma. testicle (plural: male gonad (testicle) that produces sperm and testosterone. Remember: testicles) Testicle means one testicle and testicles are two testicles. testosterone Hormone secreted by the interstitial tissue of the testicles; responsible for male sexual characteristics. vas deferens A narrow tube (one on each side) that carries sperm from the epididymis to the urethra. Also called the vas deferens.

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FIGURE 9-5 Fraternal twins. A, Observe 6-week-old embryos in two separate amniotic sacs. B, the twins Marcos and Matheus Do Carmo are 16 years old. (Courtesy Juliana Do Carmo.)

perineum/peritoneum

Don't confuse the perineum, which is the area between the anus and scrotum in men and the anus and vagina in women, with the peritoneum, which is the membrane that surrounds the abdominal cavity!

semen/sperm

Don't confuse semen with sperm. Semen is the thick, whitish discharge that comes out of the urethra during ejaculation. Sperm (sperm cells) are cells that develop in the testicles. Semen contains sperm.

Sterilization/Impotence

Don't confuse sterilization, which can be performed on both men and women, with impotence, which is a man's inability to maintain an erection or achieve ejaculation.

Terminology

Write the meanings of the medical terms in the spaces provided.

match shapes

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COMBINACIÓN MEANING FORM masculine andr/o balancen/o

mourn

glans penis (Greek balanos, acorn) cold

encrypt it

escondido

epididymis

gon/o

seed (from Greek Ido, seed) water, liquid

hydro/o orchid/o, orchid/o, orchid/o

testicle, testicle

bonito

pene

prostate

seminar/yo

semen, seed

sperm, sperm

sperm

to spend

monsters (greek terraces, monsters)

Test it

testicle, testicle

TERMINOLOGY

SENSE

androgen ___________________________________ Testosterone is an androgen. The testicles in men and the adrenal glands in both men and women produce androgens. balanitis ________________________________________ An inflammation usually caused by the overgrowth of organisms (bacteria and yeast) (Figure 9-6A). cryogenic surgery _________________________________ A technique for treating prostate cancer using freezing temperatures to destroy cancer cells. cryptorchidism __________________________________ In this congenital condition, one or both testicles fail to descend into the scrotum from the abdominal cavity at birth (Fig. 9-6B). epididymitis _____________________________________ This is an inflammation usually caused by bacteria. Signs and symptoms are fever, chills, groin pain, and tender, swollen epididymis. gonorrhea ______________________________________ See page 302. hydrocele _____________________________________ See page 300. orchiectomy _____________________________________ Castration in males. (Also called orchidectomy.) orchitis ____________________________________ Caused by injury or by the mumps virus, which also infects the salivary glands. penis _____________________________________________ -ile means belonging to. penoscrotal _____________________________________ prostatitis _____________________________________ Bacterial prostatitis (E. coli) is often associated with urethritis and lower urinary tract infection. prostatectomy __________________________________ Robot-assisted laparoscopic prostatectomy (RALP) is a treatment option for the removal of the prostate. seminiferous tubules _________________________ The suffix -ferous means to carry, carry, or transport. spermolitic _____________________________________ Noun suffixes ending in -sis, such as -lysis, form adjectives by removing -sis and adding -tic. Oligospermia _____________________________________ aspermia _____________________________________ Lack of semen (sperm and fluid). One of the causes of aspermia is retrograde ejaculation (sperm back up into the urinary bladder) as a result of prostate surgery. teratoma ____________________________________ This tumor occurs in the testicles or ovaries and is made up of different types of tissue such as bone, hair, cartilage, and skin cells. Testicular teratomas are malignant. testicular ___________________________________ The term testicle comes from a Latin term meaning witness. In ancient times, men swore an oath with one hand on their testicles, swearing on their manhood to tell the truth.

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MEANING OF COMBINATION varices/or varices

glass

vase, duct; different conductor

Zoo Garden

animal life

TERMINOLOGY

SENSE

varicocele ___________________________________ Collection of varicose (swollen, twisted) veins above the testicle. See page 300. vasectomy ______________________________________ See page 306. Remember: In this term, vas/o refers to the vas deferens, not any other vessel or duct. azoospermia _________________________ Lack of sperm in the semen. Causes include testicular dysfunction, chemotherapy, blockage of the epididymis, and vasectomy. TIP: Azoospermia is semen without sperm, while aspermia is no semen.

FIGURE 9-6 A, Balanitis. The glans penis (or glans) is the sensitive bulbous area at the distal end of the penis. B, cryptorchidism.

Suffixes SUFFIX MEANING TERMINOLOGY MEANING spermatogenesis formation _________________________________ genesis - a testosterone hormone ______________________________ Ester/o indicates that it is a type of steroid compound. Examples of other steroids are estrogen, cortisol, and progesterone. -pexy fixation, put orchidopexy ______________________________________ in place Surgical procedure to correct cryptorchidism. -new vasovasostomy ostomy __________________________________ opening Vasectomy reversal; a urologist reassembles the cut ends of the vas deferens.

orchid branch

This form of combination is derived from the Greek word orchis, which means testicle. The orchid's botanical name, the flower, is also derived from the

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same Greek word for the fleshy tubers of the plant.

Azoospermia and Infertility

Male infertility is the cause of up to 40% of infertility problems. The most common causes of male infertility are azoospermia and oligoasthenozoospermia (low sperm count and motility). The combined form asthen/o means lack of strength.

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Pathological conditions; Sexually transmitted infections Tumors and anatomical/structural disorders Testicles Testicular cancer (carcinoma of the testicles)

Malignant tumor of the testicles. Testicular tumors are rare except in the age group 15 to 35 years. The most common tumor, a seminoma, arises from embryonic cells in the testis (Figure 9-7A). Other tumors are embryonal carcinoma (Figure 97B), teratoma, choriocarcinoma, and yolk sac tumor. Teratomas contain a mixture of mature tissue such as bone, hair, cartilage, and skin cells (terat/o means monster). Testicular cancers can be cured with surgery (orchiectomy) followed by chemotherapy. Seminomas are treated with radiation therapy and/or chemotherapy. Tumors produce human chorionic gonadotropin (hCG) and alpha-fetoprotein (AFP) proteins. Serum levels of these proteins are used as tumor markers to determine the success of treatment. cryptorchidism; Undescended testicles. cryptorchidism Orchidopexy is performed to bring the testicles into the scrotum if they do not descend on their own by 1 or 2 years of age. Undescended testicles are associated with a high risk of infertility and an increased risk of developing testicular cancer. hydrocele Clear fluid sac in the scrotum. Hydroceles (Figure 9-8) can be congenital or occur in response to infection or tumor. Often idiopathic, they can be differentiated from testicular masses by ultrasound. If the hydrocele does not resolve on its own, the fluid from the sac is suctioned out with a needle and syringe, or a hydrocelectomy may be required. In this procedure, the sac is surgically removed through an incision in the scrotum. Testicular torsion of the spermatic cord (see Figure 9-8). torsion Rotation of the spermatic cord cuts off the blood supply to the testis. Torsion occurs most often in childhood. Surgical correction hours after the onset of symptoms can save the testis. varicocele Enlarged and dilated veins near the testicle. Varicocele (see Figure 9-8) may be associated with oligospermia and azoospermia. Oligopermic men with varicocele and scrotal pain should undergo varicocelectomy. In this procedure, the internal spermatic vein is ligated (the affected segment is cut and the ends are tied). This procedure can increase fertility.

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FIGURE 9-7 A, Seminoma of a testis. B, Embryonal carcinoma of a testis. Unlike seminoma, which is a pale, homogeneous mass, embryonal carcinoma is a hemorrhagic mass.

FIGURE 9-8 Hydrocele, testicular torsion, and varicocele.

testicular cancer screening

There may be no signs or symptoms of testicular cancer. However, regular testicular self-exams can help identify growths earlier, when the chance of successful treatment is greater. A man should see a doctor if he notices any mass, pain, or swelling in the scrotum.

Prostate

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benign prostatic hyperplasia (BPH)

prostate cancer (prostate cancer)

Benign growth of cells within the prostate. BPH is a common condition in men over the age of 60. Urinary obstruction and the inability to completely empty the bladder are symptoms. Figure 9-9 shows the prostate with BPH and with carcinoma. Surgical treatment by transurethral resection of the prostate (TURP) relieves the obstruction, but excessive cell growth may recur for several years. In this procedure, an endoscope (resectoscope) is inserted into the penis and through the urethra. Prostatic tissue is removed using a heated electrical circuit directed at the resectoscope (see page 305). The FDA has approved several drugs to relieve the symptoms of BPH. Finasteride (Proscar) inhibits the production of a powerful testosterone that promotes prostate enlargement. Other drugs, alpha blockers such as tamsulosin (Flomax), work by relaxing the smooth muscle in the prostate and bladder neck. Lasers can also be used to destroy prostate tissue to relieve the blockage. A TURP or GreenLight PVP laser procedure uses a green light laser at the end of an endoscope (see page 305). Malignant tumor (adenocarcinoma) of the prostate. This cancer usually occurs in men over the age of 50. Digital rectal examination (DRE) (Fig. 9.10) can detect the tumor at a later stage, but early detection depends on detection of a high level of prostate-specific antigen (PSA) in the blood. PSA is secreted into the bloodstream by tumor cells. The normal PSA level is 4.0 ng/mL or less. Diagnosis requires finding the tumor on a needle biopsy of the prostate. Transrectal ultrasound (TRUS) guides the needle biopsy performed through the rectal wall. Several needle biopsy samples are taken through the rectal wall. Computed tomography (CT) detects lymph node metastases. Treatment consists of surgery (prostatectomy) or radiotherapy for the localized tumor. Hormone therapy is used for locally advanced or metastatic disease. Because prostate cells are stimulated to grow in the presence of androgens, antiandrogen drugs slow tumor growth. One such drug is Lupron, which reduces the level of androgens in the bloodstream. Tumor cells can also be destroyed by brachytherapy (brachy = close), which means that the radioactive seeds are implanted directly into the prostate. See the story In Person: Prostate Cancer on page 309.

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FIGURE 9-9 The prostate with carcinoma and benign prostatic hyperplasia (BPH). Carcinoma usually appears on the sides of the gland, while BPH occurs in the center of the gland. Because prostate cancers are located more peripherally, they can be felt on a digital rectal exam (DRE).

FIGURE 9-10 Digital rectal exam (DRE) of the prostate.

Pene

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hypospadias

Peyronie's disease phimosis

A congenital abnormality in which the opening of the male urethra is at the bottom of the penis instead of at the tip. Hypospadias (-spadias means the state of tearing or obstruction) occurs in 1 in 300 live male births and can be corrected surgically (Fig. 9-11A). Abnormal curvature of the penis This condition is quite common and is caused by scar tissue in the connective tissue of the penis. Drug treatment can be effective in breaking down the buildup of fibrous tissue that causes penile curvature. Narrowing (stenosis) of the opening of the prepuce over the glans. This abnormal condition (phim/o = muzzle) in adolescent and adult males can interfere with urination and cause discharge to collect under the foreskin, leading to infection. Treatment consists of circumcision (cubes around the foreskin to remove it) (Fig. 9.11B).

FIGURE 9-11 A, Hypospadias. Surgical repair involves lengthening the urethra using surrounding tissue or using a tissue graft from another part of the body and leading it to the exit at the tip of the penis. B, Phimosis and circumcision to correct the condition.

Sexually Transmitted Infections Sexually transmitted infections (STDs) are infections transmitted through sexual or genital contact. Also known as sexually transmitted diseases (STDs) or venereal diseases (from the Latin Venus, the goddess of love), they occur in both men and women and are some of the most common communicable diseases in the world.

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clamidia

gonorrhea

herpes genital

human papillomavirus (HPV) infection syphilis

Bacterial infection (Chlamydia trachomatis) of the urethra and reproductive tract. Within 3 weeks of infection, men may experience a burning sensation when urinating and notice a white or clear discharge from the penis. Infected women may notice a yellowish vaginal discharge (from the endocervix), but the disease is often asymptomatic. Antibiotics cure the infection, but if left untreated, this STD can cause salpingitis (pelvic inflammatory disease [PID]) and infertility in women. Inflammation of the lining of the genital tract, caused by infection with gonococci (berry-shaped bacteria). Other areas of the body may also be affected, such as the eyes, oral mucosa, rectum, and joints. Signs and symptoms include dysuria and a yellow mucopurulent (purulent meaning pus-filled) discharge from the male urethra (Fig. 9.12A). The ancient Greeks mistakenly thought that this secretion was a leak of semen, so they called it gonorrhea, which means secretion of seeds (gon/o = seed). Many women carry the disease asymptomatically, while others experience pain, vaginal and urethral discharge, and salpingitis (PID). As a result of sexual activity, both men and women can also acquire anorectal and pharyngeal gonococcal infections. Chlamydia and gonorrhea often occur together. When treating these infections, doctors give both partners antibiotics and treat both partners. Infection of the skin and genital mucosa caused by the herpes simplex virus (HSV). Most cases of genital herpes are caused by HSV type 2 (although some are caused by HSV type 1, which is commonly associated with oral infections such as cold sores or fever blisters). The usual clinical presentation is redness of the skin with formation of small blisters and fluid-filled ulcers (Fig. 9.12B). Initial episodes may also include inguinal lymphadenopathy, fever, headache, and malaise. Remissions and periods of relapse occur; no drug is known to be effective as a cure. Neonatal herpes affects babies born to women with active infection around the time of delivery. Gynecologists may deliver babies by C-section to prevent babies from becoming infected with HSV. Studies suggest that women with genital herpes are at increased risk of developing cancer of the vulva and cervix. Infection of the skin and mucous membranes of the anogenital region by the human papilloma virus. Some types of HPV cause genital warts (see Figure 9-13A) and cause cervical cancer and cancer in men. There is a vaccine available for girls and boys that protects against nine types of HPV. Chronic STD caused by a spirochete (spiral-shaped bacteria). A chancre (hard ulcer or sore) usually appears on the external genitalia a few weeks after bacterial infection (Fig. 9.13B). Two to six months after the chancre disappears, secondary syphilis begins. Tertiary syphilis includes damage to the brain, spinal cord, and heart, which can appear years after previous symptoms disappear. Syphilis (which was so deadly in early times that it was known as "great smallpox", as opposed to the more familiar smallpox) can be congenital in the fetus if transmitted from the mother during pregnancy. Penicillin is effective for treatment in most cases.

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FIGURE 9-12 A, Gonorrhea. You can see the discharge from the penis. B. Genital herpes. The classic bullae (vesicles) are evident.

FIGURE 9-13 A. Genital warts. B, Primary syphilis with penile cancer.

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Laboratory Tests and Clinical Procedures Laboratory Tests Semen Analysis PSA

Measurement of prostate-specific antigen (PSA) levels in the blood. PSA is produced by cells within the prostate. Elevated PSA levels are associated with an enlarged prostate and may be a sign of prostate cancer. Microscopic examination of ejaculated fluid. Sperm are counted and examined for motility and shape. The test is part of the fertility studies and is necessary to establish the effectiveness of the vasectomy. Men with a sperm count of less than 20 million/ml of semen are usually infertile (not fertile). Infertility can make an adult man sick with mumps, an infectious disease that affects the testicles (inflammation leads to deterioration of sperm).

Castration Clinical Procedures

circumcision digital rectal examination (DRE) photoselective vaporization of the prostate (GreenLight PVP) transurethral resection of the prostate (TURP) vasectomy

Surgical excision of testicles or ovaries. Castration can be performed to reduce the production and secretion of hormones that stimulate the growth of malignant cells (in breast cancer and prostate cancer). When a boy is castrated before puberty, he becomes a eunuch (Greek, eune, bed; echein, to keep). The male secondary sexual characteristics do not develop. Surgical procedure to remove the foreskin (foreskin) of the penis. See Figure 9-11B, page 303. Finger palpation through the anal canal and rectum to examine the prostate. See Figure 9-10, page 301. Tissue removal to treat benign prostatic hyperplasia (BPH) with a green light laser ("TURP laser"). This minimally invasive procedure in selected cases replaces TUR in the treatment of BPH. Removal of portions of the prostate through the urethra. This procedure treats benign prostatic hyperplasia (BPH). A heated electrical loop cuts the prostate tissue; Pieces of tissue (fragments) are removed through the resectoscope (Figure 9-14). Bilateral surgical removal of a portion of the vas deferens. A urologist cuts the vas deferens, removes a piece, and ligates (tie and tie off) the free ends with sutures (Figure 9-15); this is repeated on the opposite side. The procedure is performed under local anesthesia and through an incision in the scrotum. Since sperm cannot leave the body, the vasectomized male is sterile but not neutered. Normal hormone secretion, sexual desire, and potency (ability to have an erection) are intact. The body reabsorbs the sperm not expelled. In some cases, a vasovasostomy can successfully reverse a vasectomy.

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FIGURE 9-14 Transurethral resection of the prostate (TURP). A, The resectoscope contains a light, valves to control the irrigation fluid, and an electrical circuit that cuts the tissue and seals the blood vessels. B, The urologist uses a wire loop through the resectoscope to remove obstructing tissue one piece at a time. The pieces are transported by the fluid to the bladder and are washed at the end of the operation.

FIGURE 9-15 Vasectomy.

abbreviations

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BPH DRE ED GU HPV HSV NSU PID PIN PSA PVP RALP RPR STD DST

benign prostatic hyperplasia digital rectal examination genitourinary erectile dysfunction human papillomavirus herpes simplex virus nonspecific urethritis (not due to gonorrhea or chlamydia) pelvic inflammatory disease prostatic intraepithelial neoplasia; a photoselective spray of prostate-specific antigen, a precursor to prostate cancer; Robot-assisted laparoscopic prostatectomy GreenLight PVP rapid plasma reagin [test]; a test for syphilis, sexually transmitted disease, sexually transmitted infection, transrectal ultrasound [exam]; test to evaluate the prostate and guide the precise placement of a transurethral incision of the prostate with TUIP needle biopsy; successful in less enlarged and less invasive prostates than TURP TUMT transurethral microwave thermotherapy TUNA transurethral needle ablation; radiofrequency energy destroys prostate tissue TURP transurethral resection of the prostate

Practical applications

Reproduced here, from actual medical records, is a case report of a patient with post-TURP complaints. Basic data and explanations of more difficult terms are added in square brackets. Answers to the questions are on page 317. Also presented for your review is an actual surgical pathology report from a man diagnosed with prostate cancer, as well as a summary of current knowledge on anabolic steroids.

Case report: a man with post-turp complaints The patient is a 70-year-old man who underwent TURP for BPH 5 years ago and now has severe obstructive urinary symptoms with a large postvoid residue. On rectal examination, he presented a large, voluminous, and nodular prostate, with palpable extension to the left seminal vesicle. His PSA level was 15 ng/mL [normal is 0 to 4 ng/mL] and a bone scan was negative. A CT scan revealed a bilateral external iliac adenopathy with lymph nodes averaging 1.5 cm [normal lymph node size is less than 1 cm]. A prostate biopsy revealed a poorly differentiated adenocarcinoma. This patient likely has at least stage T3 N+ [extension to seminal vesicles and nodal metastases]. The recommendation is the pharmacological treatment of anti-testosterone hormone. Questions about the Case Report

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1. Five years earlier, what type of surgery had the patient had? a. Removal of testicles b. perineal prostatectomy c. Partial prostatectomy (transurethral) 2. What was the reason for the surgery then? a. cryptorchidism b. Benign prostatic overgrowth c. Testicular cancer 3. What symptoms do you have now? a. Burning pain when urinating b. urinary retention c. Premature ejaculation 4. What test allowed the doctor to feel the tumor? a. Palpation by a finger inserted into the rectum b. CT scan c. Prostate specific antigen test 5. Where has the tumor spread? a. tests b. Pelvic lymph nodes and left seminal vesicle c. Pelvic bone 6. What can stimulate the growth of prostatic adenocarcinoma? a. Hormonal pharmacological treatment b. Prostate biopsy c. Testosterone secretion 7. Stage T3 N+ means that the tumor a. It is located in the hip area b. It is confined to the prostate c. It has spread locally and beyond the lymph nodes 8. Why is tumor staging important? a. Classify the extent of tumor spread and plan treatment b. To make the initial diagnosis c. To make a proper biopsy of the tumor.

Surgical Pathology Report: Prostate Cancer/Hyperplasia Patient Name: Bill Sco Date of Birth: 9/14/1942 (78 years) Gender: M Clinical Findings: ?Nodule, right side of prostate; PSA 7.1 Sample(s): A. Right prostate biopsy B. Left prostate biopsy FINAL PATHOLOGY DIAGNOSIS

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A. Needle biopsy of right sided prostate (six cores) ADENOCARCINOMA, MODERATE TO POORLY DIFFERENTIATED Gleason score 4 + 3 = 7 Estimated tumor burden, 10% of prostate tissue Represented in both specimens A and B B. Needle biopsy of the prostate on the left side Gland BENIGN HYPERPLASIA

About Anabolic Steroids Anabolic steroids are male hormones (androgens) that increase body weight and muscle size and may be used by doctors to enhance growth in boys who are not physically maturing as expected for their age. Athletes may also use steroids in an effort to increase strength and improve performance; however, significant harmful side effects of these medications have been recognized: • High levels of anabolic steroids cause acne, liver tumors, and sterility (testicular atrophy and oligospermia). • In women, the androgenic effect of anabolic steroids leads to male hair loss, a deeper voice, amenorrhea, and clitoral enlargement. • The use of anabolic steroids also causes hypercholesterolemia, hypertension, jaundice (liver abnormalities), and water and salt retention (edema).

gleason score

The Gleason score (named for Dr. Donald Gleason, a pathologist who developed it in the 1960s) is based on the microscopic appearance of the prostate biopsy sample. Cancers with a higher Gleason score are more aggressive and have a worse prognosis. The pathologist assigns one grade (number) to the most common tumor cells and another to the next most common tumor cells. The sum of these numbers gives the Gleason score. Scoring is based on a scale of 1 to 5. Cells that are better differentiated (closer to normal) are scored lower, and cells that are poorly differentiated (malignant) are scored higher.

prostate cancer personally

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This is the first person narration of a man diagnosed with prostate cancer. As with many men in their 50s, the PSA prostate-related lab test was the first item I always looked at when I had my annual physical. Over the course of a few years, the PSA increased gradually, but nothing that seemed to indicate anything unusual. So it came as a surprise when my primary care physician suggested that it might be time for further medical review of the slowly increasing results. PSA was 4.37 ng/mL (4.0 or less is considered normal). Due to my overall good health, I expected the follow-up prostate exam and biopsy to be routine. It was a big surprise that the prostate biopsy showed that 3 out of 12 samples were positive for cancer cells. My Gleason score was 6 (3+3). This situation was described to me as favorable, an early stage cancer. However, I had no idea what treatment options were available. I decided the best way to make a decision about a treatment plan was to meet with the doctors at the Genitourinary Clinic at Mass General Cancer Center, where they would review my situation and learn more about my options. I realized that the possibilities varied widely, including watchful waiting, external radiation, internal radiation, and prostate surgery (prostatectomy). In the end, the decision is yours with early-stage prostate cancer, and that in itself can make you doubt your choice. After careful thought and review with my doctors and family, I decided to pursue the option of internal radiation or brachytherapy, often called radiation seed implantation. Even up until the time of the procedure, I was left wondering if I was making the right decision. Should I wait a bit and see how things go? Would there be any of the side effects listed for this procedure, such as bowel or bladder irritation? I did internal radiation at MGH. The entire medical team made the process from start to finish as easy as one could hope for. The best news was that after the procedure, when the tumor was gone, my PSA started to drop.

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Now a year has passed and I am happy to see that the PSA has continued to decline. Long-term side effects of the brachytherapy procedure were related to urination and erectile dysfunction. Although post-procedure urination was painful, the discomfort dissipated in about a week. Long-term urination control was a problem, but after a year it definitely improved. Erectile dysfunction after any type of prostate procedure is a problem. I found it to be a great effect at first, but less so as time went by. The PSA test needed to see if the tumor has not come back is still missing. But taking the warning signs seriously, getting informed, and making an informed decision with the help of the best possible medical team will make you feel good about your choices. Kevin Mahoney is a US Veteran and now works as a Program Manager. He likes to spend time with his family, including his wife, children and his grandchildren.

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Exercises Remember to check your answers carefully with those given in Answers to the exercises, page 316.

A Using the following terms, complete the flowchart showing the passage of sperm. epididymis ejaculatory duct penis seminiferous tubules urethra vas deferens

B Select from the list of terms that match the descriptions below. bulbourethral glands epididymis prepuce

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prostate scrotum seminal vesicles seminiferous tubules spermatozoa testis vas deferens 1. one of a pair of long, tightly coiled tubes over each testis; transports and stores sperm ________ 2. exocrine gland at the base of the male urinary bladder _____________________________ 3. narrow, spiral-shaped tubules that produce sperm in the testicles ______________________________ 4. spermatozoon ________________________________________________________ __________________ 5. foreskin __________________________________________ __________________________ 6. male gonad; produces testosterone and sperm _____________________________________ 7. Sac-like exocrine glands that secrete fluid into the vas deferens _____________________ 8. External sac that contains the testes ________________________________________________ ___ 9. Narrow tube that carries sperm from the epididymis to the urethra _____________________ 10. Pair of exocrine glands near the male urethra; Cowper's glands _______________________

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C Select from the list of terms that match the descriptions below. ejaculation ejaculatory duct erectile dysfunction flagellum twins glans penis identical twins interstitial cells parenchymal tissue perineum 1. hair-like projection on a sperm that makes it motile _________________________________ 2. sensitive tip of the penis ________________________________________________ ____________ 3. duct through which semen enters the urethra ____________________________________ 4. two babies resulting from the division of a fertilized egg into separate embryos ______________ 5. outer region between the anus and scrotum ____________________________________ 6. essential distinctive cells of an organ ________________________________________________ _______ 7. two babies resulting from the fertilization of two eggs for two sperm ______________________ 8. inability of an adult male to achieve an erection; impotence ________________________________

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9. Specialized cells adjacent to the seminiferous tubules __________________________ 10. Ejection of sperm and fluid from the urethra __________________________________________ D Match the terms listed with the descriptions below. aspermia azoospermia impotence oligospermia sterilization of semen stromal tissue testis testosterone 1. external male reproductive organ ____________________________________ 2. sperm and seminal fluid ________________________________________________ _______ 3. hormone secreted by the interstitial cells of the testis _________________________________ 4. connective tissue that supports an organ ________________________________________ 5. lack of semen ________________________________________ ______________ 6. lack of sperm in the semen _______________________________________________

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___ 7. procedure that removes a person's ability to produce or release reproductive cells ________ 8. semen with low concentration of sperm ____________________________________________ 9. male gonad ________________________________________________ ________________ 10. inability of a man to maintain or obtain an erection ________________________________ E Construct medical terms for the following settings. Parts of words are given. 1. inflammation of the testicles: __________________________itis 2. inflammation of the tube that carries sperm into the vas deferens: ___________________________________itis 3. resection of the prostate: __________________________ectomy 4. inflammation of the prostate: __________________________itis 5. production process (the formation of) sperm: _________________________________genesis 6 fixation of undescended testicle: orchio________________________ 7. inflammation of the glans penis: ___________________________itis 8. sperm shortage condition: __________________________spermia 9. lack of semen: a________________________

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10. belonging to a testicle: __________________________ar F True or false answer: 1. ___________ Cryogenic surgery uses cold temperatures to destroy tissue. 2. ___________ Estrogen is an example of an androgen. 3. ___________ Castration (orchiectomy or oophorectomy) is an example of sterilization. 4. ___________ A teratoma is a benign tumor of the prostate. 5. ___________ Spermolytic means formation of sperm. 6. ___________ Balanitis is inflammation of a testicle. 7. ___________ Azoospermia causes infertility. 8. ___________ Aspermia can result from retrograde ejaculation. 9. ___________ The seminiferous tubules are the interstitial cells of the testes. 10. ___________ Testosterone is produced by the parenchymal tissue of the testicles. 11. ___________ Vasectomy causes impotence. 12. ___________ Vasovasostomy is an anastomosis that can restore fertility (ability to reproduce offspring). G Match the term in column I with its meaning in column II. Write the correct letter in the space provided.

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COLUMN I 1. Castration 2. Semen analysis 3. Ejaculation 4. Purulent 5. Vasectomy 6. Circumcision 7. Ligation 8. Cryosurgery 9. Seminoma 10. Phimosis

_______ _______ _______ _______ _______ _______ _______ _______ _______ _______

COLUMN II A. Tying off or tying off B. Removal of a piece of the vas deferens C. Orchiectomy D. Removal of the foreskin E. Destruction of the tissue by freezing F. Filling with pus G. Fertility (reproductive capacity) test H . Ejection of sperm and fluid from the urethra I. Narrowing (stricture) of the opening of the foreskin over the glans penis J. Malignant testicular tumor

H Select from the terms listed to fit the descriptions below. adenocarcinoma of the prostate benign prostatic hyperplasia cryptorchidism gonorrhea genital herpes HPV infection hydrocele hypospadias syphilis varicocele 1. non-malignant prostatic enlargement ________________________________________________ _ 2. urethral opening on the lower surface of the penis _________________________________ 3. HSV infection of the skin and genital mucosa ________________________________________________ Four . malignant tumor of the prostate ________________________________________________ 5. enlarged and swollen veins near the testicles ________________________________________________

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6. Sexually transmitted disease with primary stage characterized by the formation of a chancre ___________ 7. Infection of the skin and mucous membranes in the anogenital region by the human papillomavirus __________________________________________ 8. STD caused by berry-shaped bacteria and characterized due to inflammation of the genital mucosa and mucopurulent discharge ________________________ 9. undescended testicles ________________________________________________ _____________ 10. bag of clear fluid in the scrotum ________________________________________________ ______ I Spell the abbreviations in column I. Then match each abbreviation with its correct meaning in column II.

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COLUNA I

_______ 1. Public Service Announcement ___________________________________________________________________________

_______ 2. HPB __________________________________________________________________________

_______ 3. UTR _______________________________________________________________________

_______ 4. TRUST ___________________________________________________________________________

_______ 5. DRE _______________________________________________________________________

_______ 6. VHS _______________________________________________________________________

_______ 7. Daylight Saving Time _______________________________________________________________________

_______ 8. RALP ________________________________________________________________________

COLUMN II A. Manual diagnostic procedure to examine the prostate B. Removal of portions of the prostate through the urethra C. Etiologic agent of a sexually transmitted disease characterized by blistering D. Noncancerous enlargement of the prostate E. Chlamydia , gonorrhea, and syphilis are examples of this general category of infections F. A useful procedure for guiding a prostate biopsy needle G. Elevated serum levels of this protein indicate carcinoma of the prostate H. Laparoscopic-assisted surgery to remove the prostate

J Give the meanings of the following parts of the words. 1. -one _________________________ 2. -stomia ___________________________ 3. semin/i ___________________________ 4. -cele _________________________ 5. -pexy __________________________ 6. -genesis __________________________

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7. -plasia __________________________ 8. prostat/o __________________________ 9. orch/o __________________________ 10. terat/o __________________________ 11. gon/o __________________________ 12. hydr/o __________________________ 13. pen/o __________________________ 14. balance ___________________________ 15. varic/o ________________________ 16. vas/o __________________________ 17. test/o __________________________ 18. zo/o ______________________________ 19. crypt/o ___________________________ 20. andr/o __________________________ K Combine the listed surgical procedures with the following reasons for performing them. circumcision hydrocelectomy orchiectomy orchiopexy photoselective vaporization of the prostate radical (complete) prostatectomy varicocelectomy vasectomy vasovasostomy 1. prostate cancer _________________________ 2. cryptorchidism _________________________

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3. sterilization (hormones remain and potency is not affected) ______________________________ 4. benign prostatic hyperplasia _________________________ 5. abnormal fluid accumulation in a scrotal sac _________________________ 6. reversal of sterilization procedure _________________________ 7. embryonal carcinoma of the testis ____________________________________ 8 phimosis _________________________ 9 .ligation of swollen and twisted veins above the testicles _________________________ L Use the definitions given to complete the terms. Check your answers carefully. 1. gland at the base of the urinary bladder in males: pro gland _________________________ 2. coiled tube at the top of each testis: epi _________________________ 3. essential tissue of an organ: par tissue _________________________ 4. foreskin: pre _________________________ 5 .bacterial infection that invades the urethra and reproductive tract of men and women and is the main cause of nonspecific urethritis in men and cervicitis in women: ch _________________________ 6. ulcer that forms on the genital organs after infection with syphilis: ch ________________________ 7. androgen produced by the interstitial cells of the testis: test _________________________

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8. fluid secreted by the male reproductive glands and ejaculated with sperm: se ___________________ 9. malignant tumor of the testicle: sem _________________________ 10. belonging to the penis: caneta _________________________ M Circle the correct term(s) to complete the sentences to follow. 1. When Fred was a newborn, his doctors could only feel one testicle inside the scrotum and suggested close monitoring of his condition (gonorrhea, cryptorchidism, benign prostatic hyperplasia). 2. Bob has had many sexual partners, one of whom has been diagnosed with (testosterone, phimosis, chlamydia), a highly transmissible STD. 3. At age 65, Mike had some difficulty with urgency and discomfort when urinating. His doctor has performed a digital rectal exam to examine his (prostate, urinary bladder, vas deferens). 4. Shortly after Nick's birth, his parents had a hard time deciding whether to submit their newborn son (TURP, castration, circumcision). 5. Ted noticed a hard ulcer on his penis and made an appointment with his doctor, one (gastroenterologist, gynecologist, urologist). The doctor examined a sample of the ulcer under a microscope and did a blood test, which revealed that Ted had contracted it (gonorrhea, genital herpes, syphilis), so the ulcer was one (blister, chancre, seminoma). 6. After the birth of his fifth child, Art decided to have one (vasovasostomy, hydrocelectomy, vasectomy) to

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prevent the conception of another child. One (nephrologist, urologist, abdominal surgeon) performed the cut and ligate procedure (urethra, epididymis, vas deferens). 7. Lance, 26, noticed a hardened testicular mass. His doctor has prescribed a brief test with (antibodies, antibiotics, painkillers) to rule out (epididymitis, testicular cancer, varicocele). The mass remained and Lance underwent (epididymectomy, orchiectomy, prostatectomy). The mass was a (seminoma, prostate cancer, hydrocele). 8. Sarah and Steve had been trying to conceive a child for 7 years. Steve had one (digital rectal exam, TURP, semen analysis) which revealed a normal sperm count of 25% with motility of 10%. They told him that he had (phimosis, azoospermia, oligospermia). 9. To increase his sperm count, Steve was given (estrogen, testosterone, progesterone). As a side effect, this (androgen, progestogen, enzyme) gave him a case of acne that lasted for several months. 10. Sarah finally got pregnant. An ultrasound examination showed two embryos with two separate placentas and in separate sacs (peritoneal, scrotal, amniotic). Sarah gave birth to healthy twin girls (identical, fraternal, perineal).

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Answers to exercises A 1. seminiferous tubules 2. epididymis 3. vas deferens 4. ejaculatory duct 5. urethra 6. penis B 1. epididymis 2. prostate 3. seminiferous tubules 4. sperm 5. foreskin 6. testis 7. seminal vesicles 8 scrotum 9 vas deferens 10 bulbourethral (Cowper) glands C 1 flagellum 2 glans penis 3 ejaculatory duct

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4. identical twins 5. perineum 6. parenchymal tissue 7. twins 8. erectile dysfunction 9. interstitial cells 10. ejaculate D 1. penis 2. semen 3. testosterone 4. stromal tissue 5. aspermia 6. azoospermia 7. sterilization 8 . oligospermia 9. testis 10. impotence E 1. orchitis 2. epididymitis 3. prostatectomy 4. prostatitis 5. spermatogenesis

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pg 6. orchidopexy 7. balanitis 8. oligospermia 9. aspermia 10. testicular F 1. True. 2. False. Estrogen is a female hormone. Androgens are male hormones. Testosterone is an androgen. 3. True. 4. False. Teratoma is a malignant tumor in the testicle. 5. False. Spermolytic is the destruction of sperm. Spermatogenesis is the formation of sperm. 6. False. Balanitis is an inflammation of the glans penis. Orchitis is inflammation of a testicle. 7. True. 8. Truth. The semen is discharged backwards into the urinary bladder and is not ejaculated. 9. False. The seminiferous tubules are the parenchymal tissue of the testes. The interstitial cells of the testis are the Leydig cells that secrete testosterone. 10. False. Testosterone is produced by the interstitial cells of the testicles. 11. False. Vasectomy results in the inability of sperm to leave the body in semen. It does not affect erectile dysfunction and does not cause impotence. 12. Truth.

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G 1. C 2. G 3. H 4. F 5. B 6. D 7. A 8. E 9. J 10. I H 1. benign prostatic hyperplasia 2. hypospadias 3. genital herpes 4. prostate adenocarcinoma (cancer prostate) 5. varicocele 6. syphilis 7. HPV infection 8. gonorrhoea 9. cryptorchidism 10. hydrocele I 1. prostate-specific antigen: G

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p p g 2. benign prostatic hyperplasia: D 3. transurethral resection of the prostate: B 4. transrectal ultrasound: F 5. DRE: A 6. herpes simplex virus: C 7. sexually transmitted infection: E 8. laparoscopy-assisted prostatectomy by robot: H J 1. hormone 2. opening 3. semen, seed 4. hernia, swelling 5. fixation 6. shaping 7. forming 8. prostate 9. testicle 10. monster 11. seed 12. water 13. penis 14. glans 15. varicose veins 16. vessel, duct, deferent duct

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17. testicle, testicle 18. animal life 19. occult 20. K male 1. radical (complete) prostatectomy 2. orchidopexy 3. vasectomy 4. photoselective vaporization of the prostate 5. hydrocelectomy 6. vasovasostomy 7. orchiectomy 8. circumcision 9. Varicocelectomy L 1. prostate 2. epididymis 3. parenchyma 4. foreskin 5. chlamydia 6. cancer 7. testosterone 8. semen or seminal fluid 9. seminoma

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10. penis M 1. cryptorchidism 2. chlamydia 3. prostate 4. circumcision 5. urologist; syphilis; cancer 6. vasectomy; urologist; vas deferens 7. antibiotics; epididymitis; orchiectomy; seminoma 8. semen analysis; oligospermia 9. testosterone; androgen 10. amniotic; Fraternal responses to practical applications Case report: a man with post-TURP complaints

1. c 2. b 3. b 4. a 5. b 6. c 7. c 8. a

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Pronunciation of Terms

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TERM androgen aspermia azoospermia balanitis benign prostatic hyperplasia bulbourethral glands castration cancer chlamydia circumcision cryogenic surgery cryptorchidism digital rectal examination ejaculation ejaculatory duct embryonic carcinoma epididymis epididymitis erectile dysfunction flagellum twins glans penis gonorrhea genital herpes human papillomavirus hydrocele hypospadias identical twins impotence interstitial cells infertility testicles ligation oligospermia orchiectomy orchiopexy orchitis parenchymal tissue of the penis penile penoscrotal perineum Peyronie's disease phimosis photoselective vaporization of the prostate foreskin prostate cancer prostate prostatectomy prostatitis scrotum purulent semen

PRONUNCIATION AN-dro-jen a-SPER-me-ah a-zo-o-SPER-me-ah bal-ah-NI-tis be-NINE pros-TAH-tik hi-per-PLA-ze-ah bul- glândula bo-u-RE-thral kah-STRA-shun SHANK-er klah-MID-e-ah señor-kum-SIZH-un kri-o-GEN-ik SUR-jer-e crypta-OR-kid-ism DIH -jeh-tal REK-tal ek-ZAM eh-jak-u-LA-shun eh-JAK-u-lah-tor-e dukt em-bre-ON-al kar-sih-NO-mah ep-ih-did -ih-miss ep-ih-did-ih-MI-tis e-REK-tile dis-FUNK-shun fila-JEL-um frah-TER-nal twinz glanz PE-nis gon-o-RE-ah HER-peez jen-ih-TAL-is HU-man pap-ih-LO-mah-vi-rus HI-dro-seel hi-po-SPA-de-as i-DEN-tih-kal twinz IM-po-tents in- fer-TIL-ih-te in-ter-STIH-shul selz do TES-tis li-GA-shun ol-ih-go-SPER-me-ah or-ke-EK-to-me or-ke-o - PEK-se ou-KI-tis pah-RENK-ih-mal TIH-shu PE-nile PE-nis pe-no-SKRO-tal peh-rih-NE-um pah-RO-ne dih-zeez fih-MO - sis fo-to-see-LIKE-tiv va-por-ih-ZA-shun do PROSTATE PRE-pus PROS-tight CAN-see PROS-tight gland pros-tah-TAKE-to-me pros-tah-TI -tis PU-ru-lent SCRO-tum SE-men

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TERM semen analysis seminal vesicles seminiferous tubules seminoma spermatogenesis sperm sterilization sperm stromal tissue syphilis teratoma testicular cancer testicular torsion testis testosterone transurethral resection of the prostate varicocele vas deferens vasectomy vasovasostomy

PRONUNCIATION SE-men ah-NAH-lih-sis SEH-mih-nal VES-ih-kils seh-mih-NIF-er-us TOOB-ules seh-mih-NO-mah sper-mah-to-JEN-eh- sis sper-mah-to-ZO-ah sper-mah-to-ZO-en sper-mo-LIH-rik ster-ih-lih-ZA-shun STRO-mal TIH-shu SIF-ih-list ter-ah- TO-mah tes-DO-ku-lar tes-DO-ku-lar CAN-ser tes-DO-ku-lar TOR-shun TES-tis tes-TOS-teh-rone tranz-u-RE-thral re-SEK -shun de PROS-tight VAR-ih-ko-seel and DEF-er-enz and-EK-for-me and-o-and-OS-for-me

revision sheet

Write the meanings of the word parts in the spaces provided. Check your answers with the information in the chapter or in the Glossary (Parts of Medical Words—English) at the end of the book.

match shapes

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FORM OF COMBINATION andr/o balan/o cry/o crypt/o epididymis/o gon/o hydr/o orch/o orchi/o orchid/o pen/o prostate/o semin/i sperm/o spermat/o terat/ the test/the varicose vein/the vas deferens/the zo/the

Sufijos SUFIJO -cele -ectomia -gen -genesis -genic -lysis -lytic -one -pexy -plasia -rrhea -stomy -tomy -trofeo

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CHAPTER 10

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Nervous System CHAPTER SECTIONS: Introduction 322 General Structure of the Nervous System 322 Neurons, Nerves, and Glial Cells 326 The Brain 328 Spinal Cord and Meninges 331 Vocabulary 333 Terminology 335 Pathology 340 Laboratory Tests and Clinical Procedures 349 Abbreviations 352 Practical Applications 352 In Person: Sciatica 356 Exercises 357 Answers to Exercises 364 Pronunciation of Terms 367 Review Sheet 370

CHAPTER OBJECTIVES • Name, locate, and describe the main organs of the nervous system and their functions. • Learn combination forms of the nervous system and use them with suffixes and prefixes. • Define pathological conditions that affect the nervous system.

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• Describe laboratory tests related to the nervous system, clinical procedures, and abbreviations. • Apply your new knowledge to understand medical terms in their proper contexts, such as medical reports and records.

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Introduction The nervous system is one of the most complex of all systems in the human body. More than 100 billion nerve cells are constantly working throughout the body to coordinate the activities we do consciously and voluntarily, as well as those that occur unconsciously or involuntarily. We speak, we move muscles, we hear, we taste, we see and we think. Our glands secrete hormones and we react to danger, pain, temperature and touch. All of these functions comprise only a small number of the many activities controlled by the nervous system. Fibers emerging from microscopic nerve cells (neurons) assemble into macroscopic bundles called nerves, which carry electrical messages throughout the body. External stimuli, as well as internal chemicals such as acetylcholine, activate the cell membranes of nerve cells, resulting in electrical discharges from those cells. These electrical discharges, nerve impulses, can travel along the associated nerves. External receptors (sense organs), as well as internal receptors in muscles and blood vessels, receive these impulses and, in turn, can transmit them to the complex network of nerve cells in the brain and spinal cord. Within this central part of the nervous system, impulses are recognized, interpreted, and ultimately transmitted to other nerve cells that extend to all parts of the body, such as muscles, glands, and internal organs.

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General Structure of the Nervous System The nervous system is classified into two main divisions: the central nervous system (CNS) and the peripheral nervous system (PNS). The central nervous system is made up of the brain and spinal cord. The peripheral nervous system consists of cranial nerves and spinal nerves, plexuses, and peripheral nerves throughout the body (Figure 10-1). The cranial nerves carry impulses between the brain and the head and neck. The only exception is the tenth cranial nerve, called the vagus nerve. It carries messages to and from the neck, chest, and abdomen. Figure 10-2 shows the cranial nerves, their functions, and the parts of the body that they carry messages to and from. Spinal nerves carry messages between the spinal cord and the thorax, abdomen, and extremities.

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FIGURE 10-1 The brain and spinal cord, spinal nerves, and spinal plexuses. The femoral nerve is a lumbar nerve that runs to and from the thigh region (the femur is the thigh bone). The sciatic nerve is a nerve that starts in a region of the hip. The cauda equina (Latin for "horse's tail") is a bundle of spinal nerves below the end of the spinal cord.

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FIGURE 10-2 Cranial nerves (I to XII) from the base of the brain and showing the parts of the body that they affect. Sensory or afferent nerves are blue in color and carry messages to the brain. Motor or efferent nerves are red in color and carry messages from the brain to the muscles and organs. Some (mixed) nerves carry sensory and motor fibers. Don't try to memorize this figure! Just an overview: the cranial nerves carry messages to and from the brain to all parts of the head and neck, and also (in the case of the vagus nerve) to other parts of the body.

A plexus is a large network of nerves in the peripheral nervous system. The cervical, brachial (brachial means arm), and lumbosacral plexuses are examples that include the cervical, lumbar, and sacral nerves.

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Figure 10-1 illustrates the relationship of the brain and spinal cord to the spinal nerves and plexuses.

Plexus

There are other plexuses in the body: intersecting networks of blood vessels (vascular) and lymphatic vessels. • The lymphatic plexus is an interconnected network of lymphatic vessels. • The rectal plexus is a plexus of veins in the rectal region. • The vertebral plexus is a plexus of veins related to the spinal column. The spinal and cranial nerves are made up of nerves that help the body respond to changes in the outside world. They include sensory receptors for vision (eye), hearing and balance (hearing), smell (olfactory) and touch (skin sensation), and sensory (afferent) nerves that carry messages related to changes in the environment. environment to the spinal cord and brain. . In addition, motor (efferent) nerves travel from the spinal cord and brain to the muscles of the body, telling them how to respond. For example, when you touch a hot stove, temperature and pain receptors in your skin stimulate afferent nerves, which carry messages to your spinal cord and brain. Instantly, the message is transmitted to different nerve cells in the spinal cord, which then activate voluntary muscles to move the hand away from the stove. In addition to the spinal and cranial nerves (whose functions are primarily voluntary and are related to the sensations of smell, taste, sight, hearing, and muscle movement), the peripheral nervous system also contains a large group of nerves that function in involuntarily or automatically, without conscious control. These peripheral nerves belong to the autonomic nervous system. This system of nerve fibers carries impulses to glands, the heart, blood vessels, involuntary muscles found in the walls of ducts such as the intestines, and hollow organs such as the stomach and urinary bladder. Some autonomic nerves are sympathetic nerves and others are parasympathetic nerves. Sympathetic nerves stimulate the body in times of stress and crisis. They increase heart rate and strength, dilate (relax) the airways so more oxygen can get in, and increase blood pressure. In addition, sympathetic neurons stimulate the adrenal glands to secrete epinephrine (adrenaline), while inhibiting intestinal contractions to slow digestion. The parasympathetic nerves normally act as a balance for the sympathetic nerves. Parasympathetic nerves slow heart rate, lower blood pressure, and stimulate bowel function.

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contractions to cleanse the rectum. Figure 10-3 shows the differences in the actions of the sympathetic and parasympathetic nerves.

FIGURE 10-3 Actions of the parasympathetic and sympathetic nerves.

Figure 10-4 summarizes the divisions of the central and peripheral nervous systems.

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FIGURE 10-4 Divisions of the central nervous system (CNS) and peripheral nervous system (PNS). The autonomic nervous system is a part of the peripheral nervous system.

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Neurons, Nerves, and Glial Cells A neuron is an individual nerve cell, a microscopic structure. Impulses pass through parts of a nerve cell in a definite way and direction. The parts of a neuron are depicted in Figure 10-5; label it as you study the following.

FIGURE 10-5 Parts of a neuron and the pathway of a nerve impulse. Neurons are the parenchymal (essential) cells of the nervous system. The inset drawing shows what happens in a synapse: vesicles store neurotransmitters at the fiber ends of axons. The receptors on the dendrites pick up the neurotransmitters. Inactivators shut down the neurotransmitters when they have finished their work.

A stimulus initiates an impulse in the branching fibers of the neuron, which are called dendrites [1]. A change in the electric charge of the

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Thus the dendritic membranes are initiated and the nerve impulse moves along the dendrites like the movement of falling dominoes. The impulse, which travels in only one direction, reaches the cell body [2], which contains the nucleus of the cell [3]. The small collections of nerve cell bodies outside the brain and spinal cord are called ganglia (singular: ganglion). Extending from the cell body is the axon [4], which carries the impulse away from the cell body. Axons can be covered with a fay tissue called myelin. The purpose of this myelin sheath [5] is to insulate the axon and speed up the transmission of the electrical impulse. Demyelination is the loss of myelin that insulates the nerve fiber and is characteristic of multiple sclerosis, an acquired disease that affects the CNS. The myelin sheath gives the nerve fiber a white appearance, hence the term white matter, as in parts of the spinal cord and the white matter of the brain and most peripheral nerves. The gray matter of the brain and spinal cord is made up of the cell bodies of neurons that appear gray because they are not covered by a myelin sheath. The nerve impulse crosses the axon to leave the cell through the terminal fibers [6] of the neuron. The space where the nerve impulse jumps from one neuron to another is called a synapse [7]. The transfer of the impulse across the synapse depends on the release of a chemical, called a neurotransmitter, by the neuron that carries the impulse to the synapse. See the boxplot in Figure 10-5. Small sacs (vesicles) containing the neurotransmitter sit at the ends of neurons and release the neurotransmitter into the synapse. Acetylcholine, norepinephrine, epinephrine (adrenaline), dopamine, serotonin, and endorphins are examples of neurotransmitters. While a neuron is a microscopic structure within the nervous system, a nerve is macroscopic and can be seen with the naked eye. A nerve consists of many axons that travel together like strands of rope. The peripheral nerves that carry impulses to the brain and spinal cord from stimulus receptors such as the skin, eyes, ears, and nose are afferent or sensory nerves; Those that carry impulses from the CNS to the organs that produce responses, such as muscles and glands, are the efferent or motor nerves. Neurons and nerves are the parenchyma of the nervous system. The parenchyma is the essential distinctive tissue of an organ. In the brain and spinal cord, the neurons that conduct electrical impulses are the parenchymal tissue. The stroma of an organ is the connective and supportive tissue of an organ. The stromal tissue of the central nervous system consists of glial (neuroglial) cells, which constitute its support structure and help prevent infection. Glial cells do not transmit impulses. They are much more numerous than neurons and can reproduce.

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There are four types of supporting or glial cells (see Figure 10-6). Astrocytes (astroglial cells) have a star-like appearance (astr/o means star) and transport water and salts between capillaries and neurons. Microglial cells are small cells with many branching processes (dendrites). Like phagocytes, they protect neurons in response to inflammation. Oligodendroglial cells (oligodendrocytes) have few dendrites (oligo/o means few or few). These cells form the myelin sheath in the CNS. By contrast, ependymal cells (from the Greek ependyma meaning upper garment) line the membranes within the brain and spinal cord where CSF is produced and circulates.

FIGURE 10-6 Glial cells (neuroglial cells). These are the cells of support, protection and connective tissue of the CNS. Glial cells are stromal tissue (structure), while neurons carry nerve impulses.

Glial cells, particularly astrocytes, are associated with blood vessels and regulate the passage of potentially harmful substances from the blood to nerve cells in the brain. This protective barrier between the blood and brain cells is called the blood-brain barrier (BBB). This barrier consists of special lining cells (endothelial) that, together with astrocytes, separate the capillaries from the nerve cells. Therefore, the administration of chemotherapy drugs to treat brain tumors is difficult because the BBB blocks the access of the drug to the brain tissues. Figure 10-6 illustrates glial cells.

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The Brain The brain controls the activities of the body. In the adult human, it weighs around 3 kilos and has many different parts, all controlling different aspects of the body's functions. The largest part of the brain is the "thinking" area, or cerebrum. On the surface of the brain, nerve cells are found in layers, which make up the cerebral cortex. These sheets, arranged in folds called gyri, are separated from each other by grooves known as sulci. The brain is divided in half, a right side and a left side, which are called the cerebral hemispheres. Each hemisphere is further subdivided into four main lobes named for the bones of the skull (cranium) that cover them. Figure 10-7 shows these lobes (frontal, parietal, occipital, and temporal) as well as the gyri and sulci.

FIGURE 10-7 Left cerebral hemisphere (lateral view). The gyri (gyri) and sulci (fissures) are indicated. Look at the lobes of the brain and the functional centers that control speech, vision, movement, hearing, thinking, and other processes. Neurologists believe that the two hemispheres have different capacities. The left side of the brain is more concerned with language, mathematical functioning, reasoning, and analytical thinking. The right side of the brain is more active in spatial relationships, art, music, emotions, and intuition.

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The brain has many functions. It is responsible for thought, judgment, memory, association, and discrimination. Furthermore, sensory impulses are received via the afferent cranial nerves and, when registered in the cortex, form the basis of perception. Nerve impulses from the brain propagate to the muscles and glands producing movement and internal changes in the body. Figure 10-7 shows the location of some of the centers in the cerebral cortex that control the processes of speech, vision, smell, movement, hearing, and thought. In the middle of the brain are spaces, or canals, called ventricles (represented in Figure 10-8). They contain a watery fluid that flows throughout the brain and around the spinal cord. This fluid is cerebrospinal fluid (CSF) and it protects the brain and spinal cord from shock by acting as a shock absorber. CSF is usually clear and colorless and contains lymphocytes, sugar, and protein. Cerebrospinal fluid may be removed for diagnosis or to relieve pressure on the brain; this is called a lumbar puncture (LP). For this procedure, a hollow needle is inserted into the lumbar region of the spine below the region where the nerve tissue of the spinal cord ends, and the CSF is withdrawn.

FIGURE 10-8 Circulation of cerebrospinal fluid (CSF) in the brain (ventricles) and around the spinal cord. CSF is formed within the ventricles and circulates between the membranes that surround the brain and within the spinal cord. The CSF empties into the bloodstream through the membranes that surround the brain and spinal cord.

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Two other important parts of the brain are the thalamus and the hypothalamus (Figure 10-9). The thalamus acts as a sorting center. It decides what is important and what is not, selectively processing and transmitting sensory information to the cerebral cortex. The thalamus also plays an important role in maintaining levels of perception and consciousness. The hypothalamus (below the thalamus) contains neurons that control body temperature, sleep, appetite, sexual desire, and emotions such as fear and pleasure. The hypothalamus also regulates the release of hormones from the pituitary gland at the base of the brain and integrates the activities of the sympathetic and parasympathetic nervous systems.

FIGURE 10-9 Parts of the brain: cerebrum, thalamus, hypothalamus, cerebellum, midbrain, pons, and medulla oblongata. Note the location of the pituitary gland below the hypothalamus. The basal ganglia (a group of cells) regulate the purposeful movements of the body. The corpus callosum is located in the center of the brain and connects the two hemispheres (halves).

The following structures within the brain lie in the back and below the cerebrum and connect the cerebrum to the spinal cord: cerebellum, midbrain, pons, and medulla oblongata. The midbrain, pons, and medulla oblongata form the brainstem. See Figure 10-9. The cerebellum functions to coordinate voluntary movements and maintain balance and posture.

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The midbrain is the upper portion of the brain stem. It contains pathways that connect the brain to the lower parts of the brain and the structures involved with vision and hearing. The pons is a part of the brain stem that literally means bridge. It contains tracts of nerve fibers that connect the cerebellum and cerebrum with the rest of the brain. Nerves that affect the face and eye movement are located here. The medulla oblongata, also in the brainstem, connects the spinal cord to the rest of the brain. Nerve pathways cross from right to left and from left to right in the medulla oblongata. For example, the nerve cells that control movement on the left side of the body are found in the right half of the brain. These cells send axons that cross (decussate) to the opposite side of the brain in the medulla oblongata and then down the spinal cord. In addition, the medulla oblongata contains three important vital centers that regulate the internal activities of the body: 1. Respiratory center: controls the respiratory muscles in response to chemicals or other stimuli 2. Heart center: slows the heart rate when the heart beats too fast 3. Vasomotor center: affects (contracts or dilates) the muscles in the walls of blood vessels, which influences blood pressure. Figure 10-9 shows the locations of the thalamus, hypothalamus, cerebellum, pons, and medulla oblongata. Table 10-1 reviews the functions of these parts of the brain. TABLE 10-1 FUNCTIONS OF THE PARTS OF THE BRAIN Structure Brain Thalamus

Function(s) Thought, personality, sensations, movement, memory Relay station (“sorting center”) for sensory input; control of perception and consciousness Hypothalamus Body temperature, sleep, appetite, emotions; control of the pituitary gland Cerebellum Coordination of voluntary movements and balance Bridging and connection of nerve pathways and nerve fibers, including those of the midbrain eyes and face Medulla Nerve fibers cross, left to right and right to left; contains elongated centers that regulate the heart, blood vessels, and respiratory system

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The Spinal Cord and Meninges Spinal Cord The spinal cord is a column of nervous tissue that extends from the medulla oblongata to the second lumbar vertebra within the vertebral column. Beneath the end of the spinal cord is the cauda equina (Latin for "horse's tail"), a fan of nerve fibers (see Figure 10-1, page 323). The spinal cord carries all the nerves to and from the extremities and lower body, and is the pathway for impulses to and from the brain. A cross-sectional view of the spinal cord (Figure 10-10) reveals an inner region of gray matter (containing cell bodies and dendrites) and an outer region of white matter (containing the myelin-sheathed nerve fiber tracts) that conduct impulses to and from the spinal cord to the brain.

FIGURE 10-10 The spinal cord, showing the gray and white matter (sectional view). Afferent neurons carry impulses from a sensory receptor (such as the skin) to the spinal cord. Efferent neurons carry impulses from the spinal cord to effector organs (such as skeletal muscle). The central channel is the space through which the CSF travels.

Meninges The meninges are three layers of connective tissue membranes that surround the brain and spinal cord. Mark Figure 10-11 as you study the following description of the meninges.

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FIGURE 10-11 The meninges, posterior view.

The outermost membrane of the meninges is the dura mater [1]. This thick, tough membrane contains channels (dural sinuses) that contain blood. The subdural space [2] is below the dural membrane. The second layer that surrounds the brain and spinal cord is the arachnoid membrane [3]. The arachnoid (spider-like) membrane is loosely attached to the other meninges by web-like fibers, so there is a space for fluid between the fibers and the third membrane. This is the subarachnoid space [4], which contains CSF. The third layer of the meninges, closest to the brain and spinal cord, is the pia mater [5]. It contains delicate connective tissue (from the Latin pia) with a rich supply of blood vessels. Most physicians refer to the pial and arachnoid membranes together as pial-arachnoid.

Vocabulary

This list reviews new terms introduced in the text. Short definitions reinforce your understanding of the terms. See the Pronunciation of Terms section for help with unfamiliar or more difficult words.

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acetylcholine afferent nerve arachnoid membrane astrocytes autonomic nervous system axon blood-brain barrier brainstem cauda equina cell body central nervous system (CNS) cerebellum cerebral cortex cerebrospinal fluid (CSF) cerebrum

A chemical neurotransmitter released at the ends of nerve cells. It carries messages to the brain and spinal cord (sensory nerve). Afferent comes from af- (a form of ad-, meaning to) and -ferent (meaning to carry). The middle layer of the three membranes (meninges) that surround the brain and spinal cord. From the Greek arachne means spider. A type of glial (neuroglial) cell that transports water and salts from the capillaries of the nervous system. Nerves that control involuntary bodily functions of muscles, glands, and internal organs. Microscopic fiber that is part of a neuron and carries the nerve impulse along a nerve cell. Protective separation between blood and brain cells. This makes it harder for substances (such as cancer drugs) to penetrate the walls of the capillaries and enter the brain. The posterior portion of the brain that connects the brain to the spinal cord; includes the midbrain, pons, and medulla oblongata. Collection of spinal nerves below the end of the spinal cord. The part of a nerve cell that contains the nucleus. Brain and spinal cord. The back part of the brain that coordinates muscle movements and maintains balance. Outer region of the brain, containing sheets of nerve cells; gray matter of the brain. It circulates throughout the brain and spinal cord.

The largest part of the brain; responsible for voluntary muscle activity, vision, speech, taste, hearing, thinking, and memory. cranial nerves Nerves carry messages to and from the brain to all parts of the head and neck and also (in the case of the vagus nerve) to other parts of the body. There are 12 pairs of cranial nerves. dendrite A microscopic branching fiber of a nerve cell (neuron) that is the first part to receive a nerve impulse. dura thick outer layer of the meninges that surrounds and protects the brain and spinal cord. Latin for "hard mother." efferent nerve Carries messages from the brain and spinal cord; motor nerve. Eﬀerent comes from ef- (meaning away from) and -ferent (meaning to carry). ependymal cell A glial cell that lines the membranes within the brain and spinal cord and helps form cerebrospinal fluid. ganglion (plural: Set of nerve cell bodies in the peripheral nervous system. ganglia) glial cell Supportive and conjunctival nerve cell that does not carry nerve impulses (glial cells). Examples are astrocytes, microglial cells, ependymal cells, and oligodendrocytes. Glial cells can reproduce, unlike neurons. gyrus (plural: sheet of nerve cells that produces a rounded ridge on the surface of the gyri) cerebral cortex; convolution. hypothalamus Portion of the brain below the thalamus; controls sleep, appetite, body temperature, and secretions from the pituitary gland. medulla Part of the brain just above the spinal cord; controls breathing, heartbeat, oblongata and the size of blood vessels; Nerve fibers cross here. meninges Three protective membranes that surround the brain and spinal cord.

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microglial cell midbrain motor nerve myelin sheath neuron neurotransmitter nervous

oligodendroglial cell parenchyma of parasympathetic nerves

peripheral nervous system pia mater plexus (plural: plexuses) receptor bridge sciatic nerve sensory nerve spinal nerves stimulus (plural: stimuli) stroma sulcus (plural: sulci) sympathetic nerves synapse thalamus

Phagocytic glial cell that removes waste products from the central nervous system. Upper part of the brain stem. It carries messages from the brain and spinal cord to the muscles and organs; efferent nerve. White fairy tissue covering that surrounds and insulates the axon of a nerve cell. Myelin speeds up the conduction of impulses along the axons. Gross collection of string-like fibers (axons) that carry electrical impulses. Nerve cell necessary for impulses to be conducted throughout the nervous system; parenchyma of the nervous system. Chemical messenger released at the end of a nerve cell. It stimulates or inhibits another cell, which may be a nerve, muscle, or gland cell. Examples of neurotransmitters are acetylcholine, norepinephrine, dopamine, and serotonin. Glial cell that forms the myelin sheath that covers axons. Also called oligodendrocytes. Involuntary autonomic nerves that regulate normal bodily functions, such as heart rate, breathing, and the muscles of the gastrointestinal tract. Essential and distinctive tissue of any organ or system. The parenchyma of the nervous system includes the neurons and nerves that carry nerve impulses. The parenchymal cells of the liver are the hepatocytes, and the parenchymal tissue of the kidney includes the nephrons, where urine is formed. Note the pronunciation: păr-ĔN-kĭ-mă. Nerves outside the brain and spinal cord: cranial, spinal, and autonomic nerves. Thin and delicate inner membrane of the meninges. Great intertwined network of nerves. Some examples are the lumbosacral, cervical, and brachial plexuses (brachial means arm). The term originates from the Indo-European plek, which means to weave together. Part of the brain anterior to the cerebellum and between the medulla oblongata and the rest of the midbrain. It is a bridge that connects various parts of the brain. In Latin, pons means bridge. Organ that receives and transmits a stimulus to the sensory nerves. The skin, ears, eyes, and taste buds are receptors. Nerve that runs from the base of the spine to the thigh, lower leg, and foot. Sciatica is pain or inflammation along the path of a nerve. Carries messages to the recipient's brain and spinal cord; afferent nerve. Pairs of nerves, which arise one on each side of the vertebral column. They carry messages to and from the spinal cord. Change agent in the internal or external environment that evokes a response. It can be light, sound, touch, pressure, or pain. Connective and supporting tissue of an organ. Glial cells form the stromal tissue of the brain. Depression or groove on the surface of the cerebral cortex; fissure. Autonomic nerves that involuntarily influence bodily functions in times of stress. The space through which a nerve impulse travels between nerve cells or between nerve and muscle or gland cells. From the Greek synapsis, point of contact. Main relay center of the brain. Conducts impulses between the spinal cord and the brain; Incoming sensory messages are transmitted through

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thalamus to the appropriate centers in the brain. From the Latin thalamus means room. The Romans, who gave this structure its name, thought that this part of the brain was hollow, like a small room. vagus nerve Tenth cranial nerve (cranial nerve X). Its branches reach the larynx, trachea, bronchi, lungs, aorta, esophagus, and stomach. From the Latin vagus means to wander. Unlike the other cranial nerves, the vagus leaves the head and "wanders" into the abdominal and thoracic cavities. canal ventricles in the brain that contain cerebrospinal fluid. The ventricles are also the brain found in the heart: they are the two lower chambers of the heart.

Terminology

This section is divided into terms that describe organs and structures of the nervous system and those that relate to neurological signs and symptoms. Write the meanings of the medical terms in the spaces provided.

Bodies and Structures

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MATCHING MEANING FORM cerebel/the cerebellum cerebr/the brain

stand

brain

gli/o lept/o

me me

mi/mi/mi/mi

neuro/the point/the

TERMINOLOGY

SENSE

cerebellar ________________________________________ cerebrospinal fluid _______________________________________ cerebral cortex _______________________________________ Cortical means pertaining to the cortex or outer area of an organ. Subdural hematoma of the dura mater __________________________________________ Remember: hematomas are not blood tumors, but collections of blood. epidural hematoma __________________________________ Figure 10.12 shows subdural, epidural, and intracerebral hematomas. Cerebral encephalitis ________________________________________ encephalopathy ________________________________________ Chronic traumatic encephalopathy (CTE) is a progressive degenerative disease associated with repetitive brain trauma (concussion). anencephaly ______________________ A congenital brain malformation; it is not compatible with life and can be detected with amniocentesis or ultrasound of the fetus. glial cell glioblastoma ______________________________________ This is a highly malignant tumor (-blast means immature). Gliomas are tumors of glial (neuroglial) cells. thin and thin leptomeningeal __________________________________________ The pia and arachnoids are known as leptomeninges because of their thin and delicate structure. meningeal membranes ________________________________________ meningioma of the meninges __________________________________________ Benign slow-growing tumor. myelomeningocele __________________________________________ Neural tube defect caused by failure of the neural tube to close during embryonic development. This abnormality occurs in babies born with spina bifida. See page 341. myoneural muscle __________________________________________ spinal cord myelopathy _______________________________________ (means polio bone __________________________________________ medulla in polio - means gray matter. This viral disease affects the other gray matter of the spinal cord, leading to paralysis of the muscles on which contexts depend) damaged neurons. Effective vaccines developed in the 20th century made "polio" relatively rare. nervous neuropathy ____________ polyneuritis ____________________________________ pontocerebellar bridge ______________________________ The suffix -ine means belonging to.

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COMBINATION FORM OF MEANING radicle/or nerve root (of spinal nerves)

thalam/o thec/o

inaccurate

TERMINOLOGY

SENSE

Radiculopathy ____________________________________ Sciatica is a radiculopathy that affects the root of the sciatic nerve in the back. A herniated disc is a common cause of leg pain, weakness, or numbness. See In Person: Sciatica History on page 356. Radiculitis _____________________________________ This condition usually causes pain and loss of function. thalamus thalamus __________________________________ sheath intrathecal injection (refers to the ______________________________ meninges) Chemicals, such as chemotherapy drugs, can be delivered into the subarachnoid space. vagus vagal nerve _____________________________________ (10th cranial This cranial nerve has branches to the head and neck, as well as nerve) as well as to the thorax.

FIGURE 10-12 Bruises. A subdural hematoma results from rupture of the veins between the dura mater and the arachnoid membranes. It is often the result of blunt trauma, such as blows to the head in boxers or in elderly patients who have fallen out of bed. An epidural hematoma occurs between the skull and the dura as a result of a ruptured meningeal artery, usually after a skull fracture. An intracerebral hematoma is caused by bleeding directly into brain tissue, as can occur with uncontrolled hypertension (high blood pressure).

signs and symptoms

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COMBINATION OF MEANING TERMINOLOGY SUFFIX MEANING alges/o, sensitivity to analgesia ______________________________________ algesia pain hypoalgesia __________________________________________ Decreased sensation of pain. (Note that the o in hypocaid). Hyperalgesia is an increased sensitivity to pain. - pain pain (see neuralgia ______________________________________ page 355 for trigemal neuralgia involves flashes of pain that radiate along the course of the trigemal nerve (fifth cranial nerve). scalp. cause/or burning cause pain ______________________________________ Intense burning pain after injury to a sensory nerve. coma/deep comatose sleep __________________________________________ (coma) A coma is a state of unconsciousness from which the patient cannot be awakened. Semicomatosis refers to a stupor (unresponsiveness) from which a patient can be awakened. In an irreversible coma (brain death), there is a complete lack of response to stimuli, no breathing or spontaneous movement, and a flat electroencephalogram (EEG). anesthesia, sensation, anesthesia __________________________________________nervous aesthesia Lack of normal sensation (for example, no sensation of touch or sensation of pain). Two common types of regional anesthesia are spinal and epidural (caudal) blocks (Fig. 10.13). An anesthesiologist is a doctor who administers anesthesia. Anesthetics are agents that reduce or eliminate sensation. General and local anesthetics are listed in Table 21-2, page 829. hyperesthesia ________________________________________ An abnormally intense sensation to a specific stimulus, such as a light touch with a pin. The decreased sensitivity to pain is called hypesthesia. paresthesia __________________________________ Par- (from para-) means abnormal. Paresthesias include tingling, burning, and "pins and needles" sensations. kinesi/o, movement bradykinesia ______________________________________ kinesi/o hyperkinesia _____________________________________ kinesia, Amphetamines (CNS stimulants) are used to treat kinesia, hyperkinesia in children, but the mechanism of their action is not understood. dyskinesia ___________________________________ Condition marked by involuntary and jerky movements. Tardive dyskinesia (occurring later) can develop in people who take certain antipsychotic medications for long periods of time. akinetic ________________________________________ - convulsive lepsy epilepsy _____________________________________ See page 343. narcolepsy __________________________________________ Sudden and uncontrollable compulsion to sleep (narc/o = stupor, sleep). Amphetamines and stimulant drugs are prescribed to prevent seizures.

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MEANING FORM OR SUFFIX COMBINATION lex/o word, phrase -paresis

weakness

- murdered

speech

- plegia

paralysis (loss or impairment of the ability to move parts of the body)

-praxia

action

-extended

force

syncope

cut, abbreviate

tax

order, coordination

TERMINOLOGY

SENSE

dyslexia __________________________________ This is a developmental reading disorder that occurs when the brain does not correctly recognize, process, or interpret language. hemiparesis __________________________________________ Affects the right or left side (half) of the body. Paresis is also used by itself to mean partial paralysis or weakness of the muscles. aphasia __________________________________ Difficulty with speech. Motor aphasia (also called Broca's or expressive) is present when the patient knows what he wants to say but cannot. The patient with sensory aphasia has difficulty understanding language and can pronounce (articulate) words easily but use them inappropriately. hemiplegia __________________________________________ Affects the right or left half of the body and is the result of a stroke or other brain injury. Hemiplegia is contralateral to brain damage because motor nerve fibers from the right half of the brain cross to the left side of the body (into the medulla oblongata). paraplegia ______________________________________ Originally, the term paraplegia meant an effusion (paralysis) on one side (para-). Now, however, the term means paralysis of both legs and the lower body caused by injury or disease of the spinal cord or cauda equina. tetraplegia __________________________________________ Quadri- means four. All four limbs are affected. The lesion is located at the cervical level of the spinal cord. apraxia ______________________________________ Movements and behavior are unintentional. A patient with motor apraxia is unable to use an object or perform a task. Motor weakness is not the cause. neurasthenia ____________________________________ Nervous exhaustion and fatigue, often following depression. syncope __________________________________ Syncope (SIN-ko-pe) means fainting; Sudden and temporary loss of consciousness caused by inadequate blood flow to the brain. The term comes from a Greek word meaning to cut to pieces, so a faint means that one's strength has been "cut off." TIP: Syncopal means weak and is an adjective. A patient may experience a syncopal episode. ataxia __________________________________ Decreased coordination condition. Persistent unsteadiness in the feet may be due to a disorder affecting the cerebellum.

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FIGURE 10-13 A. Patient positioning for spinal anesthesia. B, Cross section of the spinal cord showing the injection sites for epidural and spinal anesthesia (anesthesia). Epidural (caudal) anesthesia is achieved by injecting an agent into the epidural space and is commonly used in obstetrics. Spinal anesthesia is achieved by injecting a local anesthetic into the subarachnoid space. Patients may experience numbness and paralysis of the feet, legs, and abdomen.

honey/o and mi/o

Do not confuse these combined forms. Myel/o means spinal cord or bone marrow, while my/o means muscle. Another pair to watch out for is the pyel/o (kidney renal pelvis) and the py/o (pus).

Neuropathies

Neuropathies are diseases of the peripheral nerves. They can affect motor, sensory and autonomic functions. Polyneuropathies affect many nerves, while mononeuropathies affect individual nerves.

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Pathology The bones of the skull, vertebral column, and meninges, which contain cerebrospinal fluid, provide a hard covering with an interior cushion around the brain and spinal cord. In addition, the glial cells that surround the neurons form a blood-brain barrier that prevents many potentially harmful substances in the bloodstream from gaining access to the neurons. However, these protective factors are offset by the extreme sensitivity of nerve cells to oxygen deficiency (brain cells die within minutes when deprived of oxygen). Neurological disorders can be classified into the following categories:

• Congenital • Degenerative, movement and convulsive • Infectious (meningitis and encephalitis) • Neoplastic (tumors) • Traumatic • Vascular (stroke) Congenital disorders hydrocephalus

spina bifida

Abnormal accumulation of fluid (CSF) in the brain. If the circulation of CSF in the brain or spinal cord is disturbed, fluid accumulates under pressure in the ventricles of the brain. To relieve pressure on the brain, a catheter (shunt) may be placed from the ventricle of the brain to the peritoneal space (ventriculoperitoneal shunt) or the right atrium of the heart so that cerebrospinal fluid is continually drained from the brain. Hydrocephalus can also occur in adults as a result of tumors and infections. Birth defects in the lumbar spine caused by imperfect union of the vertebral parts (neural tube defect). In spina bifida occulta, the spinal defect is covered by skin and is only apparent on x-rays or other images. Cystic spina bifida is a more severe form, with cyst-like growths. In meningocele, the meninges protrude outside the body, and in myelomeningocele (or meningomyelocele), both the spinal cord and the meninges protrude (Fig. 10.14A and B). The etiology of neural tube defects is unknown. The defects originate in the first weeks of pregnancy as the spinal cord and vertebrae develop. Prenatal diagnosis is aided by imaging methods and analysis of maternal blood samples for alpha-fetoprotein.

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FIGURE 10-14 A. Spina bifida (neural tube defects). B, Cystic spina bifida with myelomeningocele.

Degenerative, Movement Disorders and Seizures

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Alzheimer's disease (AD) (Alzheimer's)

amyotrophic lateral sclerosis (ALS)

epilepsy

Huntington

A brain disorder characterized by gradual and progressive mental decline (dementia), personality changes, and impairment of daily functioning. Features of AD include confusion, forgetfulness, disorientation, restlessness, and speech disturbances. Anxiety, depression, and emotional disturbances may also occur. The disease sometimes begins in middle age with mild defects in memory and behavior, but it can worsen after age 70. At autopsy, there is often atrophy of the cerebral cortex and widening of the cerebral sulci, especially in the frontal and temporal regions (Figure 10-15A and B). Microscopic examination shows senile plaques resulting from degeneration of neurons and neurofibrillary tangles (bundles of fibrils in the cytoplasm of a neuron) in the cerebral cortex. Amyloid (a protein) deposits occur in neurofibrillary tangles, senile plaques, and blood vessels. The cause of AD remains unknown, although genetic factors may play a role. A mutation on chromosome 14 has been associated with familial cases. There is still no effective treatment. Degenerative disorder of motor neurons in the spinal cord and brain stem. ALS manifests itself in adulthood. Signs and symptoms are weakness and atrophy of the muscles of the hands, forearms, and legs; Difficulty swallowing and speaking and dyspnea develop as the muscles of the throat and breathing are affected. The etiology (cause) and cure of ALS is unknown. A famous baseball player, Lou Gehrig, fell victim to this disease in the mid-20th century, thus the condition became known as Lou Gehrig's disease. Chronic brain disorder characterized by recurrent seizure activity. Seizures are sudden, abnormal bursts of electrical activity in the brain. Seizures are often symptoms of underlying brain pathology, such as brain tumors, meningitis, vascular disease, or scar tissue from a head injury. Tonic-clonic seizures (grand mal or ictal events) are characterized by a sudden loss of consciousness, falling, and then tonic contractions (tightening of the muscles) followed by clonic contractions (jerking and jerking movements of the extremities). These seizures are usually preceded by an aura, which is a peculiar sensation experienced by the affected person before the onset of a seizure. Dizziness, numbness, and visual or olfactory (sense of smell) disturbances are examples of an aura. Absence seizures are a form of seizure that consists of momentary clouding of consciousness and loss of awareness of the environment. These include petit mal seizures in children. Drug therapy (anticonvulsants) is used to control epileptic seizures. Following seizures, there may be neurological symptoms such as weakness, called postictal events. In temporal lobe epilepsy, seizures begin in the temporal lobe (on each side of the brain near the ears) of the brain. The most common type of seizure is a complex partial seizure. Complex means altered consciousness and partial means not generalized. Commonly, these patients have seizures that cause them to stop what they are doing, become confused, and have memory problems. The term epilepsy comes from the Greek epilepsis, which means apprehension. The Greeks thought that a seizure victim was trapped by some mysterious force. The word ictal comes from the Latin ictus, which means blow or blow. An inherited disorder marked by degenerative changes in the

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disease (Huntington's disease)

multiple sclerosis (MS)

myasthenia gravis (MG)

paralysis

Parkinson's disease (Parkinson's)

brain damage leading to sudden involuntary movements and mental deterioration. In this genetic condition, symptoms often begin in adulthood and include personality changes along with choreic (ie, dancing) movements (irregular, uncontrollable arm and leg movements and facial grimaces). It is also known as Huntington's chorea. The genetic defect in patients with Huntington's disease is located on chromosome 4. Patients can be tested for the gene; however, there is no cure and management is symptomatic. Destruction of the myelin sheath in neurons of the CNS and its replacement by plaques of sclerotic (hard) tissue. One of the leading causes of neurological disability in people aged 20 to 40, MS is a chronic disease often characterized by long periods of stability (remission) and worsening (relapse). Demyelination (loss of myelin insulation) prevents the conduction of nerve impulses through the axon. See Figure 10-16A. Demyelination causes paresthesias, muscle weakness, unsteady gait (gait), and paralysis. There may be visual disturbances (blurred and double vision) and also speech disturbances. Areas of myelin scarring (plaques) can be seen on MRI scans of the brain (Fig. 10.16B). The etiology is unknown, but it is probably an autoimmune disease of lymphocytes that react against myelin. Currently, there are many useful disease-modifying drugs for the treatment of MS. These drugs affect the inflammation or immune abnormalities in the CNS associated with this disease. Autoimmune neuromuscular disorder characterized by weakness of voluntary muscles. MG is a chronic autoimmune disease. The antibodies block the ability of acetylcholine (a neurotransmitter) to transmit the nerve impulse from the nerve to the muscle cell. The onset of symptoms is usually gradual. Brainstem signs are prominent and include ptosis of the upper eyelid, double vision (diplopia), and facial weakness. Respiratory paralysis is the main clinical concern. Therapy to reverse symptoms includes anticholinesterase drugs, which inhibit the enzyme that breaks down acetylcholine. Immunosuppressive therapy is used, including medications such as corticosteroids (prednisone) and other immunosuppressive medications. Thymectomy is also a treatment method and is beneficial for many patients. Paralysis (partial or complete loss of motor function). Cerebral palsy is partial paralysis and lack of muscle coordination caused by loss of oxygen (hypoxia) or blood flow to the brain during pregnancy or the perinatal period. Bell's palsy (or Bell's palsy) (Fig. 10.17) is paralysis of one side of the face. The likely cause is a viral infection, and therapy is directed against the virus (antiviral drugs) and inflammation of the nerves (corticosteroids). Degeneration of neurons in the basal ganglia, which occurs later in life and causes tremors, muscle weakness, and slow movement. This slowly progressive condition is caused by a deficiency of dopamine, a neurotransmitter produced by cells in the basal ganglia (see Figure 10-9). Motor disorders include hunched posture, a shuffling gait, and muscle rigidity (rigidity). Other signs are a typical "rolling pill" tremor in the hands and a characteristic mask-like lack of facial expression. See Figure 10-18. Drug therapy such as levodopa plus carbidopa (Sinemet) to increase dopamine levels in the brain is palliative (relieves symptoms

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Touré Syndrome (Toure)

but not curative). Many patients can have clinical features of Parkinson's (parkinsonism) and still not have the disease itself. They would not benefit from antiparkinsonian medication. Some Parkinson's patients may benefit from stimulation by electrodes surgically placed in the brain. Implantation of fetal brain tissue containing dopamine-producing cells is an experimental treatment but has had uncertain results. Involuntary jerking and jerking movements; uncontrollable vocal sounds; and inappropriate words. These involuntary movements, which usually begin with twitching of the eyelid and facial muscles accompanied by verbal outbursts, are called tics. Although the cause of Toure syndrome is unknown, it is associated with excess dopamine or dopamine hypersensitivity. Psychological problems do not cause Toure syndrome, but doctors have had some success treating it with the antipsychotic drug haloperidol (Haldol), antidepressants, and mood stabilizers.

FIGURE 10-15 A, Alzheimer's disease. Widespread loss of brain parenchyma (neuronal tissue) results in narrowing of the cerebral gyri and widening of the sulci. B, Cross-sectional comparison of a normal brain and a brain of a person with Alzheimer's disease.

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FIGURE 10-16 Multiple sclerosis. A, Demyelination of a nerve cell. B, This MRI shows several abnormal white areas that correspond to EM plaques (arrows). Plaques are scar tissue that forms when myelin sheaths are destroyed.

FIGURE 10-17 A, Bell's palsy. Note the paralysis on the left side of this man's face: the eyelid does not close properly, the forehead is not wrinkled as one would expect, and there is a clear paralysis in the lower part of the face. B, The paralysis resolved spontaneously after 6 months.

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FIGURE 10.18 The main symptoms of Parkinson's disease are tremors in the hands, arms, legs, jaw, and face; stiffness or stiffness of the limbs and trunk; bradykinesia (slow gait), stooped posture, and mask facies.

Epilepsy and Seizures

Epilepsy is a brain disorder in which at least two or more seizures occur spontaneously and recurrently. Having a single seizure does not mean that the affected person has epilepsy.

Infectious disorders

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herpes zoster (shingles)

meningitis

human immunodeficiency virus (HIV) encephalopathy

Viral infection that affects the peripheral nerves. The blisters and pain spread along the peripheral nerves (see Figure 1019A) and are caused by inflammation caused by a herpes virus (herpes zoster), the same virus that causes chickenpox. Reactivation of the chickenpox virus (herpes varicella-zoster) occurs, which remains in the body after the person has had chickenpox. The painful blisters follow the underlying route of the cranial or spinal nerves. Shingrix is a vaccine to prevent shingles. It is recommended for people over 50 years of age. Inflammation of the meninges; leptomeningitis This condition can be caused by bacteria (pyogenic meningitis) or viruses (aseptic or viral meningitis). Signs and symptoms are fever and signs of meningeal irritation such as headache, photophobia (sensitivity to light), and stiff neck. Lumbar punctures are done to examine the CSF. Doctors use antibiotics to treat the more severe pyogenic form and antivirals for the viral form. Brain disease and dementia that occur with AIDS. Many AIDS patients develop neurological dysfunction. In addition to encephalitis and dementia (loss of mental functioning), some patients develop brain tumors and other infections.

FIGURE 10-19 A. Herpes zoster (shingles) in a typical location around the trunk of the body. Zoster in ancient Greek means belt or belt. B, Glioblastoma seen on MRI.

Neoplastic disorders

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tumor cerebral

Abnormal growth of brain tissue and meninges. Most primary brain tumors arise from glial cells (gliomas) or from the meninges (meningiomas). Types of gliomas include astrocytoma (Figure 10.19B), oligodendroglioma, and ependymoma. The most malignant form of astrocytoma is glioblastoma multiforme (-blast means immature) (see Fig. 10-19B). Tumors can cause swelling (cerebral edema) and hydrocephalus. If the pressure of the cerebrospinal fluid increases, swelling near the optic nerve (at the back of the eye) can also occur. Other symptoms include a severe headache and new seizures. Sometimes gliomas can be surgically removed. Brain tumors are also treated with chemotherapy and radiation therapy. Steroids are used to reduce inflammation in the brain. Meningiomas are usually benign and surrounded by a capsule, but they can compress and distort the brain. Brain tumors can also be single or multiple metastatic growths. Most arise from the lungs, breasts, skin (melanoma), kidneys, and gastrointestinal tract and spread to the brain.

traumatic disorders concussion

concussion

A type of traumatic brain injury caused by a blow to the head. There is usually no evidence of structural damage to brain tissue, and loss of consciousness may not occur. Rest is very important after a concussion because it allows the brain to heal. Doctors generally recommend avoiding strenuous physical and mental activities until symptoms fully resolve. Contusion of brain tissue resulting from direct trauma to the head. A concussion may be associated with edema and increased intracranial pressure. A skull fracture may be present. Subdural and epidural hematomas occur (see Figure 10.12), leading to permanent brain damage with abnormalities such as memory or speech problems, as well as the development of epilepsy.

Vascular disorders

636

cerebrovascular accident (stroke)

migraine

Interruption in the normal blood supply to the brain; drain. This condition, also known as a stroke, is the result of poor oxygen supply to the brain. There are three types of stroke (Figure 10-20): 1. Thrombotic: A blood clot (thrombus) in the arteries leading to the brain, causing occlusion (blockage) of the vessel. Atherosclerosis leads to this common type of stroke, as blood vessels become clogged over time. Before total occlusion occurs, the patient may experience symptoms that point to a gradual occlusion of the blood vessels. These brief episodes of neurological dysfunction are known as transient ischemic attacks (TIAs). 2. Embolic: An embolus (a displaced thrombus) travels into the cerebral arteries and occludes a vessel. This type of stroke happens very suddenly. 3. Hemorrhagic: a cerebral artery ruptures and bleeding occurs. This type of stroke can be fatal and is the result of old age, atherosclerosis, or high blood pressure, all of which result in degeneration of the brain's blood vessels. With minor bleeds, the body reabsorbs the blood and the patient recovers well with only mild disability. In a younger patient, cerebral hemorrhage is usually caused by mechanical injury associated with a skull fracture or rupture of an arterial aneurysm (weakened area in the vessel wall that swells and may eventually rupture). See Figure 10-21. The main risk factors for stroke are high blood pressure, diabetes, smoking and heart disease. Other risk factors include obesity, substance abuse (cocaine), and high cholesterol levels. Thrombotic strokes are treated with antiplatelet or anticoagulant (clot-dissolving) therapy. Tissue plasminogen activator (tPA) can be started soon after the onset of a stroke. Surgical intervention with carotid endarterectomy (removal of atherosclerotic plaque along with the inner lining of the affected carotid artery) is also possible. Severe, recurrent, unilateral and vascular headache. A migraine may be associated with an aura (peculiar sensations that precede the onset of the disease). Aura symptoms are temporary visual and sensory disturbances, including flashes of light and zigzag lines. Sensitivity to sound (phonophobia) and light (photophobia) are associated with migraine itself. The etiology of pain in migraines is not fully established, but there are clearly changes in the cerebral blood vessels. Treatment to prevent a migraine attack includes medications such as sumatriptan succinate (Imitrex), which targets serotonin receptors in blood vessels and nerves. Medications of this type reduce inflammation and restrict the dilation of blood vessels.

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FIGURE 10-20 Three types of stroke: embolic, hemorrhagic, and thrombotic.

FIGURE 10-21 Cerebral aneurysm.

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study section

The following list reviews new terms used in the Pathology section. Practice spelling each term and learn its meaning. absence seizure aneurysm

Form of seizure consisting of momentary clouding of consciousness and loss of awareness of surroundings. Enlarged, weakened area in an arterial wall, which can rupture, leading to bleeding and stroke. astrocytoma A malignant brain tumor of astrocytes (glial brain cells). aura A peculiar symptom or sensation that occurs before the onset (prodromal) of a migraine attack or epileptic seizure. Dementia Decline and mental deterioration. demyelination Destruction of myelin in the axons of neurons (as in multiple sclerosis). CNS dopaminergic neurotransmitter deficient in patients with Parkinson's disease. embolus A clot of material that travels through the bloodstream and suddenly blocks a vessel. gait Manner of walking. ictal event Pertaining to a sudden and acute onset, as in the seizures of an epileptic seizure. Occlusion lock. palliative Relieve symptoms, but not cure them. thymectomy Removal of the thymus gland (a gland that produces lymphocytes in the chest); used as a treatment for myasthenia gravis. TIA Transient ischemic reaction. TIAs can occur with all three types of stroke: thrombolytic, embolic, and even hemorrhagic (if minor). They are characterized by a limited period of neurological deficits. tic Involuntary movement of a small group of muscles, such as the face; characteristic of Toure syndrome e. Major convulsive (grand mal) tonic-clonic seizure marked by sudden loss of convulsive consciousness, rigidity of muscles, and jerking and jerking movements.

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Laboratory Tests and Clinical Procedures Laboratory Tests Cerebrospinal Fluid Analysis

CSF samples are examined. CSF analysis measures protein, glucose, and red blood cells (RBCs) and white blood cells (WBCs), as well as other chemical contents of the CSF. CSF analysis can also detect tumor cells (by cytology), bacteria, and viruses. These tests are used to diagnose infections, tumors, or multiple sclerosis.

Clinical procedures X-ray examinations Cerebral angiography

computed tomography (CT) of the brain

X-ray images of arterial blood vessels in the brain after injection of contrast material. Contrast is injected into the femoral artery (in the thigh) and X-ray images are taken. These images diagnose vascular diseases (aneurysm, occlusion, hemorrhage) in the brain. A computerized X-ray technique that generates multiple images of the brain and spinal cord. Contrast material can be injected intravenously to highlight abnormalities. The contrast filters through the blood-brain barrier from blood vessels into brain tissue, showing tumors, aneurysms, hemorrhages, brain injuries, skull fractures, and blood clots. Operations are performed using computed tomography as a local guide. CT scans are also particularly useful for visualizing blood and bone.

Magnetic Resonance Imaging Techniques Magnetic Resonance Imaging (MRI)

The magnetic field and pulses of radio wave energy create images of the brain and spinal cord. MRI is better than CT for evaluating the brain parenchyma. It is excellent for visualizing brain damage related to infections, inflammations or tumors. It is also used to look for the causes of headaches, help diagnose a stroke, and detect bleeding problems and head trauma. Contrast material can be used to enhance images. Magnetic resonance angiography (MRA) produces images of blood vessels using magnetic resonance imaging techniques.

Radionuclide studies

640

positron emission tomography (PET)

Radioactive glucose is injected and then detected in the brain to generate images of the cells' metabolic activity. PET scans provide valuable information about brain tissue function in patients to detect malignancy and evaluate brain abnormalities in Alzheimer's disease, stroke, schizophrenia, and epilepsy (Fig. 10.22). Combined PET-CT scans provide images that identify the location of abnormal metabolic activity within the brain.

FIGURE 10-22 PET scans. A, Normal brain. B, Brain affected by Alzheimer's disease. Red and yellow areas indicate high neural activity. Blue and purple indicate low neural activity.

Ultrasound examination Doppler ultrasound studies

Sound waves detect blood flow in the carotid and intracranial arteries. The carotid artery carries blood to the brain. These studies detect occlusion in the blood vessels.

Other Procedures

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electroencephalography (EEG) lumbar puncture (LP)

stereotactic radiosurgery

Recording of the electrical activity of the brain. The EEG demonstrates seizure activity resulting from brain tumors, other diseases, and injuries to the brain. It can also help define diffuse cortical dysfunctions (encephalopathies). CSF is taken between two lumbar vertebrae for analysis (Fig. 10.23). A device to measure CSF pressure can get stuck at the tip of the needle after insertion. An intrathecal injection of drugs may also be given. Some patients experience headache after LP. An informal name for this procedure is "lumbar puncture." Use of a specialized instrument to locate and treat targets in the brain. The stereotaxic instrument is fixed to the skull and guides the insertion of a needle using three-dimensional measurement. A Gamma Knife (high energy radiation beam) is used to treat deep and often inaccessible intracranial brain tumors and abnormal masses of blood vessels (arteriovenous malformations) without surgical incision. Proton stereotactic radiosurgery (PSRS) delivers a uniform dose of proton radiation to a target while sparing surrounding normal tissue (Fig. 10.24A and B).

FIGURE 10-23 Lumbar puncture. The patient lies on his side, with the knees bent towards the abdomen and the chin towards the chest. This position increases the spaces between the vertebrae. The lumbar puncture needle is inserted between the third and fourth (or fourth and fifth) lumbar vertebrae and then advanced to enter the subarachnoid space.

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FIGURE 10-24 A, Patient positioned in proton stereotaxic unit, ready for alignment radiograph. B, The stereotactic frame holds the patient's head in place for proton beam radiosurgery treatment. (Courtesy of the Department of Radiation Therapy, Massachusetts General Hospital, Boston).

abbreviations

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AD AFP

Alzheimer's disease alpha-fetoprotein; elevated levels in amniotic fluid and maternal blood are associated with congenital malformations of the nervous system, such as anencephaly and spina bifida ALS amyotrophic lateral sclerosis: Lou Gehrig's disease AVM arteriovenous malformation; congenital tangle of arteries and veins in the brain BBB blood-brain barrier CNS central nervous system CSF CSF cerebrospinal fluid CTE Chronic traumatic encephalopathy Stroke EEG electroencephalography GABA gamma-aminobutyric acid (neurotransmitter) ICP intracranial pressure (normal pressure is 5 to 15 mm Hg ) LP Lumbar puncture MAC Monitored anesthetic care MG Myasthenia gravis ARM Magnetic resonance angiography MRI MRI MS Multiple sclerosis Hemiparesis P PCA Patient-controlled analgesia PET Positron emission tomography PNS Peripheral nervous system PSRS Stereotactic proton radiosurgery Sz Seizures TBI Traumatic brain injury TENS transcutaneous electrical nerve stimulation ; technique using a battery-powered device to relieve acute and chronic pain TIA transient ischemic attack; temporal interference with the blood supply to the brain TLE temporal lobe epilepsy tPA tissue plasminogen activator; a clot-dissolving drug used as therapy for stroke

Practical Applications Case Study: Report of a Patient with Ulnar Nerve Neuropathy I am definitely not one of those ambidextrous people. I am truly right-handed, so the "experiment" of becoming left-handed out of necessity didn't work out very well. Over the past decade, I have slowly lost feeling in my right little finger and a fair amount of function in my right hand. You might think I should have been careful to treat him when he initially presented with an electric shock to my arm from hitting my "funny bone" repeatedly. The "funny bone", of course, is not a bone. It is the ulnar nerve, which runs along the medial and posterior aspect of the

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the elbow as it moves toward the hand. See Figure 10-25. After multiple injuries to my elbow, my little finger has become useless and numb.

FIGURE 10-25 Course of the ulnar nerve behind the elbow joint (medial epicondyle of the humerus) and into the hand.

As a doctor, I realized that my ulnar nerve had become trapped and scarred from repeated injuries. Over the years, I tolerated this situation because other nerves remained intact, providing sensation and function to my hand. It wasn't until I saw myself on video (my hand looked like a claw) that I recognized how compromised the function of the hand had been. During an examination by an elbow orthopedic specialist, the test revealed poor tenderness and atrophy of the muscles in his right hand. My grip strength was also affected and was now stronger on my left than on my right. Surgery was immediately scheduled in hopes of stopping the atrophy and scratching of my hand and regaining feeling in my little finger. My surgeon performed an Eaton procedure. He moved the scarred ulnar nerve out of its vulnerable path and placed sutures to hold the ulnar nerve in its new place under the fascia (connective tissue) of my elbow. He created a small "curtain" with the fascia to prevent the nerve from moving again. Ultimately, this allowed the nerve to take a "shortcut" on its way to my hand, while relieving tension on the injured nerve and keeping it away from the bony prominence of the elbow.

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When I woke up from the anesthesia, I immediately noticed that something was different in my hand. My previously numb fingers tingled and soon I had a sensation of warmth and even sweat in the palm of my hand. These findings demonstrated the return of autonomic nerve function, something that had also been affected by the longstanding injury. My arm was in a sling until my post-op appointment. Figure 10-26 shows my arm and scar just after the 2-week post-op checkup. A compression sleeve prevented swelling and reminded me not to overuse my arm.

FIGURE 10-26 Postoperative scar from ulnar nerve surgery.

Three months after surgery, I was back to my usual routine of typing, writing, and using my hand. The sensation gradually returned to my little finger and the function in my hand also improved, but very slowly. Injured nerves can regenerate as long as they are not completely severed or crushed. The nerve heals from proximal to distal (starting at the elbow and working toward the tip of the finger). Doctors cite the statistic of one millimeter per day for nerve regeneration, or approximately one inch per month. The feeling in my little finger is still not normal, but it is improving and it is encouraging to see the progress. The muscles in my hand are also getting stronger. The real test will be checking my grip strength when I return for my 6 month follow up appointment.

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I am grateful for the quick action and skillful surgery that was possible before my ulnar nerve was permanently damaged. I am also thankful that the body can heal itself when given the right help. I was so used to the numb feeling that I had no idea what I was missing! Answers to the following case report and case study questions can be found on page 366.

Clinical Case: Stroke This patient was admitted on January 14 with a history of progressive right hemiparesis in the last 1 to 2 months; fluctuating numbness of the right arm, chest, and buttocks; spasms in the right leg; periods of speech interruption; reading comprehension problems; and recent development of hemiplegic gait. Given the progressive evolution of the neurological difficulties, it was suspected that he suffered from a left parietal tumor. [The parietal lobes of the brain lie on either side below the roof of the skull.] Prehospitalization tests included skull x-rays, EEG, and cerebrospinal fluid analysis, all of which were normal. On admission, an MRI was abnormal in the left parietal region, as was the EEG. An MRI scan to assess cerebral blood vessels was deflated, but the patient became progressively more restless and agitated after sedation, so the procedure was discontinued. During the recovery phase from sedation, the patient was alternately drowsy [sleepiness] and violent, but it later became apparent that he had developed almost complete aphasia and right hemiplegia. Over the next few days, he became more alert, although he remained dysarthric [Greek arthroun, to uer distinctively] and hemiplegic. MRI and MRI with the patient under general anesthesia on January 19 showed complete occlusion of the left internal carotid artery with cross-filling of the left anterior and middle cerebral arteries of the right internal carotid circulation. Final diagnosis: Stroke on the left side due to occlusion of the left internal carotid artery. [Figure 10-27 shows the common carotid arteries and their branches in the head and brain.]

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FIGURE 10-27 Common carotid arteries and their branches.

Questions about the case report 1. The patient was admitted with a history of: a. Right-sided paralysis caused by a previous stroke b. Paralysis of the left side of the body c. Increasing paresis on the right side of the body 2. The patient has also had periods of: a. aphasia and dyslexia b. Dysplastic gait c. Apraxia and aphasia 3. After you were admitted to the hospital, where did the MRI show any abnormalities? a. Right posterior brain region b. Left and right sides of the brain c. Left brain 4. What test determined the final diagnosis? a. EEG for both sides of the brain b. CSF analysis and cerebral angiography c. MRI and MRA 5. What was the final diagnosis? a. Drain; ischemic tissue damage to the left side of the brain caused by obstruction of an artery b. Cross-filling of blood vessels from the left to the right side of the brain c. Cerebral palsy on the left side of the brain with cross-filling of two cerebral arteries

pain medication

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Pain is an important symptom in many medical conditions. Both the area of injury and the way the brain treats it affect pain sensations. Pain relievers (analgesics) work in different ways: • Nonsteroidal anti-inflammatory drugs (NSAIDs) relieve pain by stopping inflammation. Some examples are over-the-counter medications such as ibuprofen (Advil, Motrin, Excedrin), aspirin (Anacin, Ascriptin, Bufferin), and naproxen (Aleve). Other NSAIDs that require a prescription are Toradol (ketorolac) and Feldene (piroxicam). • Acetaminophen (Tylenol) relieves fever and mild pain, but is not an anti-inflammatory drug. It is not clear how paracetamol works. • Opiates (narcotics) relieve pain by affecting receptors in the brain that control pain perception. Some examples are morphine, codeine, oxycodone, and hydrocodone. Combinations of narcotics and acetaminophen are Vicodin (acetaminophen with hydrocodone) and Percocet (acetaminophen with oxycodone). Given the addictive potential of this class of drugs, opioids are generally only prescribed in limited amounts and used sparingly.

Neuropathic Pain with a Case Study Neuropathic pain is a unique type of pain that accompanies illness and trauma. Patients may describe this pain as: • radiating or spreading • a sensation similar to an electric shock • warmth or burning • stinging, shooting, shooting, or throbbing (narrowing) • abnormal skin sensations (paresthesias): numbness, tingling, “ pricks” and needles” ” • painful to touch • extreme sensitivity to common and innocuous stimuli • often independent of movement Case study: A 68-year-old man woke up one morning with severe pain in his right shoulder. When turning his head or lifting his shoulder, he felt extreme discomfort and excruciating pain. The pain was a sharp, burning pain shooting through her shoulder and down her right arm. Finding a comfortable position to lie down was difficult. A cervical MRI study showed no bone abnormalities, while a

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Neurological examination provided evidence of damage to various peripheral nerves. He developed weak shoulder muscles and was unable to raise his right arm. The final diagnosis was brachial plexus neuritis [also known as Parsonage-Turner syndrome]. The cause of the illness is unknown, but it may be related to a flu shot she received 2 weeks earlier. Treatment consisted of painkillers and physical therapy to rehabilitate the weakened muscles in her arm and shoulder. Questions about the case study 1. The cervical magnetic resonance study showed: a. Damage to the neck vertebrae b. Nerve entrapment in the upper spine c. Damage to multiple peripheral nerves d. Normal vertebrae in the neck 2. The excruciating pain is: a. Pain to light touch b. Characterized by paresthesia c. stab, stab, throw d. Characterized by numbness and tingling 3. The patient's diagnosis is best described as: a. Inflammation of the cervical nerve roots affecting your shoulder and arm b. Inflammation of a network of nerves in the shoulder that control the muscles of the arm c. The early stages of a heart attack, marked by radiating pain down the arm d. Autoimmune disorder affecting the voluntary muscles of the shoulder and arm

Sciatica in person This is the first-person account of a woman in her early forties who lives with sciatica. Twelve years ago, I would not have believed that picking up a laundry basket could change my life. But in January 2009, it happened. I had my first back pain a few days before after a long car ride. A google search told me to apply ice for the first 48 hours and then heat if the pain persisted. My husband took over the children's school routine while I recovered. On that third morning, I could hear my youngest looking for his favorite sweatshirt; I knew he was at the foot of my bed, waiting for it to be fixed. In the instant that he took

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As I started to pull that sweatshirt out of the laundry basket, my back went from a dull ache to a crippling pain that radiated all the way down my left leg to the ball of my left foot. An MRI confirmed the diagnosis: spinal disc herniation, projecting into the nerve roots affecting the sciatic nerve and causing pain in my leg. With surgery presented as a last resort, I embarked on a crash course of physical therapy, NSAIDs, oral steroids, muscle relaxants, epidural steroid injections, and lots and lots of patience. I had a gradual improvement over about three months, to the point where I was able to resume a modified daily routine. Then the improvement stopped. Conventional treatment was over. I was at the "last resort" stage. So "I cried man" and asked for a surgical consultation. The surgeon ordered a follow-up MRI, which showed good news: there was great improvement in the hernia. To my surprise, the MRI also revealed that the nerve roots that innervate the sciatic nerve were now clean and free from impingement. If the nerve returned to normal, why was he still in so much pain? Because, apparently, the nerve was injured by his ordeal. It's not weird, it calmed me down. This development has taken the surgical option off the table. After all, the goal of surgery would be to relieve compression on the nerve affected by the bulging disc. In my case, even the relieved nerve was causing problems, and that didn't mean surgery, just more patience. The waiting began: to see if the nerve would heal on its own (I was told it could take years), or worse, if I was facing permanent nerve damage. Three years later, the verdict seems clear: my sciatic nerve has suffered what appears to be permanent damage. To this day, I have not regained full use of my left leg. Along with dull, chronic pain, there are also paresthesias - simultaneous burning and numbness along the path of the sciatic nerve, accompanied by constant involuntary muscle spasms. I've lost my Achilles reflex and my left foot is so numb I can't feel it hit the ground when I walk. In those first critical months, I thought that my options were to resolve the hernia with surgery or to resolve it without surgery. It never occurred to me that four years later the wound would remain unresolved. There is always a new treatment, specialist, or medication that seems promising or has actually worked for a friend of a friend. Until recently, it seemed like he was losing hope if he didn't follow all the leads. I am now focusing more on adjusting to my new circumstances rather than finding a "cure". I don't want my whole life to revolve around sciatica. I found a medication that reduces chronic pain to a nuisance instead of a flare-up (with occasional flare-ups).

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I lost my old life and I wanted it back. At the risk of sounding like a late-night pharmaceutical ad, I won't give up; I'm going. AUTHOR'S NOTE Everyone's experience with sciatica is unique. I, too, have experienced the condition, as a result of a herniated L4-L5 disc. After 7 months of pain radiating down my right leg, I underwent microdiscectomy surgery, which fortunately alleviated the pain and sciatica.

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Exercises Remember to check your answers carefully with Answers to Exercises, page 364.

A Match the neurological structures listed with the descriptions/definitions below. astrocytes axon cauda equina cerebral cortex dendrites meninges myelin sheath neuron oligodendroglial cells plexus 1. microscopic fiber exiting the cell body that carries the nerve impulse along a nerve cell _________________________ 2. large intertwined network of nerves _________________________ 3. three protective membranes surrounding the brain and spinal cord _________________________ 4. microscopic branching fiber of a nerve cell that is the first part to receive a nerve impulse _________________________ 5. outer region of most of the brain; composed of gray matter ________________________

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6. glial cell that transports water and salts between capillaries and nerve cells ___________________ 7. glial cell that produces myelin _________________________ 8. nerve cell that transmits a nerve impulse _________________________ 9. collection of spinal nerves below the end of the spinal cord at the level of the second lumbar vertebra _________________________ 10. fa and tissue surrounding the axon of a nerve cell _________________________ B Give the meaning of the following terms. 1. dura _________________________ 2. central nervous system _________________________ 3. peripheral nervous system _________________________ 4. arachnoid membrane _________________________ 5. hypothalamus _________________________ 6. synapse _________________________ 7. sympathetic nerves _________________________ 8. medulla oblongata ________________________ 9. pons _________________________ 10. cerebellum _________________________ 11 thalamus ________________________ 12. ventricles of the brain _________________________ 13. brainstem _________________________ 14. brain _________________________ 15. ganglion _________________________

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C Combine the following terms with the meanings or associated terms below. Glial cells Motors Gironerves Neurotransmitters Parenchymal cells Pia mater Sensory nerves Subarachnoid space Grooves 1. Inner meningeal membrane _____________________________________ 2. Carry messages (efferent) from the brain and spinal cord to muscles and glands ____________________________ 3. Carry messages to (afferent) the brain and the spinal cord of receptors __________________________ 4. grooves in the cerebral cortex ________________________________ 5. contains cerebrospinal fluid _____________________________________ 6. elevations in the cerebral cortex ________________________________ 7. chemical released at the end of a nerve cell and stimulates or inhibits another cell (example : acetylcholine) _________________________ 8 .essential cell of the nervous system; a neuron __________________________

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9. Connective and supporting tissue (stromal) __________________________ D Circle the correct term in bold for the given definition. 1. disease of the brain (encephalopathy, myelopathy) 2. part of the brain that controls muscle coordination and balance (cerebrum, cerebellum) 3. pooling of blood above the dura mater (subdural hematoma, epidural hematoma) 4. inflammation of the sink and arachnoid membranes (leptomeningitis, causalgia) 5. brain-absent condition (hypalgesia, anencephaly) 6. inflammation of the gray matter of the spinal cord (poliomyelitis, polyneuritis) 7. belonging to the membranes surrounding the brain and spinal cord ( cerebelarpontineus), meningeal) 8. disease of the nerve roots (of the spinal nerves) (neuropathy, radiculopathy) 9. herniation of the spinal cord and meninges (myelomeningocele, meningioma) 10. belonging to the tenth cranial nerve (thalamic, vagal) And Give the meanings of the following terms. 1. cerebral cortex ____________________________________________ ________________________ 2. intrathecal __________________________________________ ________________________

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3. polyneuritis ________________________________________ ________________________ 4. thalamic __________________________________________ ________________________ 5. myelopathy ________________________________________________ ________________________ 6. meningioma ________________________________________ ________________________ 7. glioma ____________________________________________ _________________________ 8. subdural hematoma __________________________________________ ____________________ F Match the neurological symptoms listed with the definitions/descriptions below. aphasia ataxia bradykinesia causalgia dyslexia hemiparesis hyperesthesia motor apraxia narcolepsy neurasthenia

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syncope paraplegia 1. reading disorder _______________________________ 2. impaired coordination _______________________________ 3. slowness of movement _______________________________ 4. increased sensitivity _______________________________ 5. sleep seizures; uncontrollable compulsion to sleep ________________________________ 6. slurred speech ________________________________ 7. inability to perform a task ________________________________ 8. weakness in the right or left half of the body ________________________________ 9. severe burning pain due to nerve damage ____________________________________ 10. lower paralysis of the body the body the body ________________________________ 11. fainting ________________________________ 12. nervous exhaustion (lack of strength) and fatigue ________________________________ G Give the meaning of the following terms. 1. Analgesia ________________________________________________________ ________________________

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2. motor aphasia _____________________________________________ _______________________ 3. paresis _____________________________________________ ____________________________ 4. quadriplegia _____________________________________________ _________________________ 5. asthenia _____________________________________________ __________________________ 6. coma _____________________________________________ __________________________ 7. paresthesia _____________________________________________ 8. hyperkinesia _____________________________________________ _________________________________ 9. anesthesia _____________________________________________ __________________________ 10. causalgia _____________________________________________ _________________________________ 11. akinetic ______________________________________________________________ _______________________________

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12. hypoalgesia __________________________________________________ ___________________________ 13. dyskinesia __________________________________________ ___________________________ 14. migraine _____________________________________________ ___________________________ H Match the neurologic pathology terms listed with the descriptions below. Terms in bold are clues! Alzheimer's disease amyotrophic lateral sclerosis Bell's palsy epilepsy Huntington's disease hydrocephalus multiple sclerosis myasthenia gravis Parkinson's disease myelomeningocele The vertebral column is imperfectly united (a split occurs at one vertebra), and part of the meninges and

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spinal cord may herniate out of spinal cavity: ______________________________ 4. Atrophy of muscles and paralysis caused by damage to motor neurons in spinal cord and brain stem: ____________________________________ 5. Patient exhibits bizarre, jerky, involuntary movements, such as of dance, as well as decline in mental functions: ________________________________ 6. Cerebrospinal fluid accumulates in the head (in the ventricles of the brain): _________________ 7. Loss of muscle strength due to the inability of a neurotransmitter (acetylcholine) to transmit impulses of nerve cells to muscle cells: _______________________________ 8. Degeneration of nerves in the basal ganglia that occurs later in life, causing tremors, a shuffling gait, and muscle stiffness; dopamine (neurotransmitter) is deficient in the brain: _______________________________ 9. Impaired mental ability (dementia); autopsy shows atrophy of the cerebral cortex, enlarged cerebral sulci, and microscopic neurofibrillary tangles: _______________________________ 10. Unilateral facial palsy: _______________________________ I State the meaning of the following terms for abnormal conditions. 1. astrocytoma ____________________________________________ ________________________

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10 cerebral hemorrhage ________________________________________________ _________________ 11. cerebral aneurysm _________________________________________________ ___________________

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12. HIV encephalopathy _____________________________________________ __________________ J Match the term in Column I with the letter of its description or meaning in Column II. COLUMN I 1. ataxia 2. aura 3. transient ischemic attack 4. tonic-clonic seizure 5. herpes zoster 6. palliative 7. dopamine 8. occlusion 9. absence seizures 10. glioblastoma multiforme

_______ _______ _______ _______ _______ _______ _______ _______ _______ _______

COLUMN II A. alleviates but does not cure B. virus that causes chickenpox and shingles C. incoordination of gait D. neurotransmitter E. peculiar sensation experienced by the patient before the onset of the seizure F. malignant brain tumor of immature glial cells G. largest epileptic seizure; ictal event H. blood flow to the brain is interrupted for a brief period of time I. minor seizure J. blockage

K Describe what happens in the following two procedures. 1. MRI of the brain: _____________________________________________ ______________________ 2. Gamma knife stereotactic radiosurgery: _____________________________________________ _____________________________________________ __________________________________________ L Combine these easily confused neurological pathology terms with the following meanings/descriptions. analgesia anesthesia aphasia apraxia ataxia

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dyskinesia dyslexia hyperkinesia neurasthenia paresthesia paresthesia 1. lack of nerve strength _________________________ 2. inability to speak _________________________ 3. inability to perform purposeful actions _________________________ 4. numbness to pain condition _________________________ 5. loss of sensation condition ____________________________________ 6. tingling sensations, numbness , or “pins and needles” _________________________ 7. incoordination _________________________ 8. excessive movement _________________________ 9. abnormal, involuntary, and jerky movements _________________________ 10. developmental reading disorder _________________________ 11. partial paralysis ____________________________________ M Spell out the abbreviations in Column I and then select the best association card from Column II for each.

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COLUNA I 1. EEG _______________ 2. PET ________________ 3. AFP ________________ 4. MS ________________ 5. MRI ________________ 6. LP _________________ 7. AVC ________________ 8. AD _________________ 9. TIA _________________ 10. LCR ________________

_______ _______ _______ _______ _______ _______ _______ _______ _______

COLUMN II A. Gradually progressive dementia. B. stroke; embolism, hemorrhage, and thrombosis are etiologic factors. C. Intrathecal medications can be administered through this procedure. D. This fluid is tested for abnormal blood cells, chemicals, and proteins. E. Procedure to diagnose abnormal electrical activity in the brain. F. Neurological symptoms and/or signs due to temporary interference with the blood supply to the brain. G. Elevated levels in amniotic fluid and maternal blood are associated with spina bifida. H. Diagnostic procedure that allows excellent visualization of the soft tissues of the brain. I. The brain absorbs radioactive materials, such as glucose, and images are recorded. J. Destruction of the myelin sheath in the CNS occurs with plaques of hard scar tissue.

_______

N Circle the terms in bold that complete the meaning of the sentences. 1. Maria had such severe headaches that she could only find relief with strong painkillers. Her condition (spina bifida, migraine, epilepsy) was debilitating. 2. Paul was in a coma after his high-speed car accident. His doctors were concerned that he had suffered one (paralysis, myelomeningocele, concussion, and subdural hematoma) as a result of the accident. 3. Dick went to the ER complaining of dizziness, nausea, and a headache. Suspecting an increase in ICP, the doctor prescribed corticosteroids and Dick's symptoms disappeared. However, they returned when the steroids were stopped. A/an (brain MRI, electroencephalogram, cerebrospinal fluid analysis) revealed a large brain lesion. he was removed

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surgically determined as a/an (embolus, glioblastoma multiforme, migraine). 4. Dorothy felt weakness in her hand and numbness in her arm and noted blurred vision, all signs of (herpes zoster, meningitis, TIA). Her doctor ordered (myelogram, MRI, lumbar puncture) to assess for any damage to the cerebral blood vessels and possible stroke. 5. When Bill noticed ptosis and muscle weakness in his face, he reported these symptoms to his doctor. The doctor diagnosed her condition as (Toure syndrome, Huntington's disease, myasthenia gravis) and prescribed (dopamine, anticonvulsants, anticholinesterases), which alleviated her symptoms. 6. To rule out bacteria (epilepsy, encephalomalacia, meningitis), Dr. Phillips, a pediatrician, requested that a (EEG, PET scan, LP) be performed on the febrile (febrile) child. 7. Eight-year-old Barry had reversed letters and was having difficulty learning to read and write words. His GP diagnosed his problem as (aphasia, dyslexia, ataxia). 8. After his head hit the steering wheel during a recent car accident, Clark noticed (hemiparesis, paraplegia, hyperesthesia) on the left side of his body. A CT scan of the head revealed (narcolepsy, neurasthenia, subdural hematoma). 9. On her 35th birthday, Elizabeth's husband throws her a surprise party. She was so surprised by the crowd that she felt muscle weakness and unconsciousness. Her friends put her

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the back in a horizontal position with the head down to improve blood flow to the brain. He soon recovered from his episode (myoneural, syncopal, hyperkinetic). 10. As his 65th birthday approached, Edward began to have difficulty remembering recent events. Over the next 5 years he developed (dyslexia, dementia, seizures) and was diagnosed with (multiple sclerosis, myasthenia gravis, Alzheimer's disease). 11. Old Mrs. Smith had been taking antipsychotic medication for 5 years when she started lip smacking and flicking her tongue. Her physician described her condition as (radiculitis, tardive dyskinesia, hemiparesis) and discontinued her medication. She would be considered the condition acquired after the use of the drug (iatrogenic, congenital, ictal). O Complete the spelling of the following terms according to their meaning. 1. part of the brain that controls sleep, appetite, temperature, and secretions from the pituitary gland: hiccups ____________________________________________________ 2. related to fainting: no _____________________________________________ ___ 3. abnormal tingling sensations: even _______________________________________________ 4. mild paralysis: pair _____________________________________________

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________ 5. inflammation of a spinal nerve root: _____________________________________________ __ itis 6. inability to speak correctly: a _________________________________________________ _ 7. purposeless movements and behaviors: a __________________________________________ 8. lack of muscle coordination: a ________________________________________ _________ 9. speech disorder development by reading: dis ___________________________________ ______ 10. excessive movement: hyper _____________________________________________ _____________ 11. paralysis in one half (right or left) of the body: __________________________________ plegia 12. paralysis in the lower half of the body: ____________________________________________ plegia 13. paralysis in all four extremities : _____________________________________________ _____ plegia 14. nervous exhaustion and fatigue: neur ___________________________________________

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Answers to exercises A 1. axon 2. plexus 3. meninges 4. dendrite 5. cerebral cortex 6. astrocyte 7. oligodendroglial cell 8. neuron 9. cauda equina 10. myelin sheath B 1. outermost meningeal layer that surrounds the brain and spinal cord marrow 2. brain and spinal cord 3. nerves outside the brain and spinal cord; cranial, spinal, and autonomic nerves 4. middle meningeal membrane that surrounds the brain and spinal cord 5. part of the brain below the thalamus; controls sleep, appetite, body temperature, and pituitary gland secretions

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6. space through which a nerve impulse is transmitted from one nerve cell to another nerve cell or to a muscle or gland cell 7. autonomic nerves that involuntarily influence bodily functions in times of stress 8. part of the brain just above from the spinal cord spinal cord that controls breathing, heart rate, and size of blood vessels 9. part of the forebrain to the cerebellum and between the medulla oblongata and the upper parts of the brain; connects these parts of the brain 10. back part of the brain that coordinates voluntary muscle movements 11. part of the brain below the brain; relay center that conducts impulses between the spinal cord and the brain 12. channels within the brain that are filled with cerebrospinal fluid 13. lower portion of the brain that connects the brain to the spinal cord (includes the pons and medulla oblongata) 14 . most of the brain; controls voluntary muscle movement, vision, speech, hearing, thinking, memory 15. collection of nerve cell bodies outside the brain and spinal cord C 1. pia mater 2. motor nerves

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3. sensory nerves 4. sulci 5. subarachnoid space 6. gyri 7. neurotransmitter 8. parenchymal cell 9. glial D cells 1. encephalopathy 2. cerebellum 3. epidural hematoma 4. leptomeningitis 5. anencephaly 6. poliomyelitis 7. meningeal 8 radiculopathy 9. myelomeningocele 10. vagal E 1. outer region of the brain (contains gray matter) 2. belonging to a sheath through the meninges and into the subarachnoid space 3. inflammation of many nerves

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4. belonging to the thalamus 5. spinal cord disease 6. tumor of the meninges 7. glial cell tumor (a brain tumor) 8. mass of blood under the dura mater (outermost meningeal membrane) F 1. dyslexia 2 ataxia 3. bradykinesia 4. hyperesthesia 5. narcolepsy 6. aphasia 7. motor apraxia 8. hemiparesis 9. causalgia 10. paraplegia 11. syncope 12. neurasthenia G 1. insensitivity to pain 2. slurred speech (patient does not can articulate words but can understand speech and knows what he wants to say)

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3. weakness and partial loss of movement 4. paralysis in all four limbs (damage to the cervical part of the spinal cord) 5. lack of strength (weakness) 6. belonging to coma (loss of consciousness of which the patient cannot being awakened) 7. Condition of abnormal sensations (tingling, itching, burning) 8. Excessive movement 9. Condition of no sensation or nerve sensitivity 10. Intense burning pain from damage to peripheral nerves 11. Pertaining to lack of movement 12 Decreased sensation of pain 13 . impaired ability to perform voluntary movements 14. recurrent vascular headache with severe pain of unilateral onset and photophobia (sensitivity to light) H 1. multiple sclerosis 2. epilepsy 3. myelomeningocele 4. amyotrophic lateral sclerosis 5. Huntington's disease 6. hydrocephalus 7 myasthenia gravis

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8. Parkinson's disease 9. Alzheimer's disease 10. Bell's palsy I 1. Tumor of neuroglial cells of the brain (astrocytes) 2. Inflammation of the meninges (bacterial infection with formation of pus) 3. Involuntary contractions, sudden movements ( tics), uncontrollable vocal sounds and inappropriate words 4. Contusions of brain tissue as a result of direct trauma to the head 5. Interruption of the normal blood supply to the brain; stroke or cerebral infarction 6. traumatic brain injury caused by blow to the head 7. neurological condition caused by herpes zoster virus infection; blisters form along peripheral nerves 8. blockage of a blood vessel in the brain caused by material from another part of the body suddenly blocking the vessel 9. blockage of a blood vessel in the brain caused by clot formation inside the vessel 10. pooling of blood in the brain (can cause a stroke) 11. dilation of a blood vessel (artery) in the brain; the aneurysm can burst and cause a stroke

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12. brain disease (dementia and encephalitis) caused by infection with the AIDS virus J 1. C 2. E 3. H 4. G 5. B 6. A 7. D 8. J 9. I 10. F K 1. use magnetic waves to create an image (frontal, transverse, or sagittal plane) of the brain 2. an instrument (stereotaxic) is attached to the skull and locates a target by three-dimensional measurement; gamma radiation or proton beams are used to treat deep brain lesions L 1. neurasthenia 2. aphasia 3. apraxia

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4. analgesia 5. anesthesia 6. paresthesia 7. ataxia 8. hyperkinesia 9. dyskinesia 10. dyslexia 11. paresis M 1. electroencephalogram: E 2. positron emission tomography: I 3. alpha-fetoprotein: G 4. multiple sclerosis : J 5. MRI: H 6. Lumbar puncture: C 7. Cerebrovascular accident: B 8. Alzheimer's disease: A 9. Transient ischemic attack: F 10. Cerebrospinal fluid: D N 1. Migraine 2. Contusion and subdural hematoma 3. MRI of the brain ; glioblastoma multiforme

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4.ITA; ARM 5. myasthenia gravis; anticholinesterase drugs 6. meningitis; LP 7. dyslexia 8. hemiparesis; subdural hematoma 9. syncope 10. dementia; Alzheimer's disease 11. Tardive dyskinesia; Iatrogenic 1. hypothalamus 2. syncope 3. paresthesias 4. paresis 5. radiculitis 6. aphasia 7. apraxia 8. ataxia 9. dyslexia 10. hyperkinesia 11. hemiplegia 12. paraplegia 13. quadriplegia 14. neurasthenia

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Answers for practical applications Case report: cerebral infarction

1. c 2. a 3. c 4. c 5. a Neuropathic pain and case study

1. d 2. c 3. b Pronunciation of terms

Vocabulary and Combination of Shapes and Terminology

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TERM acetylcholine afferent nerves akinetic analgesia anencephaly anesthesia aphasia apraxia arachnoid membrane astrocytes ataxia autonomic nervous system axon blood-brain barrier brain stem cauda equina causalgia cell body central nervous system headache cerebellum pons cerebellum cerebellum cerebral cortex cerebrospinal fluid coma cranial nerves dendrite dyskinesia dura mater efferent nerves encephalopathy nodal epidural ependymal cell hematoma; please glioblastoma spin of the glial cells of the ganglia; please convolutions hemiparesis hemiplegia hypoalgesia hyperesthesia hyperkinesia hypothalamus intrathecal injection leptomeningitis medulla oblongata

PRONUNCIATION a-seh-til-KO-leen AH-fer-ent nervz a-kih-NET-ik ah-nal-JE-ze-ah an-en-SEH-fah-le an-es-THE-ze-ah ah-FA-ze-ah a-PRAK-se-ah ah-RAK-noyd MEM-brayn AS-tro-site a-TAK-se-ah aw-to-NOM-ik NER-vus SIS-tem AKS-on sangue-BRAYN BAH-re-er bra-de-kih-NE-se-ah BRAYN-stem KAW-dah eh-KWI-nah kaw-ZAL-jah cell BOD-e SEN-tral NER-vus SIS-tem seh- FAL-jah see-reh-BEL-ar see-reh-bel-o-PON-teen see-reh-BEL-um see-RE-bral KOR-text see-re-bro-SPI-nal FLU-id see- RE-brum KO-mah KO-mah-tohs KRA-ne-al nervz DEN-drite DUR-ah MAH-ter dis-kih-NE-ze-ah dis-LEK-se-ah EH-fer-ent nervz en- seh-fah-LI-tis en-seh-fah-LOP-ah-the eh-PEN-dih-mal sel ep-eh-DU-ral he-mah-TO-mah GANG-le-on; GANG-le-ah GLE-al sel gli-o-blah-STO-mah JI-rus; JI-re hem-e-pah-RE-sis hem-e-PLE-jah hi-pal-GE-ze-ah hi-per-es-THE-ze-ah hi-per-kih-NE-sis hi- po-THAL-ah-mus in-trah-THE-kal in-JEK-shun lep-to-men-in-JE-al meh-DUL-ah ob-lon-GAH-tah

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TERM meningeal meningeal meningioma microglial cell midbrain motor nerve myelin sheath myelomeningocele myelopathy myoneural nerve narcolepsy neurasthenia neuroglial cells neuropathy neurotransmitter oligodendroglia cell paraplegia parasympathetic nerves parenchyma paresis paresis peripheral nervous system pia mater plexus poliomyelitis polyneuritis pons quadriplegia radiculitis radiculopathy sciatic nerve receptor stromal nerve stimulation spinal nerve subdural sulcus hematoma; please grooves sympathetic nerves synapse syncope thalamus thalamus trigeminal neuralgia vagus nerve ventricles of the brain vagus

PRONOUNCE meh-NIN-je-al meh-NIN-jeez meh-nin-je-O-mah mi-kro-GLE-al cellular MID-brain MO-ter nerve MI-eh-lin bainha mi-eh-lo-meh -NIN-jo-seel mi-el-OP-ah-the mi-o-NUR-al NAR-ko-lep-se nerv nu-RAL-jah nu-ras-THE-ne-ah nu-ro-GLE- al selz NU-ron nu-ROP-ah-the nu-ro-TRANZ-mit-er ol-ih-go-den-dro-GLE-al sel par-ah-PLE-jah par-ah-sim-pah- THET-ik nervz pah-REN-kih-mah pah-RE-sis pah-res-THE-ze-ah peh-RIF-er-al NER-vus SIS-tem PE-ah MAH-ter PLEK-sus po-le -o-mi-eh-LI-tis pol-e-nu-RI-tis ponz kwod-rih-PLE-jah rah-right-u-LI-tis rah-right-u-LOP-ah-the re-SEPT -ou si-AH-tik nerv si-AH-tih-kah SEN-sor-e nervo SPI-nal nervz STIM-u-lus STRO-mah sub-DU-ral he-mah-TO-mah SUL-kus; SUL-si sim-pah-THET-ik nervz SIN-aps SIN-ko-pal SIN-ko-pe THAL-ah-mik THAL-ah-mus tri-JEM-in-al nu-RAL-jah VA-gal VA -gus nerve VEN-three cols of the brain

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Pathology, Laboratory Tests and Clinical Procedures

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TERM absence seizures Alzheimer's disease amyotrophic lateral sclerosis aneurysm astrocytoma aura Bell's palsy brain tumor cerebral angiography concussion cerebral hemorrhage cerebral palsy cerebrospinal fluid analysis stroke CT scan dementia demyelination dopamine doppler/ultrasound studies electroencephalography embolism epilepsy gait glioblastoma herpes zoster HIV encephalopathy Huntington's disease hydrocephalus stroke event lumbar puncture MRI meningitis meningocele migraine multiple sclerosis myasthenia gravis occlusion palliative paralysis Parkinson's disease positron emission tomography herpes zoster spina bifida stereotaxic radiosurgery thrombus tic-tonic-clonic seizure Toure syndrome and ischemic attack transient

PRONOUNCATION AB-sens SE-zhur ALZ-hi-mer dih-ZEEZ a-mi-o-TRO-fik LAH-ter-al skleh-RO-sis AN-ur-ih-zim as-tro-si-TO-mah AW-rah bel PAWL-ze BRAYN TU-mor seh-RE-bral an-je-OG-rah-fe seh-RE-bral kon-KUH-shun seh-RE-bral kon-TU-shun seh-RE-bral HEM-or-ij seh-RE-bral PAWL-ze seh-re-bro-SPI-nal FLU-id ah-NAH-lih-sis seh-re-bro-VAS-cu-lar AK-sih-dent com- PU-ted to-MOG-rah-fe de-MEN-she-ah de-mi-eh-lih-NA-shun DO-pah-meen DOP-ler / UL-trah-sound STUD-eez eh-lek-tro -en-sef-al-OG-rah-fe EM-bo-lus EP-ih-lep-se gate gle-o-blah-STO-mah HER-peez ZOS-ter HIV en-seh-fal-OP-ah -the HUN-thing-ton dih-ZEEZ hi-dro-SEH-fah-lus IK-tal e-VENT LUM-bar PUNK-shur mag-NET-ik REH-zo-nants IM-aj-ing meh-nin- JI-tis meh-NIN-jo-seel MI-grane MUL-this-beyond skleh-RO-sis mi-as-THE-ne-ah GRAV-is o-KLU-zhun PAH-le-ah-tiv PAWL-ze PAR-kin-sun dih-ZEEZ POS-ih-tron e-MIH-shun to-MOG-rah-fe SHING-ulz SPI-na BIF-ih-dah steh-re-o-TAK-tik ra-de-o -SUR-jer-e THROM-bus TIK TON-ik-CLONE-ik SE-zhur tur-ET SIN-drohm TRAN-ze-ent ih -SKE com ah- REAL

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revision sheet

Write the meanings of the word parts in the spaces provided. Check your answers with the information in the chapter or in the Glossary (Parts of Medical Words—English) at the end of the book.

Combined forms COMBINED FORM alges/o angi/o caus/o cephal/o cerebell/o cerebr/o comat/o crani/o cry/o dur/o encephal/o esthesi/o gli/o hydr/o kines/o, kinesi/o lept/o lex/o mening/o, meningi/o my/o myel/o narc/o neur/o olig/o pont/o radicul/o spin/o syncop/o tax/o thalam/o thec /the trophus/the vagina/the

prefixes

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PREFIJO a-, andysepihemihypointramicroparapoliopolyquadrisub-

Suffixes SUFFIX -algesia -algia -blast -cele -esthesia -gram -graphy -ine -itis -kinesia, -kinesis -kinetic -lepsy -oma -ose -paresis -pathy -fagia -phasia -plegia -praxia -ptose -sclerose - sthenia -tomy -troféu

Match the neurological pathology terms and abbreviations in Column I with the descriptions/definitions in Column II.

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COLUMNA I 1. Alzheimer 2. ALS 3. epilepsia 4. EM 5. Parkinson 6. herpes zoster 7. glioblastoma multiforme

______ ______ ______ ______ ______ ______ ______

8. AVC

______

COLUMN II A. destruction of the myelin sheath in neurons of the CNS B. cerebrovascular accident; interruption in the normal blood supply to the brain C. shingles; viral infection affecting peripheral nerves D. progressive dementia; memory failure; senile plaques and neurofibrillary tangles E. brain tumor; malignant astrocytoma F. degeneration of neurons in the basal ganglia; tremors, bradykinesia, and shuffling gait G. recurrent seizure disorder; tonic-clonic and absence types H. degeneration of motor neurons in the spinal cord and brainstem; muscle weakness and atrophy

Books with Neurological Subjects The following list of books may be of interest to you. They are either fictional characters or real individuals dealing with neurological diseases. Oliver Sacks, M.D., the late professor of neurology at New York University School of Medicine, has written extensively on neurological case histories, including The Man Who Mistook His Wife for a Hat. Please contact me with your comments and other suggestions for a good read!

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Alzheimer Disease Still Alice by Lisa Genova (the story of a woman and her family understanding and coping with the early onset of Alzheimer's disease; also made into a film). Elegy for Iris by John Bayley (short story by novelist Iris Murdoch; written by her husband, who becomes her caretaker). Amyotrophic Lateral Sclerosis I Choose to Live: A Journey Through Life with ALS by William Sintan (a story about coping with this disease). Tuesdays with Morrie by Mitch Albom (written by a student who lives with his former teacher and learns valuable life lessons). Cerebral Palsy My Left Foot by Christy Brown (Brown was born in Dublin with cerebral palsy, and this is his autobiography, later made into a movie.) Epilepsy The Spirit Catches You and You Fall Down by Anne Fadiman (History of the Hmong people and how they deal with epilepsy after arriving in the United States). The Spiral Staircase: My Climb out of Darkness by Karen Armstrong. The Idiot by Fyodor Dostoevsky (Russian novel whose main character, Prince Myshkin, like Dostoevsky himself, suffers from epilepsy). Huntington Disease Saturday by Ian McEwan (novel whose main character suffers from the disease). Parkinson Disease Life in the Balance by Thomas Graboys with Peter Zheutlin (memoir of Graboys, a leading Boston cardiologist who deals with this disease). Stroke My Stroke of Insight by Jill Brotle Taylor, PhD (a neuroscientist, who had a stroke at age 37, writes about it). The Diving Bell and the Butterfly, by Jean-Dominque Bauby, is the memoir of a 44-year-old man struggling with the aftermath of a rare type of stroke that leaves him a quadriplegic. His mind is intact (also made into a movie).

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CHAPTER 11

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Cardiovascular System CHAPTER SECTIONS: Introduction 374 Blood Vessels and Blood Circulation 374 Anatomy of the Heart 378 Physiology of the Heart 381 Blood Pressure 382 Vocabulary 384 Terminology 385 Pathology: The Heart and Blood Vessels 388 Laboratory Tests and Clinical Procedures 401 Abbreviations 408 Practical Applications 410 In Person: Myocardial Bypass Surgery 412 Exercises 413 Answers to Exercises 422 Pronunciation of Terms 425 Review Sheet 429

CHAPTER OBJECTIVES • Name the parts of the heart and associated blood vessels and their role in blood circulation. • Traces the path of blood through the heart. • Identify and describe the main pathological conditions that affect the heart and blood vessels. • Define forms of combination related to the cardiovascular system.

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• Describe important laboratory tests and clinical procedures related to the cardiovascular system and recognize relevant abbreviations. • Apply your new knowledge to understand medical terms in their proper context, such as in medical reports and records.

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Introduction The cells of the body depend on a constant supply of nutrients and oxygen. When the supplies are delivered and chemically combined, they release the energy needed to do each cell's job. How does the body ensure that oxygen and food reach all of its cells? The cardiovascular system, made up of the heart (a powerful muscular pump) and blood vessels (the fuel line and transportation network), performs this important job. This chapter explores terminology related to the heart and blood vessels.

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Blood Vessels and Blood Circulation Blood Vessels There are three types of blood vessels in the body: arteries, veins, and capillaries. Arteries are large blood vessels that carry blood away from the heart. Its walls are lined with connective tissue, muscle tissue, and elastic fibers, with an innermost layer of epithelial cells called the endothelium. Endothelial cells, found in all blood vessels, secrete factors that affect blood vessel size, reduce blood clotting, and promote blood vessel growth. Because arteries carry blood away from the heart, they must be strong enough to withstand the high pressure of the heart's pumping action. Their elastic walls allow them to expand as the heartbeat forces blood into the arterial system throughout the body. The smallest branches of the arteries are the arterioles. Arterioles are thinner than arteries and carry blood to the smallest blood vessels, the capillaries. Capillaries have walls only one endothelial cell thick. These delicate microscopic vessels carry nutrient-rich, oxygenated blood from the arteries and arterioles to the cells of the body. Their thin walls allow oxygen and nutrients to pass from the bloodstream into the cells. There, nutrients are burned in the presence of oxygen (catabolism) to release energy. At the same time, waste products, such as carbon dioxide and water, leave the cells and enter the thin-walled capillaries. The waste-filled blood then returns to the heart in tiny venules, which combine to form larger vessels called veins. Veins have thinner walls compared to arteries. They carry blood (which has given up most of its oxygen) to the heart from the tissues. Veins have little elastic tissue and less connective tissue than typical arteries, and the blood pressure in the veins is extremely low compared to the pressure in the arteries. To prevent blood from flowing back to the heart, veins have valves that prevent backflow of blood and keep blood moving in one direction. Muscular action also helps the circulation of blood in the veins. Figure 11-1 illustrates the differences in blood vessels. Figure 11-2 reviews their characteristics and their relationship to one another.

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FIGURE 11-1 Blood vessels. Note the differences in wall thickness between an artery, a vein, and a capillary. All three vessels are lined with endothelium. Endothelial cells actively secrete substances that prevent coagulation and regulate the tone of blood vessels. Examples of endothelial secretions are endothelium-derived relaxing factor (EDRF) and endothelin (a vasoconstrictor).

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FIGURE 11-2 Relationship and characteristics of blood vessels.

Blood Vessels and Blood

What is the color of blood? Blood is bright red in the arteries (contains oxygen) and dark red (brown) in the veins (contains carbon dioxide). From the outside of the body, the blood in the veins appears blue because the color is reflected from the skin. How much blood is in the body? The average adult has about 5 quarts (4.7 liters) of blood in the body. What is the length of all the blood vessels? The total length of all the blood vessels in the body is 60,000 miles!

Blood Circulation The arteries, arterioles, veins, venules, and capillaries, together with the heart, form a circulatory system for blood flow. Figure 11-3 is a more detailed representation of the entire circulatory system. Refer to it as you read the following paragraphs. (Note that the numbers in brackets in the following paragraphs match those in Figure 11-3.)

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FIGURE 11-3 Schematic diagram of the pulmonary circulation (blood flow from the heart to the pulmonary capillaries and back to the heart) and systemic circulation (blood flow from the heart to the tissue capillaries and back to the heart).

Oxygen-deficient blood flows through two large veins, the vena cava [1], on its way from tissue capillaries to the heart. The blood becomes depleted of oxygen in the capillaries of the tissues as oxygen leaves the blood and enters the cells of the body. Oxygen-poor blood enters the right side of the heart [2] and travels on that side to the pulmonary artery [3], a vessel that divides into two: one branch going to the left lung and the other to the right lung. The arteries continue to divide and subdivide within the lungs, forming smaller and smaller vessels (arterioles) and eventually reaching the pulmonary capillaries [4]. The pulmonary artery is unusual in that it is the only artery in the body that carries oxygen-deficient blood. Passing through the pulmonary (pulmonary) capillaries, the blood absorbs the oxygen that entered the body during inhalation. Freshly oxygenated blood immediately returns to the heart through

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yg and g pulmonary veins [5]. The pulmonary veins are unusual in that they are the only veins in the body that carry oxygen-rich (oxygenated) blood. The circulation of blood through the vessels from the heart to the lungs and then back to the heart is the pulmonary circulation. Oxygen-rich blood enters the left side of the heart [6] from the pulmonary veins. The muscles on the left side of the heart pump blood out of the heart through the largest artery in the body, the aorta [7]. The aorta initially moves upward (ascending aorta), but then arches dorsally and descends (descending aorta) just in front of the spine. The aorta is divided into numerous branches called arteries [8] that carry oxygenated blood to all parts of the body. The names of some of these arterial branches will be familiar to you. The carotid arteries supply blood to the head and neck. The axillary, brachial (brachio means arm), splenic, and renal arteries are examples of arteries branching from the aorta. Relatively large arterial vessels branch to form smaller arterioles [9]. The arterioles, still containing oxygenated blood, branch into smaller tissue capillaries [10], which are close to the cells of the body. Oxygen leaves the blood and passes through thin capillary walls to enter the cells of the body. There, food breaks down, in the presence of oxygen, and energy is released. This chemical process also releases carbon dioxide (CO2) as a waste product. Carbon dioxide leaves the cell into the tissue capillaries at the same time that oxygen enters. Therefore, blood returning to the heart from tissue capillaries through venules [11] and veins [12] is filled with carbon dioxide but not oxygen. As this oxygen-poor blood enters the heart through the vena cava, the circuit is completed. The path of blood from the heart to the tissue capillaries and back to the heart is the systemic circulation. Figure 11-4 shows the aorta, selected arteries, and pulse points. The pulse is the heartbeat felt through the arterial walls.

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FIGURE 11-4 The aorta and arteries. Solid gold dots indicate pulse points in the arteries. These are areas where the expansion and contraction of the pulse of a superficial artery can be felt.

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Anatomy of the Heart The human heart weighs less than 300 to 450 grams, is about the size of an adult's fist, and is located in the chest cavity, just behind the sternum, in the mediastinum (between the lungs). The heart is a pump made up of four chambers: two upper chambers called the atria (singular: atrium) and two lower chambers called the ventricles. In fact, it is a double pump, connected to an organ and carefully timed. Blood passes through each pump in a defined pattern. Pump station number one, on the right side of the heart, sends oxygen-deficient blood to the lungs, where the blood picks up oxygen and releases its carbon dioxide. The freshly oxygenated blood returns to the left side of the heart at pump station number two and does not mix with oxygen-poor blood at pump station number one. Pump station number two then forces oxygenated blood to all parts of the body. In the tissues of the body, the blood loses its oxygen, and returning to the heart at pumping station number one, the oxygen-poor (carbon dioxide-rich) blood is sent to the lungs to start the cycle all over again. Check Figure 11-5 as you learn the names of the parts of the heart and the vessels that carry blood to and from the heart.

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FIGURE 11-5 Structure of the heart. Blue arrows indicate oxygen-poor blood flow. Red arrows show oxygenated blood flow.

Oxygen-poor blood enters the heart through the two largest veins in the body, the vena cava. The superior vena cava [1] drains blood from the upper body, and the inferior vena cava [2] carries blood from the lower body. The vena cava carries oxygen-poor blood that has passed throughout the body to the right atrium [3], the thin-walled upper right chamber of the heart. The right atrium contracts to force blood through the tricuspid valve [4] (the cusps are the flaps of the valves) into the right ventricle [5], the lower right chamber of the heart. The cusps of the tricuspid valve form a one-way passage designed to maintain blood flow in only one direction. As the right ventricle contracts to pump

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oxygen-poor blood through the pulmonary valve [6] into the pulmonary artery [7], the tricuspid valve remains closed, preventing blood from flowing back into the right atrium. The pulmonary artery then branches to carry oxygen-deficient blood to each lung. Blood entering the pulmonary capillaries from the pulmonary artery soon loses its large amount of carbon dioxide in the lung tissue, and the carbon dioxide is expelled. At the same time, oxygen enters the capillaries of the lungs and returns to the heart through the pulmonary veins [8]. Freshly oxygenated blood enters the left atrium [9] of the heart through the pulmonary veins. The walls of the left atrium contract to force blood through the mitral valve [10] into the left ventricle [11]. The left ventricle has the thickest walls of the four chambers of the heart (three times the thickness of the wall of the right ventricle). You have to pump blood with great force so that the blood travels through the arteries to all parts of the body. The left ventricle forces blood through the aortic valve [12] into the aorta [13], which branches off to carry blood throughout the body. The aortic valve closes to prevent aortic blood from flowing back into the left ventricle. In Figure 11-6, note that the four chambers of the heart are separated by partitions called septa (singular: septum). (Label Figure 116 as you read these paragraphs.) The interatrial septum [1] separates the two upper chambers (atria), and the interventricular septum [2], a muscular wall, lies between the two lower chambers (ventricles).

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FIGURE 11-6 The septa (walls of the heart) and the 3 layers of the heart. Note that the apex of the heart is the bottom conical (cone-shaped) point of the heart.

Figure 11-6 also shows the three layers of the heart. The endocardium [3], a smooth layer of endothelial cells, lines the interior of the heart and heart valves. The myocardium [4], the middle muscular layer of the heart wall, is its thickest layer. The pericardium [5], a fibrous, membranous sac, surrounds the heart. It is composed of two layers, the visceral pericardium, which adheres to the heart, and the parietal pericardium (parietal means wall), which lines the outer fibrous layer. The pericardial cavity (between the visceral and parietal pericardial layers) normally contains 10 to 15 mL of pericardial fluid, which lubricates the membranes when the heart beats. Figure 11-7 shows the path of blood through the heart.

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FIGURE 11-7 Path of blood through the heart.

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Physiology of the heart Heartbeats and sounds There are two phases of the heartbeat: diastole (relaxation) and systole (contraction). Diastole occurs when the walls of the ventricles relax and blood flows to the heart from the vena cava and pulmonary veins. The mitral and tricuspid valves open in diastole, when blood passes from the right and left atria to the ventricles. The pulmonary and aortic valves close at the beginning of diastole. (Figure 11-8).

FIGURE 11-8 Phases of the heartbeat: diastole and systole. During diastole, the mitral and tricuspid valves are open as blood enters the ventricles. During systole, the pulmonary and aortic valves open as blood is pumped into the pulmonary artery and aorta. LA, left atrium; VI, left ventricle; RA, right atrium; RV, right ventricle.

So, systole occurs when the walls of the right and left ventricles contract to pump blood into the pulmonary artery and aorta. The mitral and tricuspid valves close during systole, preventing blood from flowing back into the atria (see Figure 11-8). This cardiac cycle of diastole-systole occurs between 70 and 80 times per minute (100,000 times per day). The heart pumps about 3 ounces of blood with each contraction. This means that the heart pumps about 5 liters of blood in 1 minute (75 gallons per hour and about 2,000 gallons per day). Closure of the heart valves is associated with audible sounds such as "lubb-dubb," which can be heard when listening to a normal heart with a

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stethoscope. The "lubb" is associated with the closure of the tricuspid and mitral valves at the beginning of systole, and the "dubb" with the closure of the aortic and pulmonary valves at the end of systole. The “lubb” sound is called the first heart sound (S1) and the “dubb” is the second heart sound (S2), because the normal heartbeat cycle begins with the onset of systole. Sometimes the flow of blood through the valves can cause an abnormal hissing sound known as a murmur.

The Heart's Conduction System What keeps the heart in its perfect rhythm? Although the heart has nerves that affect its rhythm, they are not primarily responsible for its heartbeat. The heart begins to beat in the embryo before it receives nerves and continues to beat in experimental animals even when the nerve supply is cut off. Label Figure 11-9 as you read the following. The primary responsibility for initiating the heartbeat rests with a small region of specialized muscle tissue in the posterior portion of the right atrium, from where an electrical impulse originates. This is the SA node (SA node) or pacemaker [1] of the heart. The current of electricity generated by the pacemaker causes the walls of the atria to contract and push blood into the ventricles.

FIGURE 11-9 The conduction system of the heart.

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Much like ripples in a lake of water when a stone is thrown, the wave of electricity passes from the pacemaker to another region of the myocardium. This region is within the interatrial septum and is the atrioventricular node (AV node) [2]. The AV node immediately sends the wave of excitation to a bundle of specialized muscle fibers called the atrioventricular bundle or bundle of His [3]. Within the interventricular septum, the bundle of His divides into a left [4] and a right [5] bundle, which form the conduction myofibers that run along the walls of the ventricle and contract when stimulated. Thus systole occurs and blood is pumped out of the heart. A brief rest period follows, and then the pacemaker starts the wave of excitation through the heart again. The recording used to detect these electrical changes in the heart muscle as the heart beats is an electrocardiogram (ECG or EKG). The normal ECG tracing shows five waves, or deflections, representing the electrical changes as a wave of excitation travels through the heart. The deviations are called the P, QRS, and T waves. Figure 11-10 illustrates the P, QRS, and T waves on a normal ECG tracing.

FIGURE 11-10 Electrocardiogram. P wave = propagation of the excitation wave over the atria immediately before contraction; QRS wave = propagation of the excitation wave over the ventricles as the ventricles contract; T wave = electrical recovery and relaxation of the ventricles. A heart attack or myocardial infarction (MI) can be recognized by an elevation in the ST segment of the electrocardiographic tracing. Therefore, one type of MI is ST-segment elevation MI (STEMI).

The heart rhythm (originating from the SA node and traveling through the heart) is called normal sinus rhythm (NSR). sympathetic nerve velocity

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increase heart rate during conditions of emotional stress or vigorous exercise. Parasympathetic nerves slow the heart rate when there is no need for additional pumping.

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Blood pressure Blood pressure is the force exerted by blood on the arterial walls. This pressure is measured with a sphygmomanometer (Figure 11-11).

FIGURE 11-11 Blood pressure measurement with a sphygmomanometer and stethoscope.

The sphygmomanometer consists of a rubber bag inside a cloth cuff that is wrapped around the arm, just above the elbow. The rubber bag is inflated with air using a hand pump. As the bag is pumped, the pressure inside the bag increases and is measured on a recording device attached to the cuff. The brachial artery in the upper arm is compressed by the pressure of the air in the bag. When there is enough air pressure in the bag to stop the flow of blood, the pulse rate in the lower arm (where the observer listens with a stethoscope) drops. Air is then let out of the bag and the pressure is slowly reduced, allowing blood to begin to flow through the gradually opening artery. At the time when the listener with the stethoscope first hears the sounds of the pulse beat, the reading on the sore cuff device shows the highest systolic blood pressure (pressure in the artery when the left ventricle contracts to force blood into the aorta and other arteries). ). As the air continues to escape, the sounds get progressively louder. Finally, when a change in sound occurs from high to low, the observer feels the pressure on the recording device. this is the diastolic

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pressure (pressure in the artery when the ventricles relax and the heart fills, drawing blood from the vena cava and pulmonary veins). Blood pressure is expressed as a fraction, for example, 120/80 mm Hg, where the top number (120) is the systolic pressure and the bottom number (80) is the diastolic pressure. A new guideline lowers the treatment goal for hypertension (high blood pressure) to 130/80. The systolic and diastolic components of hypertension are associated with an increased risk of heart attack and stroke.

Vocabulary

This list reviews new terms introduced in the text. Short definitions reinforce your understanding of the terms. See page 425 of this chapter for the pronunciation of the terms.

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aortic apex of the arteriole artery of the heart

Largest artery in the body. Lower end of the heart. small artery largest type of blood vessel; carries blood from the heart to all parts of the body. Note that the artery and the distance start with an "a". atrioventricular Specialized muscle fibers connecting the atria to the ventricles and the bundle (bundle for transmitting electrical impulses between them. His is pronounced His) "whistle." atrioventricular Specialized tissue in the wall between the atria. Electrical impulses from the node (AV node) pass from the pacemaker (SA node) through the AV node and the atrioventricular bundle, or bundle of His, into the ventricles. atrium (plural: atria) One of the two upper chambers of the heart. capillary Smallest type of blood vessel. Materials pass to and from the bloodstream through thin capillary walls. carbon dioxide Gas (waste) released by the cells of the body, carried through the veins to the heart (CO2) and then to the lungs for exhalation. Carotid arteries Two common carotid arteries located on each side of the neck branch from the aorta and supply blood to the head, neck, and brain. The word carotid comes from a Greek word meaning stupor because pressure on these arteries caused unconsciousness. coronary arteries Blood vessels that branch from the aorta and carry oxygen-rich blood to the heart muscle. Deoxygenated blood Blood low in oxygen. diastole Relaxation phase of the heartbeat. (From the Greek diastole, dilation.) electrocardiogram A record of the electrical activity of the heart. Electricity is represented by waves or deflections called P, QRS, or T. endocardium Inner lining of the heart. endothelium The inner lining of blood vessels. mitral valve Valve between the left atrium and left ventricle; Bicuspid valve. murmur An abnormal whistling sound caused by improper closure of the heart valves. myocardium Middle muscular layer of the heart. Normal sinus heart rhythm originating from the sinoatrial node with a rate in patients with a resting rhythm of 60 to 100 beats per minute. Oxygen Gas that enters the blood through the lungs and travels to the heart to be pumped through the arteries to all cells in the body. pacemaker Specialized nerve tissue in the right atrium that initiates the heartbeat (sinoatrial node). An artificial cardiac pacemaker is an electronic device implanted in the chest to stimulate weak, inoperable heart muscle. pericardium Double-layered membrane that surrounds the heart. pulmonary artery An artery that carries oxygen-poor blood from the heart to the lungs. pulmonary Flow of blood from the heart to the lungs and back to the heart. pulmonary circulation valve Valve located between the right ventricle and the pulmonary artery. pulmonary vein One of the two pairs of vessels that carry oxygenated blood from the lungs to the left atrium of the heart. pulse Heartbeat felt through the walls of the arteries. septum (plural: septum or wall dividing a cavity; as between right and left septa) atria (interatrial septum) and right and left ventricles (interventricular septum). SA node (SA pacemaker of the heart. nodule)

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sphygmomanometer Instrument for measuring blood pressure. systemic circulation The flow of blood from the body tissues to the heart and then from the heart back to the body tissues. systole Phase of contraction of the heartbeat. (From the Greek systole, contraction). Tricuspid valve Located between the right atrium and the right ventricle; it has three (tri-) leaflets, or cusps. valve A structure in the veins or heart that temporarily closes an opening so that blood can flow in only one direction. vein A thin-walled vessel that carries blood from the tissues of the body and the lungs back to the heart. Veins contain valves that prevent the backflow of blood. vena cava (plural: largest vein in the body. superior vena cava and inferior vena cava) return blood to the right atrium of the heart. ventricle One of the two lower chambers of the heart. venule Small vein.

Terminology

Write the meaning of the medical term in the space provided.

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PROPER TERMINOLOGY MEANING FORM OF MEANING Vessel angiography angio/o _____________________________________ angioplasty ________________________________________________ aortic stenosis aorta/aorta _____________________________________ arter/o, arterial arteriosclerosis _________________________________ arteri/o arterial anastomosis ________________________________ From the Greek anastomoien, to provide a mouth. arteriography __________________________________ endarterectomy __________________________________ See page 407. yellowish atheroma ________________________________________ plaque, fa y The suffix -oma means mass or collection. Atheromas are accumulations of plaque substances that protrude into the lumen (opening) of (from the Greek an artery, which weakens the muscular lining. There means atherosclerosis __________________________________ porridge) The main form of arteriosclerosis in which yellow plaque deposits accumulate ( atheromas) that contain cholesterol and lipids are found within the lining of the artery (Figure 11-12). atherectomy _____________________________________ atrium/atria, atrium ___________________________________________ upper atrioventricular chamber of heart ____________________________________ brachial arm/brachial artery _________________________________________ cardio/heart cardiomegaly ________________________________________ cardiomyopathy _________________________________ One type of cardiomyopathy is hypertrophic cardiomyopathy: abnormal thickening of the heart muscle, usually in the left ventricle. The ventricle has to work harder to pump blood. The condition can be inherited or develop over time due to high blood pressure or aging. Often the cause is unknown (idiopathic). bradycardia _____________________________________ Less than 60 beats per minute. The normal pulse is about 60100 beats per minute. Brady- means slow. tachycardia ________________________________________________ More than 100 beats per minute. Supraventricular tachycardia (SVT) involves rapid heartbeats that come from the atria (above the ventricles) and cause palpitations (abnormal sensations in the chest). Tachy- means fast. Cardiogenic shock ________________________________ Results from failure of the heart in its pumping action. Shock is a circulatory failure associated with the inadequate supply of oxygen and nutrients to body tissues. cholesterol/cholesterol hypercholesterolemia _____________________________ (a lipid Statins are drugs that work by blocking a key enzyme in the substance) production of cholesterol by the liver. coronary/heart coronary arteries _________________________________ These arteries run down over the top of the heart like a crown; see Figure 11-23A, page 402. blue cyanosis/or cyanosis ________________________________________ This bluish discoloration of the skin indicates a decreased oxygen content of the blood.

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COMBINATION OF MEANING TERMINOLOGY MEANING FORM mix/or mucous myxoma ________________________________________ A benign tumor derived from connective tissue, with cells embedded in soft mucoid stromal tissue. These rare tumors most often occur in the left atrium. ox/o oxygen hypoxia ____________________________________ Inadequate oxygen to tissues. Anoxia is an extreme form of hypoxia. pericardium/the pericardium pericardiocentesis ________________________________ Removal of excess fluid from the pericardial space. Venous phlebotomy for phlebotomy _____________________________________ A phlebotomist is trained to open veins for phlebotomy. thrombophlebitis ________________________________ Often abbreviated as phlebitis. If the affected vein is deep in a muscle, the condition is deep vein thrombosis (DVT). arrhythmia/arrhythmia arrhythmia _____________________________________ Arrhythmia is also used to describe an abnormal heart rhythm. Note that an "r" is removed. sphygmo/wrist sphygmomanometer ______________________________ A sphygmomanometer measures blood pressure. steth/the chest stethoscope _____________________________________ A misnomer because the test is performed with the ear, not the eye. Auscultation is listening to sounds inside the body, usually with a stethoscope. thrombolysis/clot thrombolysis ____________________________________ valve, valvuloplasty ______________________________ valve A balloon-tipped catheter dilates a heart valve. mitral valve disease ___________________________________ Commonly associated with rheumatic fever, an inflammatory disease caused by inappropriate treatment of a streptococcal infection. An autoimmune reaction occurs that causes inflammation and damage to the heart valves. (See Figure 11-19, page 396.) Valvotomy _____________________________________ Vasoconstriction of the vessel _________________________________ Constriction means to squeeze or constrict. vasodilation _____________________________________ vascul/o vascular ______________________________________ ven/o, ven/i venous venous ____________________________________ A venous cut is a small surgical incision to allow access to a collapsed vein. An intravenous infusion is the delivery of fluids into a vein. Venipuncture __________________________________ This procedure is done for a phlebotomy or to start an IV infusion. ventricle/ventricle, interventricular septum ________________________ lower chamber of heart

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FIGURE 11-12 Atherosclerosis. The arrow points to plaque buildup in the lumen of an artery. (Courtesy of Sid Murphree, MD, Department of Pathology, University of Texas Southwestern Medical School, Dallas, Texas.)

ater/o, arteri/o, arthr/o

These three forms combined are easily confused. ather/o = yellow plaque arteri/o = artery arthr/o = joint

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Pathology: Heart and Blood Vessels Heart

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arrhythmias

Abnormal heart rhythms (dysrhythmias). Arrhythmias are problems with the heart's conduction or electrical system. More than 4 million Americans have recurrent cardiac arrhythmias. Examples of cardiac arrhythmias are: 1. Bradycardia and failure of proper conduction of impulses from the SA node heart block through the AV node into the atrioventricular bundle (bundle block (atrioventricular of His). Damage to the SA node can cause its impulses are too weak to activate the AV node and the impulses cannot reach the ventricles The heart beats slowly and bradycardia occurs If the failure occurs only occasionally, the heart misses a beat in a rhythm at regular intervals ( partial heart block).If no impulse reaches the AV from the SA node, the ventricles contract more slowly than the atria and are not coordinated.This is complete heart block.Right and left bundle branch blocks (RBD and LBBB) are common types of heart block Involve delayed or failed impulses that travel through the right and left branches to the ventricles Implantation of an artificial cardiac pacemaker overcomes ar rhythms and keeps the heart beating at the proper rate element. The pacemaker's power source is a generator containing a computer and a lithium battery. It is implanted under the skin, just below the clavicle, with leads (wires) to both chambers or to one chamber on the right side of the heart. A new type of pacemaker, called a biventricular pacemaker, treats delays and abnormalities in ventricular contractions (dyssynergia) and may also relieve symptoms and improve quality of life for patients with congestive heart failure. Reduces exacerbations of heart failure requiring hospitalization (Fig. 11.13C). 2. flu Rapid but regular contractions, usually of the auricles. The heart rate can reach up to 300 beats per minute. Atrial fluoride is usually a symptom of heart disease and often requires treatment, such as medication, electrical cardioversion, or catheter ablation (see below under fibrillation). 3. Fibrillation Very fast, random, inefficient, and irregular heart contractions (350 beats or more per minute). Atrial fibrillation (AF) is the most common type of cardiac arrhythmia, affecting 5% to 10% of people ages 70 to 80 and more than 15% of people age 80. Electrical impulses move randomly through the atria, causing the atria to quiver instead of contracting in a coordinated rhythm. Common symptoms are palpitations (uncomfortable sensations in the chest due to lack of heartbeat), fatigue, and shortness of breath. Patients with paroxysmal atrial fibrillation (irregular heartbeats occur periodically and episodically) and permanent or persistent atrial fibrillation (irregular heartbeats continue indefinitely) are at much higher risk of stroke. This is because ineffective atrial contractions can cause blood clots to form in the left atrial appendage (the area where clots form) that can travel to the brain. Also, AF can sometimes cause the heart to beat too fast for long periods of time, causing the heart muscle to weaken. The risk of stroke with AF can be reduced by 80% with the use of anticoagulants (blood thinners such as warfarin) and blood thinners called DOACs (direct oral anticoagulants). Examples of DOACs are apixaban (Eliquis), dabiatran (Pradaxa),

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and rivaroxaban (Xarelto). Other medicines are used to restore the heart rhythm or control its rate. In ventricular fibrillation (VF), electrical impulses move randomly through the ventricles. This life-threatening situation can lead to sudden cardiac death or cardiac arrest (sudden stoppage of heart movement) unless help is given immediately. If treatment is immediate, VF can be stopped with defibrillation (application of an electric shock). Defibrillation stops electrical activity in the heart for a brief moment so that normal rhythm can resume. An implantable cardioverter-defibrillator (ICD) is a small electrical device that is implanted inside the chest (near the clavicle) to detect arrhythmias and stop them with an electrical shock. Candidates for ICD are people who have had or are at high risk of having ventricular tachycardia, ventricular fibrillation, and cardiac arrest. Automated External Defibrillators (AEDs) can be found in workplaces, airports, and other public places and are used in emergency situations to reverse ventricular fibrillation. Catheter ablation is a minimally invasive treatment to treat cardiac arrhythmias. The technique, which uses radiofrequency energy delivered through the tip of a catheter inserted into a blood vessel and into the heart, destroys the tissue that causes arrhythmias. Supraventricular tachycardia (SVT), atrial fluidity, atrial fibrillation, and ventricular tachycardia (VT) can be treated with ablation when clinically indicated. This procedure can provide a permanent cure in many clinical situations. Heart abnormalities at birth.

Congenital Heart Disease The following conditions are congenital anomalies that result from a failure to develop the fetal heart. 1. Narrowing coarctation (coarctation) of the aorta. Aorta (CoA) Figure 11-14A shows coarctation of the aorta. Surgical treatment consists of extirpation of the constricted region and end-to-end anastomosis of the aortic segments. 2. Patent ductus arteriosus The passage (ductus arteriosus) between the aorta and the pulmonary artery remains open (patent) after birth. (PDA) The ductus arteriosus normally closes after birth, but in this congenital condition it remains open (see Figure 11-14B), resulting in the flow of oxygenated blood from the aorta to the pulmonary artery. PDA occurs in premature babies, causing cyanosis, fatigue, and rapid breathing. Although the defect often closes on its own within months of birth, treatment may be necessary if patency continues. Treatments include the use of a drug (indomethacin) to promote closure; catheterization surgery (with coil embolization to “plug” the duct); and ligation (tying) made through a small incision between the ribs. 3. Septal defects Small holes in the wall between the atria (atrial septal defects) or the ventricles (ventricular septal defects). Figure 11-15A shows a ventricular septal defect. While many septal defects close spontaneously, others require open-heart surgery to close the hole between the chambers of the heart, or can be repaired through minimally invasive surgery by inserting a catheter into a blood vessel leading to the heart. . A heart-lung machine is connected to the patient's circulatory system.

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4. Tetralogy of Fallot (fah-LO)

congestive heart failure (CHF)

during open-heart surgery to relieve the heart and lungs of pumping and oxygenation functions during surgery. Congenital malformation involving four (tetra) distinct heart defects. The condition, named for Étienne-Louis Fallot, the French physician who described it in 1888, is illustrated in Figure 11-15B. The four defects are: • Pulmonary artery stenosis. The pulmonary artery is narrowed or obstructed. • Ventricular septal defect. A large hole between two ventricles allows venous blood to pass from the right to the left ventricle and out into the aorta without oxygenation. • Displacement of the aorta to the right. The aorta replaces the interventricular septum. Oxygen-poor blood passes from the right ventricle to the aorta. • Right ventricular hypertrophy. The heart muscle works harder to pump blood through a narrowed pulmonary artery. A child with this condition is described as a "blue baby" due to the extreme degree of cyanosis present at birth. Surgery for tetralogy of Fallot includes patch closure of the ventricular septal defect and removal of the flow obstruction in the pulmonary artery. Other congenital conditions such as transposition of the great arteries (TGA) (the pulmonary artery arises from the left ventricle and the aorta from the right ventricle) also cause cyanosis and hypoxia. Surgical correction of TGA involves an arterial switch procedure (the pulmonary artery and aorta are rejoined in their correct positions). The heart cannot pump the necessary amount of blood. There are two types of congestive heart failure: systolic and diastolic. In systolic CHF, there is a reduced ejection fraction (the amount of blood that leaves the left ventricle). Less blood is pumped from the heart. In diastolic CHF, fluid builds up in the lungs and other parts of the body. CHF symptoms include shortness of breath, exercise intolerance, and fluid retention. Pulmonary edema (fluid buildup in the lungs) and swelling or edema in the legs, feet, and ankles are common. Treatment includes reducing dietary sodium intake and using diuretics to promote fluid loss. For patients with CHF with reduced ejection fraction and His bundle branch block, cardiac resynchronization therapy (CRT) devices can be used. These implanted devices consist of a pulse generator and thin, insulated wires, and work like normal pacemakers and defibrillation devices. If drug therapy and lifestyle changes fail to control congestive heart failure, heart transplantation may be the only treatment option. While waiting for a transplant, patients may need a device to help the heart pump. A left ventricular assist device (LVAD) is a booster pump implanted in the abdomen, with a cannula (tube) inserted into the left ventricle. It pumps blood from the heart to all parts of the body. LVAD can be used as a "bridge to transplant" or as a "destination" therapy when heart transplantation is not possible. Due to the severe shortage of donor hearts, research efforts are directed towards the development of completely artificial hearts.

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coronary artery disease (CAD)

endocarditis

Disease of the arteries that surround the heart. The coronary arteries are a pair of blood vessels that arise from the aorta and supply oxygenated blood to the heart. After the blood leaves the heart through the aorta, a portion immediately returns to the surface of the heart through the coronary arteries. DKA is usually the result of atherosclerosis. This is the deposition of fay compounds on the inner lining of the coronary arteries (any other artery can be similarly affected). The normally smooth lining of the artery becomes rough as atherosclerotic plaque builds up in the artery. The plaque first causes the coronary artery to become blocked. The rough lining of the artery can then rupture or cause abnormal blockage of blood, leading to thrombotic occlusion (blockage of the coronary artery by a clot). Blood flow slows (ischemia) or stops completely, leading to the death (necrosis) of part of the heart muscle. This sequence of events constitutes a myocardial infarction, or heart attack, and the area of dead myocardial tissue is known as an infarct. The infarcted area is eventually replaced by scar tissue. Figure 11-16 shows the coronary arteries branching from the aorta and illustrates coronary artery occlusion that causes heart muscle ischemia and infarction. Figure 11-17 is a photograph of the myocardium after an acute myocardial infarction. Acute coronary syndromes (ACS) are conditions caused by myocardial ischemia. These conditions are unstable angina (chest pain at rest or chest pain becoming more common) and myocardial infarction (Fig. 11.18). Patients with ACS benefit from early angiography (x-ray of the coronary arteries) and PCI (percutaneous coronary intervention with balloon catheter and stents) or CABG (coronary artery bypass grafting) to improve blood flow to the heart muscle ( bypass graft). Medications used to treat ACS are anticoagulants and antiplatelet agents, such as aspirin and clopidogrel (Plavix), prasugrel (Eﬃent), and ticagrelor (Brilinta). For acute angina attacks, nitroglycerin is given sublingually (under the tongue). This drug, one of several called nitrates, is a vasodilator that increases coronary blood flow and lowers blood pressure. Nitrates also cause venodilation to reduce venous return and decrease myocardial oxygen consumption, both of which help slow the work of the heart. Doctors advise patients to avoid risk factors such as smoking, obesity, and lack of exercise and prescribe effective medications to prevent CAD and ACS. These medicines include aspirin (to prevent platelet buildup), beta-blockers (to reduce the force and speed of your heartbeat and lower blood pressure), ACE inhibitors (to reduce high blood pressure and risk of having a heart attack in the future, even if the patient is not hypertensive), calcium channel blockers (to relax the muscles in the blood vessels), and statins (to lower cholesterol levels). Cardiac surgeons perform an open-heart operation called coronary artery bypass grafting (CABG) to treat CAD by replacing blocked vessels. Interventional cardiologists perform percutaneous coronary interventions (PCIs), in which catheterization with balloons and stents opens blocked coronary arteries. Inflammation of the inner lining of the heart.

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hypertensive heart disease

mitral valve prolapse (MVP)

murmur

pericarditis

rheumatic heart disease

Damage to the heart valves from an infection (bacterial endocarditis) causes lesions called growths (which resemble cauliflower) that break off into the bloodstream as emboli (material that travels through the blood). Emboli can lodge in other vessels, leading to a transient ischemic attack (TIA) or stroke, or in small vessels in the skin, where multiple punctal hemorrhages known as petechiae (from Italian petechiae, flea bite) form. Antibiotics can cure bacterial endocarditis. High blood pressure that affects the heart. This condition results from narrowing of the arterioles, which leads to increased pressure in the arteries. The heart is affected (left ventricular hypertrophy) because it pumps more vigorously to overcome the increased resistance in the arteries. Inadequate closure of the mitral valve. This condition occurs because the mitral valve enlarges and prolapses into the left atrium during systole. The doctor hears a mid-systolic click on auscultation (listening with a stethoscope) and occasionally mitral regurgitation (reflux of blood into the left atrium). Most people with MVP live normal lives, but severely prolapsed valves can be associated with severe mitral regurgitation and, rarely, can become infected (endocarditis). Extra heart sound, heard between normal beats. Murmurs are heard with the aid of a stethoscope and are usually caused by a valve defect or disease that disrupts the regular flow of blood in the heart. They are also heard in cases of interseptal defects, in which blood flows abnormally between the chambers through holes in the septa. Functional murmurs are not caused by valve or septal defects and do not seriously endanger a person's health. A murmur (BRU-e) is a murmur heard on auscultation. It is the turbulent flow of blood through a vessel. A chill, which is a vibration felt when the chest is palpated, often accompanies a murmur. Inflammation of the membrane (pericardium) that surrounds the heart. In most cases, pericarditis results from a viral disease or the etiology may be idiopathic. Bacteria and viruses cause the condition, or the etiology may be idiopathic. General malaise, fever, and chest pain present, and auscultation often reveals a pericardial rub (heard as a scratching or scratching sound). Compression of the heart caused by the accumulation of fluid in the pericardial cavity is cardiac tamponade (tăm-pō-NŎD). Treatment includes anti-inflammatory drugs and other agents to control pain. If the pericarditis is infectious, antibiotics or antifungals are prescribed, depending on the microorganisms detected in the samples obtained by pericardiocentesis or by blood tests. Heart disease caused by rheumatic fever. Rheumatic fever is a childhood illness that follows a strep infection with a sore throat (pharyngitis). Heart valves can be damaged by inflammation and scarred by vegetation so that they do not open and close normally (Fig. 11.19A). Repeated strep infection is believed to be necessary to produce heart disease, so children with a history of rheumatic fever are treated with monthly intramuscular injections of penicillin until age 21.

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Mitral stenosis, atrial fibrillation, and congestive heart failure, caused by weakening of the heart muscle, can also result from rheumatic heart disease. Treatment consists of reduced activity, medications to control the arrhythmia, surgery to repair a damaged valve, and anticoagulant therapy to prevent emboli from forming. Artificial and porcine (porcine) valve implants can replace deteriorated heart valves (Fig. 11-19B and C).

FIGURE 11-13 A. A sensitive dual chamber pacemaker (actual size shown) is designed to sense body movement and automatically increase or decrease the paced heart rate based on levels of physical activity. B, Cardiac pacemaker with leads in the right atrium and right ventricle that allows it to sense and pace both chambers of the heart. C, Biventricular pacing with leads in the right atrium and right and left ventricles to synchronize ventricular contractions.

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FIGURE 11-14 A. Coarctation of the aorta. Localized narrowing of the aorta reduces the blood supply to the lower part of the body. B, Patent ductus arteriosus. The ductus arteriosus does not close after birth, and blood from the aorta flows through it into the pulmonary artery.

FIGURE 11-15 A, Ventricular septal defect. A hole in the ventricular septum causes blood to flow from the left ventricle to the right and to the lungs through the pulmonary artery. B, Tetralogy of Fallot showing the four defects. Blood flow is indicated by arrows.

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FIGURE 11.16 A, Ischemia and infarction caused by occlusion of the coronary artery. B, Internal view of the heart showing an area damaged by a myocardial infarction.

FIGURE 11.17 Acute myocardial infarction (MI), 5 to 7 days in duration. The infarct is visible as a pale yellow, well-defined lesion in the posterolateral region of the left ventricle. The edge of the infarct is surrounded by a dark red zone of acute inflammation.

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FIGURE 11-18 Acute coronary syndromes: sequence of pathologic changes leading to the cardiac event. A, Atherosclerotic plaque forms from lipid accumulation. B, Plaque rupture, causing platelet aggregation in the plaque. C, Non-occlusive thrombus forms causing unstable angina or NSTEMI (non-ST-segment elevation myocardial infarction). D, Alternatively, formation of an occlusive thrombus leads to myocardial infarction or STEMI (ST-segment elevation myocardial infarction).

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FIGURE 11.19 A, Acute rheumatic mitral valve disease with chronic rheumatic heart disease. Small vegetations can be seen along the closing line of the mitral valve leaflet (arrows). Previous episodes of rheumatic valvulitis have caused fibrous thickening and fusion of the chordae tendineae of the valves. B, artificial heart valve. C, porcine xenograft valve. A xenograft valve (from the Greek xen/o meaning foreign) is tissue that is transferred from an animal of one species (pig) to another species (human).

How does a pacemaker work?

The pacemaker's electrodes (wires) detect the heart's own electrical activity and transmit this information to the generator (computer). The computer analyzes the signals from the heart and decides when and where to stimulate. If the rate is slow, the generator sends a signal to stimulate contraction and increase the rate. Multilead pacemakers can pace the atrium and ventricle in the proper sequence. Rate-sensitive pacemakers have sensors that detect body movement and breathing to determine the best heart rate.

palpitation/palpation

Do not confuse palpitation with palpation, which means to touch, palpate, or examine with the hands and fingers.

blood veins

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aneurysm

deep vein thrombosis (DVT)

Hypertension (AHT)

peripheral arterial disease (PAD)

Raynaud's disease (raNO) (Raynaud's)

varicose veins

The local widening (dilation) of an arterial wall. An aneurysm (from the Greek aneurysm, enlargement) is usually caused by atherosclerosis and hypertension or a congenital weakness in the vessel wall. Aneurysms are common in the aorta, but can also occur in peripheral vessels. The danger of an aneurysm is rupture and bleeding. Treatment depends on the vessel involved, the site, and the health of the patient. For small vessel aneurysms in the brain, treatment is occlusion of the vessel with small clips. For larger arteries, such as the aorta, a stent may be sewn into the affected vessel. Figure 1120A shows an abdominal aortic aneurysm (labeled "AAA") and Figure 11-20B illustrates a stent in place. Note that the graft is anastomosed to the normal portion of the aorta and the aneurysm sac is closed around the graft to prevent fistula formation from the graft to the intestine. The blood clot (thrombus) forms in a large vein, usually in a lower extremity. This condition can lead to a pulmonary embolism (clot travels to the lung) if not treated effectively. Examples of anticoagulants (anticoagulant medications) are warfarin (Coumadin) and direct oral anticoagulants (DOACs). They are used to prevent DVT and pulmonary embolism (PE). Hypertension. Most high blood pressure is essential hypertension with no identifiable cause. The categories of blood pressure readings are shown in Table 11-1. Diuretics, ACE inhibitors, calcium channel blockers, and beta blockers are used to treat essential hypertension. Losing weight, limiting sodium (salt) intake, quitting smoking, and reducing fat in the diet can also lower blood pressure. In secondary hypertension, the increased pressure is caused by another associated lesion, such as glomerulonephritis, pyelonephritis, or adrenal or vascular disease. Blockage of the arteries that carry blood to the legs, arms, kidneys, and other organs. Any artery can be affected, such as the carotid (neck), femoral (thigh), or popliteal (back of the knee) artery. A sign of PAD in the lower extremities is intermittent claudication (no pain or discomfort in one leg at rest, but pain, tightness, and weakness after starting to walk). Treatment consists of exercise, avoiding nicotine (which constricts blood vessels), and controlling risk factors such as high blood pressure, hyperlipidemia, and diabetes. Surgical treatment includes endarterectomy and bypass grafting (from the proximal normal vessel around the diseased area to a normal vessel distally). Percutaneous treatments include balloon angioplasty, atherectomy, and stenting. Embolic protection devices are parachute-shaped filters used to capture embolic debris during stent placement. Recurrent episodes of paleness and cyanosis, particularly of the fingers and toes. This is a rare disorder of unknown cause that affects blood flow in the arteries. Raynaud's disease is sometimes referred to as a disease, phenomenon, or syndrome. It is characterized by brief episodes of intense constriction and vasospasm of the arterioles in healthy young women. See Figure 11-21. Episodes can be triggered by low temperatures, emotional stress, or smoking and caffeine. Raynaud's can be controlled by protecting the body from the cold and avoiding other triggers. Medications that increase blood flow to the hands and feet may relieve symptoms. Abnormally swollen and twisted veins, usually in the legs.

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is coming

This condition is caused by damaged valves that do not prevent backflow of blood (Figure 11-22A to C). The blood then pools in the veins, which stretch to many times their normal size. Due to the slow blood flow in varicose veins and the frequent injury to the vein, thrombosis can also occur. Hemorrhoids (hemorrhoids) are varicose veins near the anus. Doctors now treat varicose veins with sclerotherapy (injections with a sclerosing solution) or laser and pulsed light treatments to seal the veins. Surgical interventions, such as vein stripping and ligation, are used less frequently.

FIGURE 11-20 A. Abdominal aortic aneurysm (AAA). A dissecting aortic aneurysm is a division or dissection of the wall of the aorta due to the entry of blood through a rupture or hemorrhage within the walls of the vessel. B, Stent graft placed. This stent graft procedure is an endovascular aneurysm repair, or EVAR.

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FIGURE 11-21 Raynaud's disease.

FIGURE 11-22 A. Valve function in normal vein and varicose vein. B, Varicose veins. C, Slow flow in the veins increases susceptibility to thrombophlebitis (clot formation), edema, and pigmented skin (pools of blood in the lower legs and fluid leakage from small distended capillaries). If a thrombus breaks free from its place in the vein, it can travel to the lungs (pulmonary embolism) and block a blood vessel there.

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TABLA 11-1

Aortic aneurysms and Marfan syndrome

Aortic aneurysms are often associated with Marfan syndrome, a genetic disorder characterized by long, spindly fingers, large arms, a displaced lens, and loose joints. Abraham Lincoln is believed to have had Marfan syndrome, and the syndrome has also been diagnosed in basketball and volleyball players who died suddenly as a result of ruptured aortic aneurysms.

Warfarin (Coumadin) and DOAC

While the oral anticoagulant warfarin is used to prevent or treat thromboembolic diseases, warfarin treatment requires careful monitoring and is complicated by drug-drug or food-drug interactions. Direct oral anticoagulants (DOACs), such as apixaban (Eliquis), edoxaban (Savaysa), dabigatran (Pradaxa), and rivaroxaban (Xarelto), address these limitations and have been approved by the Food and Drug Administration (FDA) for anticoagulation in cases of non-valvular atrial fibrillation and for the prevention and treatment of DVT and PE.

study section

Practice spelling each term and learn its meaning.

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acute coronary syndromes (ACS) angina (pectoris) auscultation of angiotensin converting enzyme (ACE) inhibitor

Unstable angina and myocardial infarction (heart attack), which are consequences of plaque rupture in the coronary arteries. Chest pain due to myocardial ischemia. Stable angina occurs predictably with exertion; Unstable angina is chest pain that occurs more frequently and with less effort. An antihypertensive drug that blocks the conversion of angiotensin I to angiotensin II, causing the blood vessels to dilate. Prevents heart attacks, CHF, strokes, and death. See Table 21-7 on page 835 for the names of ACE inhibitors and other cardiovascular drugs.

Listen for sounds in blood vessels or other structures in the body, usually with a stethoscope. beta-blocker A drug used in the treatment of angina, hypertension, and arrhythmias. It blocks the action of epinephrine (adrenaline) at receptor sites on cells, slowing the heartbeat and reducing the workload on the heart. biventricular A device that allows the ventricles to beat together (synchronized) so that more pacemaker blood is pumped out of the heart. bruit An abnormal murmur or wheezing sound heard when listening to an artery or organ. calcium A drug used to treat angina and high blood pressure. It dilates blood vessels by blocking the entry of calcium into the muscle cells lining the vessels. blockade cardiac arrest Sudden and unexpected arrest of heart action, often leading to sudden cardiac death. Cardiac Pressure on the heart caused by fluid in the pericardial space. tamponade claudication Pain, tightness and weakness in one leg after beginning to walk, but without pain at rest. digoxin A drug that treats arrhythmias and strengthens the heartbeat. embolus A clot or other substance that travels to a distant location and suddenly becomes blocked (plural: a blood vessel. emboli) infarct Area of dead tissue. nitrates Medicines used to treat angina. They dilate the blood vessels, increasing the flow of blood and oxygen to the myocardial tissue. Nitroglycerin nitrate drug used in the treatment of angina. occlusion Closure of a blood vessel due to an obstruction. palpitations Uncomfortable sensations in the chest related to cardiac arrhythmias, such as premature ventricular contractions (PVCs). open patent. pericardial scratching or scratching sound heard on auscultation of the heart; suggestive of frictional pericarditis. Petechiae Small punctual hemorrhages. statins Drugs used to lower cholesterol in the bloodstream. emotion Vibration felt in an area of turbulence in blood flow (such as a blocked artery). vegetation Clusters of platelets, protein cloning, microorganisms and red blood cells in diseased heart valves.

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Laboratory tests and clinical procedures Laboratory tests BNP test

cardiac biomarkers

lipid tests (lipid profile)

lipoprotein electrophoresis

Measurement of BNP (Brain Natriuretic Peptide) in blood. BNP is elevated in patients with heart failure and is useful in the diagnosis of CHF in patients with dyspnea presenting to the emergency department. Their presence also identifies patients at risk of complications when they have acute coronary syndromes (eg, myocardial infarction, unstable angina). It is secreted when the heart is overworked and acts as a diuretic to help return heart function to normal. Cardiologists also measure NT-proBNP levels to assess the degree of heart failure. NT means N-terminal. The reference to the brain in this term comes from the initial identification of the protein in the brain of a pig. Chemicals are measured in the blood as evidence of a heart attack. Damaged heart muscle releases chemicals into the bloodstream. The substances analyzed are troponin-I (cTnI) and troponin-T (cTnT). Troponin is a heart muscle protein that is released into the circulation after myocardial injury. C-reactive protein (CRP) is a biomarker of inflammation. High-sensitivity PCR (Hs-CRP) is useful in predicting the risk of heart attack, stroke, or other serious heart disease. Measurement of cholesterol and triglycerides (fats) in a blood sample. High lipid levels are associated with atherosclerosis. The general guideline for total blood cholesterol is less than 200 mg/dL. Saturated fats (from animal sources, such as milk, butter, and meats) raise blood cholesterol, while polyunsaturated fats (from plant sources, such as corn and safflower oil) lower blood cholesterol. Treatment of hyperlipidemia includes proper diet (low fat, high fiber) and exercise. Niacin (a vitamin) also helps to lower lipids. Drug therapy includes statins, which reduce the risk of heart attack, stroke, and cardiovascular death. Statins lower cholesterol by reducing its production in the liver. Some examples are simvastatin (Zocor), atorvastatin (Lipitor), pravastatin (Pravachol), and rosuvastatin (Crestor). Lipoproteins (combinations of fat and protein) are physically separated and measured in a blood sample. Examples of lipoproteins are low-density lipoproteins (LDL) and high-density lipoproteins (HDL). High LDL levels are associated with atherosclerosis. The National Guideline for LDL is less than 130 mg/dL in normal persons and less than 70 mg/dL in patients with CAD, PAD, and diabetes mellitus. High HDL levels protect adults from atherosclerosis. Factors that increase HDL are exercise and moderate alcohol consumption.

Clinical procedures: diagnostic X-rays and electron beam tests

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computed tomography angiography (CTA)

digital subtraction angiography (DSA) electron beam computed tomography (EBCT or EBT)

X-ray images of blood vessels after injection of contrast material. Arteriography is an X-ray image of the arteries after contrast is injected through a catheter into the aorta or artery. Three-dimensional X-ray images of the heart and coronary arteries using computed tomography (64-slice CT). This new technique takes hundreds of images of the heart every second. The cross-sectional images are assembled by computer into a three-dimensional image. It is less invasive than angiography (contrast material is injected into a small peripheral vein with a small needle) and provides excellent views of the coronary arteries to diagnose coronary artery disease (Fig. 11.23A). Video equipment and a computer produce X-ray images of the blood vessels. After taking an initial X-ray image and storing it in a computer, doctors inject contrast material and take a second image of that area. The computer compares the two images and subtracts the digital data from the first to the second, leaving an image of contrasting vessels. Electron beams and CT scans identify calcium deposits in and around coronary arteries to diagnose early CAD. A coronary artery calcium score is obtained to indicate future risk of heart attack and stroke (see Figure 11.23B).

FIGURE 11.23 A, Computed tomography angiography (CTA) showing the coronary arteries. B, Electron beam computed tomography showing significant calcification (white areas) in the coronary arteries, indicating advanced coronary artery disease. (A, courtesy of Massachusetts General Hospital, Boston).

Coronary artery calcium score

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0-99 100-399 >400

low risk intermediate risk high risk

A calcium score > 400 is associated with almost a 25% chance of having a heart attack or stroke within 10 years.

Ultrasound examination Doppler ultrasound studies

echocardiography (ECH)

Sound waves measure blood flow within blood vessels. An instrument focuses sound waves on blood vessels, and the echoes are reflected off red blood cells. The examiner may hear various changes in blood flow caused by a blocked vessel. Duplex ultrasound combines Doppler and conventional ultrasound to allow doctors to visualize the structure of blood vessels and measure the velocity of blood flow. Carotid artery occlusion, aneurysms, varicose veins, and other vascular disorders can be diagnosed with duplex ultrasound. Echoes generated by high-frequency sound waves produce images of the heart (Fig. 11.24A). ECHOs show the structure and movement of the heart. In transesophageal echocardiography (TEE), a transducer placed in the esophagus provides ultrasound and Doppler information (Fig. 11.24B). This technique detects cardiac masses, prosthetic valve function, aneurysms, and pericardial fluid.

FIGURE 11-24 A, Echocardiogram. Note that in this view, the ventricles are above the atria. B. Transesophageal echocardiography.

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Positron emission tomography (PET) nuclear cardiology scan with technetium Tc 99m sestamibitalium scan 201

Images show blood flow and myocardial function after radioactive glucose uptake. PET scanning can detect CAD, myocardial function, and differences between ischemic heart disease and cardiomyopathy. Technetium Tc 99m sestamibi injected intravenously is absorbed into cardiac tissue, where it is detected by scanning. This scan is used in people who have had a heart attack to assess the amount of heart muscle damage. It is also used with an exercise tolerance test (ETT-MIBI). Sestamibi is a radioactive tracer compound used to define areas of poor blood flow in heart muscle. The concentration of radioactive thallium is measured to provide information about the blood supply to the heart muscle. Thallium studies show the viability of heart muscle. Infarcted or scarred myocardium appears as "cold spots."

Magnetic Resonance Imaging (MRI) Cardiac MRI

Images of the heart are produced using energy from radio waves in a magnetic field. These multiplane images provide information on left and right ventricular function, wall thickness and fibrosis, aneurysms, cardiac output, and peripheral and coronary artery patency. The magnetic waves emitted during MRI can interfere with implanted pacemakers due to their metal content and heat generation, so it is currently contraindicated for a patient with a pacemaker to undergo a cardiac MRI. However, new MRI-safe pacemakers have been approved. Magnetic resonance angiography (MRA) is a type of MRI that provides highly detailed images of blood vessels. Doctors use MRA to visualize the arteries and the blockages within the arteries. Gadolinium is the most common contrast agent used for MRI procedures.

Other diagnostic procedures

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cardiac catheterization

electrocardiography (ECG)

holter monitoring

test stress

A thin, flexible tube is guided to the heart through a vein or artery. This procedure detects pressures and blood flow patterns in the heart. Contrast can be injected and X-ray images of the heart and blood vessels can be taken (Fig. 11.25). This procedure can be used in the diagnosis and treatment of heart problems (see Percutaneous Coronary Intervention [PCI] on page 407). At the time of catheterization, the interventional cardiologist may also perform an intravascular ultrasound (IVUS) to assess the severity of the narrowing of the vessels. It also measures fractional flow reserve (FFR) to determine the impact of coronary artery blockage on blood flow. Recording of the electricity flowing through the heart. Continuous monitoring of a patient's heart rate in hospitals is done using telemetry (electronic data transmission - tele/o means distant). Sinus rhythm begins in the SA node, and the normal rate is 60 to 100 beats per minute. Figure 11-26 shows ECG strips for normal sinus rhythm and various types of arrhythmias (abnormal rhythms). An ECG device is used for a long period of time to detect cardiac arrhythmias. The rhythm changes are correlated with the symptoms recorded in a diary. The exercise tolerance test (ETT) determines the heart's response to physical exertion (stress). A common protocol uses 3-minute stages at defined speeds and elevations on a treadmill. Continuous monitoring of vital signs and ECG rhythms is important in diagnosing CAD and left ventricular function.

FIGURE 11-25. Transradial cardiac catheterization. The catheter is passed retrograde (backwards) from the radial artery into the aorta and then into the left ventricle.

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FIGURE 11-26 ECG rhythm strips showing normal sinus rhythm and dysrhythmias (arrhythmias).

Clinical Procedures: Treatment

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catheter ablation

coronary artery bypass graft (CABG) surgery

defibrillation

endarterectomy

cardiopulmonary bypass

heart transplant

percutaneous coronary intervention (PCI)

Brief delivery of radiofrequency energy to ablate (remove) areas of heart tissue that may be causing arrhythmias. A catheter is guided through a vein in the leg into the vena cava and into the heart. The abnormal electrical pathway is located and removed (destroyed) using the energy emitted from the catheter. See figure 1127A. The arteries and veins are anastomosed to the coronary arteries to avoid blockages. Internal mammary (breast) and radial (arm) arteries and saphenous vein (leg) grafts are used to maintain the supply of oxygenated blood to the myocardium (Fig. 11.27B). Cardiac surgeons perform minimally invasive CABG surgery using smaller incisions instead of the traditional sternotomy to open up the chest. Vein and artery grafts are also removed endoscopically through small incisions. Although most operations are performed using a heart-lung machine ("on-pump"), an increasing number are being performed "off-pump" with a beating heart. See In Person: Coronary Artery Bypass Surgery, page 412. Short bursts of electricity are delivered to the chest to stop arrhythmias (ventricular fibrillation). For patients at high risk of sudden cardiac death from ventricular arrhythmias, an implantable cardioverter-defibrillator (ICD) or implantable cardioverter-defibrillator (AICD) is placed in the upper chest. Cardioversion is another technique that uses less energy to treat atrial fibrillation, atrial fluoride, and supraventricular tachycardia. Surgical removal of plaque from the inner lining of an artery. Fatty deposits (atheromas) and clots are removed to open clogged arteries. Carotid endarterectomy is a procedure to remove plaque buildup in the carotid artery to reduce the risk of stroke. The heart-lung machine diverts blood away from the heart and lungs while the heart is being repaired. Blood leaves the body, enters the heart-lung machine, where it is oxygenated, and then returns to a blood vessel (artery) to circulate through the bloodstream. The machine uses the technique of extracorporeal membrane oxygenation (ECMO). A donor's heart is transferred to a recipient. While waiting for a transplant, the patient may need a left ventricular assist device (LVAD), which is a booster pump implanted in the chest or abdomen with cannulas (flexible tubes) from the left ventricle to the ascending aorta. A balloon-tipped catheter is inserted into a coronary artery to open the artery; stents are placed. An interventional cardiologist places the catheter in the femoral or radial artery and then threads it through the aorta to the coronary artery. Stents (expandable metal tubes that serve as permanent support devices) create large lumens and make restenosis less likely. Drug-eluting stents (DES) are coated with polymers that elute (release) anti-inflammatory and antiproliferative drugs to prevent scar tissue formation that leads to restenosis (Figure 11.28). Other devices are bioresorbable vascular scaffolds (BVS), made of soluble material, and drug-coated balloons (DCBs) that deliver paclitaxel. PCI techniques include percutaneous transluminal coronary angioplasty (PTCA), stent placement, laser angioplasty (a small

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thrombolytic therapy

Transcatheter aortic valve replacement (TAVR)

at the tip of a catheter vaporizes plaque) and atherectomy. Clot-dissolving drugs are injected into the bloodstream of patients with coronary thrombosis. Tissue plasminogen activator (tPA) and streptokinase restore blood flow to the heart and limit irreversible damage to heart muscle. The drugs are given within 12 hours of the start of a heart attack. Thrombolytic agents reduce the mortality rate in patients with myocardial infarction by 25%. Placement of a balloon-expandable aortic heart valve into the body via a catheter. The catheter is guided into the heart through the femoral artery and a stent valve device is inserted using the catheter. This is a minimally invasive catheter-based technology used to treat aortic stenosis.

FIGURE 11-27 A. Catheter ablation. SVT, atrial flutter, AF, and VT can be treated with ablation when clinically indicated. B, Coronary artery bypass graft (CABG) surgery with anastomoses of arterial and venous grafts. (1) A section of a leg vein is removed and anastomosed (inverted due to its directional valves) to a coronary artery to bypass an area of arteriosclerotic obstruction. (2) An internal mammary artery is grafted onto a coronary artery to avoid blockage.

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FIGURE 11.28 Placement of an intracoronary drug-eluting stent. A, The stent is placed at the lesion site. B, The balloon is inflated, expanding the stent and compressing the plaque. C, When the balloon is removed, the stent supports the artery and delivers a drug to reduce the risk of restenosis. Stents are stainless steel scaffolding devices that help keep arteries open, such as the coronary, renal, and carotid arteries.

abbreviations

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AAA ACE Inhibitor ACLS ACS ADP

angiotensin converting enzyme inhibitor abdominal aortic aneurysm

advanced cardiac life support; CPR plus drugs and defibrillation acute coronary syndrome adenosine diphosphate; ADP blockers are used to prevent cardiovascular death, heart attack and stroke and after all stent procedures. DEA. Automatic external defibrillator. AF, atrial fibrillation. AICD. implantable cardioverter defibrillator. aortic stenosis ASD AV atrial septal defect, A-V atrioventricular AVR aortic valve replacement BBB bundle branch block BNP brain natriuretic peptide; elevated in congestive heart failure BP blood pressure CABG coronary artery bypass grafting CAD coronary artery disease CCTA coronary CT angiography CCU catheterization catheterization CHF congestive heart failure CK creatine kinase; enzyme released after cardiac muscle injury CoA coarctation of the aorta CPR cardiopulmonary resuscitation CRT cardiac resynchronization therapy; defibrillation devices and biventricular pacemakers NICTs or cardiac troponin-I and cardiac troponin-T; troponin is a protein released by cTnI; CTNT the bloodstream after myocardial injury or drug-eluting stent cTnT DES DOAC direct oral anticoagulant DSA digital subtraction angiography DVT deep vein thrombosis ECG; also electrocardiography seen as EKG ECHO echocardiography ECMO extracorporeal membrane oxygenation ejection fraction EF; measurement of the amount of blood that is pumped out of the heart with each beat Electrophysiological study EPS; Catheters with electrodes inserted into the veins and inserted into the heart to measure electrical conduction (elicit and analyze tachycardias) ETT exercise tolerance test ETT-MIBI exercise tolerance test combined with a radioactive tracer (sestamibi) EVAR scan Repair endovascular high-density lipoprotein fractional HDL flow reserve FFR aneurysm; Elevated blood levels mean a lower incidence of coronary artery disease

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hsCRP

high sensitivity C-reactive protein; biomarker for inflammation in predicting heart attack risk HTN hypertension (high blood pressure) IAB intra-aortic balloon pump; used to help patients in cardiogenic shock AHF invasive coronary angiography ICD implantable cardioverter-defibrillator IVUS intravascular ultrasound left anterior descending LAD (coronary artery) LBBB Left bundle branch block LDL low-density lipoprotein; elevated blood levels lead to cholesterol buildup in arteries LMWH low molecular weight heparin LV left ventricle LVAD left ventricular assist device LVEF left ventricular ejection fraction LVH left ventricular hypertrophy MI myocardial infarction MUGA multiple acquisition scan; a radioactive test of cardiac function MVP mitral valve prolapse NSR normal sinus rhythm NT-proBNP pro-BNP N-terminal peptide NSTEMI MI non-ST elevation PAC premature atrial contraction PAD peripheral arterial disease PCI percutaneous coronary intervention PDA patent ductus arteriosus PE embolism pulmonary PVC ventricular premature contraction RBBB right bundle branch block SA, S-A sinoatrial node SCD sudden cardiac death LOW shortness of breath SPECT single photon emission computed tomography; used to image the myocardium with sestamibi STEMI scans ST-segment elevation myocardial infarction SVT supraventricular tachycardia; rapid heartbeats arising from the atria causing palpitations, dyspnea, and dizziness TAVR transcatheter aortic valve replacement TEE transesophageal echocardiography TEVAR endovascular thoracic aneurysm repair TGA transposition of the great arteries tPA tissue-type plasminogen activator; a drug used to prevent UA thrombosis unstable angina; chest pain at rest or with increasing rate VF ventricular fibrillation VSD ventricular septal defect VT ventricular tachycardia WPW Wolff-Parkinson-White syndrome; abnormal ECG pattern associated with paroxysmal tachycardia

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Practical applications

Answers to practical applications are on page 425.

Operating Room Layout: General Hospital Match the surgical treatment in Column I with the appropriate surgical indication (diagnosis) in Column II. COLUMN I 1. Coronary artery bypass surgery 2. Left carotid endarterectomy 3. Sclerosing injections and laser treatment 4. LV aneurysmectomy 5. Atrial septal defect repair 6. Left ventricular assist device 7. Pericardiocentesis 8. Aortic valve replacement 9. Pacemaker implantation 10. Femoropopliteal bypass graft

COLUMN II _______ A. Congestive heart failure B. Cardiac tamponade (fluid in the _______ space around the heart) C. Atherosclerotic occlusion of a major artery leading _______ to the head D. Congenital hole in the wall of the _______ upper chamber of the heart _______ E. Angina Extensive and disabling coronary atherosclerosis _______ despite medical treatment F. Peripheral vascular disease _______ G. Heart block _______ H. Varicose veins I. Protrusion of the wall of an inferior cardiac chamber _______ J. Aortic stenosis _______

Important New Cardiovascular Drugs Antiplatelet Agents: These drugs are used after stent placement or after ACS (acute coronary syndrome). • clopidogrel (Plavix) • prasugrel (Effent) • ticagrelor (Brilinta) DOACs (direct oral anticoagulant agents): These drugs are used to prevent atrial fibrillation-related strokes and blood clots. • apixaban (Eliquis) • dabidatran (Pradaxa) • edoxaban (Savaysa) • rivaroxaban (Xarelto) Entresto: New and exciting drug combination to treat heart failure. It outperformed traditional angiotensin-converting enzyme (ACE) inhibitors in a major clinical trial and was shown to reduce mortality from heart failure. • valsartan/sacubitril

Clinical Cases: What is your diagnosis?

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Case 1: A 24-year-old woman with a history of palpitations [heartbeat is unusually strong, fast, or irregular so the patient is aware of this] and vague chest pains is admitted to the hospital. With the patient in the supine position, a mid-systolic click is heard followed by a grade 3/6 honk murmur [moderately loud: 6/6 is loud and 1/6 is low]. 1. Her diagnosis is: a. Tetralogy of Fallot b. mitral valve prolapse c. Raynaud's disease D. Congestive heart failure Case 2: Mr. Smith is rushed to the emergency room for prolonged chest pain. His ECG showed ST-segment elevation in the anterior leads, so he was transferred to the cardiac catheterization lab. An angiogram reveals a 100% blockage of the left anterior descending (LAD) coronary artery. PCI with stent is recommended. 1. What did the ECG reveal? a. NSTEMI and unstable angina b. Aortic aneurysm c. CHF d. STEMI 2. Your diagnosis for this patient is: a. heart ck b. Rheumatic heart disease c. Unstable angina d. Patent ductus arteriosus 3. What treatment is recommended? a. Myocardial revascularization surgery b. Catheterization with drug-eluting stent placement c. Defibrillation and cardioversion d. Thrombolytic drugs Case 3: A 42-year-old runner, recovering from an upper respiratory tract infection, presents to the emergency room complaining of constant, sharp chest pain, worse when lying down and lessening when standing up and leaning forward. Serum troponin levels rule out an acute myocardial infarction. The ER doctor hears a pericardial rub. 1. What is your diagnosis for this patient? a. myocardial ischemia b. Unstable angina and NSTEMI

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C. Endocarditis D. Pericarditis 2. The danger of this condition is the risk of progression to: a. Cardiac tamponade b. aneurysm c. Pulmonary embolism d. limp

Myocardial bypass surgery in person

Possible heart attack? You must be kidding. He had none of the supposed symptoms: shortness of breath or chest pain. Instead, I had intermittent episodes of atrial fibrillation for several months. I got tired easily and could feel my blood pressure drop. After lying down for about an hour I was fine so in November 2010 I decided to get checked out. My cardiologist decided to do a stress test. He put me on a treadmill, which felt like forever, and then he did an ultrasound on me. I exercise every day on a treadmill and recumbent bike, so I try it out on

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the treadmill wasn't that hard, although I loved the words "just a few seconds to go." The Johns Hopkins cardiologist told me after the stress test that it looked like he had a slight blockage in an artery. No problem, I thought. Angioplasty was indicated. During the angioplasty, a catheter was inserted into my right arm and even though I was slightly sedated I still felt it, especially when the doctor found a problem and needed to do a little correction. I was sure I would have a stent put in and I would be home for the weekend. "No," my doctor said. "He has three obstructions and will need heart bypass surgery." I thought he must be talking about someone else. This can't be me! The blocks did not require immediate surgery. After all, he was pain free and asymptomatic. Still, I asked for an earlier date for the surgery, and it was scheduled for January 11, 2011. (That was 1/11/11. How strange.) Triple coronary artery bypass surgery opened me up like a stranded tuna and made me an official member of the "zipper club." Atrial fibrillation was corrected with radiofrequency ablation. After surgery, I had to lie on my back, which meant minimal sleep for a week. Lasix (a diuretic) was my biggest problem, along with a dozen pills that I had to take far too often. According to my surgeon, who visited me a day later, things had gone well and I was walking the halls of Hopkins with the help of a nurse and a walker. I got home in a week. Interestingly, the hardest part of the ordeal was trying to make it to the bathroom on time and the difficult journey home. These blows made me hold that pillow [for abdominal support] as close as I could. Over there. After I got home two nurses came in for home care and they were fabulous. I lost about 20 kilos before the operation and another 17 kilos after. I went from 210 pounds to around 173 pounds. Nowadays I don't eat red meat, nothing with salt and as little fat and salt as possible. In other words, I mainly eat fish. I exercise every day (between 30 and 60 minutes) and have regular check-ups with my cardiologist. I was lucky because atrial fibrillation alerted my doctors to a deeper problem that could have resulted in a heart attack or even death. Second, I was lucky to have true professionals who helped me through the darkest days of my life. Many people who have had bypass surgery have told me that I would have more power after surgery because of my new plumbing. This occurred within 6-7 months of my surgery. Stan Ber was born in Maine and graduated from Bowdoin College. He retired from his career as a sports editor and columnist for the Columbia Flier and Howard County Times in December 2014 after 44 years. was sworn in

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inducted into the Howard County Sports Hall of Fame in 2009 and has been recognized by the Maryland State Legislature.

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Exercises Remember to check your answers carefully with the Answers to the exercises, page 422.

A Match the structures listed with the descriptions below. aorta arteriole atrium capillary inferior vena cava mitral valve pulmonary artery superior vena cava tricuspid valve ventricle venule 1. valve between the right atrium and right ventricle _________________________ 2. smallest blood vessel _________________________ 3. carries oxygenated blood from the lungs to the heart _______________________ 4 largest artery in the body _______________________ 5. carries oxygen-poor blood to the heart from the upper parts of the body __________________ 6. upper chamber of the heart _________________________

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7. carries oxygen-poor blood from the heart to the lungs ____________________ 8. small artery _______________________ 9. valve between the left atrium and left ventricle _________________________ 10. carries blood from the lower half of the body to the heart _________________________ 11. small vein _______________________ 12. lower chamber of the heart _______________________ B Traces the path of blood through the heart. It begins when blood enters the right atrium through the vena cava (and includes the valves inside the heart). 1. right atrium______________________ 2. ________________________________ 3. _______________________________ 4. ______________________________ 5. ______________________________ 6. pulmonary capillaries_____________ 7. _________________________ 8. _________________________ 9. ___________________________ 10. ___________________________ 11. __________________________ 12. aorta______________________ C Complete the following sentences. 1. The pacemaker of the heart is the ____________________________________.

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2. The sac-like membrane that surrounds the heart is _____________________________. 3. The wall of the heart between the right and left atria is _____________________. 4. The relaxation phase of the heartbeat is called __________________________________. 5. The specialized conducting tissue in the wall between the ventricles is the _______________. 6. The inner lining of the heart is the _____________________________________________. 7. The contraction phase of the heartbeat is called __________________________________. 8. A gas released as a metabolic product of catabolism is ________________________. 9. The specialized conducting tissue at the base of the wall between the two upper chambers of the heart is the _____________________. 10. The inner lining of the pericardium, which closely surrounds the heart, is the ____________________. 11. An abnormal heart sound due to inadequate closure of the heart valves is a _____________________. 12. The heartbeat that is felt through the walls of the arteries is called _____________________. D Complete the following terms using the definitions given. 1. hardening of the arteries: artery _____________________ 2. heart muscle disease condition: cardio _____________________

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3. enlarged heart: cardio _____________________ 4. inflammation of a vein: phleb _____________________ 5. fast heartbeat condition: _____________________ cardias 6. slow heartbeat condition: _____________________ cardias 7. high blood cholesterol levels: hyper _____________________ 8 .valve surgical repair: valve _____________________ 9. oxygen-deficient condition: hip _____________________ 10. belonging to an upper chamber of the heart: _____________________ at 11. mitral valve narrowing: mitral _____________________ 12. clot rupture: thrombus _____________________ E Give the meanings of the following terms. 1. cyanosis ____________________________________________ ___ 2. phlebotomy ___________________________________________________ ___ 3. arterial anastomosis _____________________________________________ ___

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4. cardiogenic shock __________________________________________________ ___ 5. atheroma ___________________________________________________ ___ 6. arrhythmia ____________________________________________________ 7. sphygmomanometer _____________________________________________ ___ 8. stethoscope ____________________________________________ ___ 9. mitral valve _____________________________________________ ___ 10. atherosclerosis _____________________________________________ __ 11. vasoconstriction _____________________________________________________________ ____ 12.___________________ vasodilation after cardiac diseases pathologies with their meanings below. atrial septal defect coarctation of the aorta

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congestive heart failure coronary artery disease endocarditis fibrillation hypertensive heart disease mitral valve prolapse ductus arteriosus pericarditis tetralogy of Fallot 1. inflammation of the inner lining of the heart _________________________ 2. rapid but regular atrial or ventricular contractions _________________________ 3. small hole between the chambers superior cardiac ; congenital abnormality ________________________ 4. inadequate closure of the valve between the left atrium and ventricle during systole _________________________ 5. obstruction of the arteries around the heart causing ischemia ________________________ 6. high blood pressure affecting the heart ________________________ 7. rapid, random contractions and ineffective irregularities of the heart ________________________ 8. inflammation of the sac that surrounds the heart _________________________

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9. inability of the heart to pump the required amount of blood _________________________ 10. congenital malformation involving four separate heart defects _________________________ 11. congenital narrowing of the large artery leaving the heart _________________________ 12. a passage between the aorta and the pulmonary artery, which normally closes right after birth, stays open _________________________ G Give the meaning of the following terms. 1. heart block ________________________________________ _________________________ 2. cardiac arrest __________________________________________ _______________________ 3. palpitations _____________________________________________ ________________________ 4. artificial cardiac pacemaker ____________________________________________ ____________ 5. thrombotic occlusion _____________________________________________ ________________ 6. angina _____________________________________________ __________________________ 7. myocardial infarction _____________________________________________ _________________

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8. necrosis __________________________________________________ __________________________ 9. infarction __________________________________________ __________________________ 10. ischemia _________________________________________________ __________________________ 11. nitroglycerin _____________________________________________ ________________________ 12. digoxin _____________________________________________ __________________________ 13. murmur _____________________________________________ __________________________ 14. emotion _____________________________________________ __________________________ 15. acute coronary syndromes _____________________________________________ _____________ 16. pericardial rub rub __________________________________________________ 17. Deep vein thrombosis __________________________________________ ______________

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18. Biventricular pacemaker _____________________________________________ ______________ H Match the following terms with their descriptions. aneurysm auscultation claudication emboli essential hypertension murmur peripheral artery disease petechiae Raynaud's disease rheumatic heart disease secondary hypertension vegetations 1. lesions that form on the heart valves after damage from infection ____________________________________ 2. clots that travel to a blood vessel and suddenly block it ____________________________________ 3 small , irregular bleeds __________________________ 4. an extra heart sound heard between normal heartbeats that is caused by a valve defect or a condition that interrupts the regular flow of blood through the heart __________________________ 5. listen with a stethoscope ____________________________________

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6. Heart disease caused by rheumatic fever ____________________________________ 7. Arterial hypertension when the etiology is idiopathic _____________________________ 8. Hypertension related to kidney disease _____________________________________ 9. Episodes of paleness, numbness, and cyanosis in the fingers and toes caused by constriction of arterioles _________________________________ 10. local widening of an artery _________________________________ 11. pain, tightness, and weakness in a limb after beginning to walk ___________________________ 12. obstruction of arteries in lower extremities; etiology is atherosclerosis ______________ I Give short answers to the following. 1. The types of drugs used to treat acute coronary syndromes include ___________________________________________ _________________________________________. 2. When damaged valves in the veins do not prevent the backflow of blood, the resulting condition (swollen and twisted vein) is ____________________________________. 3. Swollen, twisted veins in the rectal area are called _________________________________. 4. Name the four defects in Tetralogy of Fallot from their descriptions:

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a. narrowing of the artery leading to the lungs from the heart ______________________________ b. gap in the wall between the ventricles ____________________________________ c. the large vessel leaving the left ventricle moves over the interventricular septum _______________ d. overdevelopment of right lower heart chamber wall _____________________________________________________ _____________________________________ J Select from the list of cardiac tests and procedures to complete the settings below. angiography (arteriography) cardiac biomarkers cardiac magnetic resonance coronary artery bypass graft defibrillation echocardiography endarterectomy lipid test (profile) lipoprotein electrophoresis thallium stress test 201 1. surgical removal of plaque from the inner lining of an artery ___________________________ 2. application of brief electrical shocks through the chest to stop pulseless and ventricular fibrillation

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ventricular tachycardia __________________________________ 3. measurement of the levels of fay substances (cholesterol and triglycerides) in the bloodstream __________________________________ 4. measurement of the heart's response to physical exertion (patient monitored while running on a treadmill) __________________________________ 5. measurement of troponin -T and troponin - I after myocardial infarction _____________________ 6. Injection of contrast into vessels and X-rays __________________________________ 7. Recording of electricity in the heart __________________________________ 8. Intravenous injection of a radioactive substance and measurement of its accumulation in the heart muscle __________________________________ 9. Use of high-frequency sound wave echoes to produce images of the heart ______________ 10. separation of HDL and LDL from a blood sample __________________________________ 11. anastomosis of vessel grafts to existing coronary arteries Tents to maintain blood Apply to the myocardium io _________________________________ 12. Irradiation of magnetic waves in the heart to produce images of its structure _________________ K Give the meaning of the following terms. 1. Digital subtraction angiography _____________________________________________

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2. Heart transplantation __________________________________________________ __________ 3. TTE-MIBI __________________________________________ __________ 4. Doppler ultrasound _____________________________________________ __________ 5. Holter monitoring ________________________________________________________ __________ 6. Thrombolytic therapy _____________________________________________ __________ 7. Cardiopulmonary bypass _____________________________________________ __________ 8. Cardiac catheterization _____________________________________________ __________ 9. Percutaneous coronary intervention ___________________________________________ 10 . Drug-eluting stent __________________________________________________ __________ 11. Electron beam computed tomography ___________________________________________________ ___ 12. CT angiography _____________________________________________

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__________ L Identify the following cardiac arrhythmias from their abbreviations. 1. AF _________________________________________ ___ 2. VT _____________________________________________ ___ 3. VF __________________________________________________ ___ 4. CVP _____________________________________________ ___ 5. PAC _________________________________________ ___ M Identify the following abnormal heart conditions by their abbreviations. 1. CHF _____________________________________________ _ 2. VSD ___________________________________________ _ 3. MI ___________________________________________ _

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4. PDA _________________________________________ _ 5. MVP ___________________________________________ _ 6. AS ___________________________________________ _ 7. CAD _________________________________________ _ 8. ASD _________________________________________ _ N Combine the listed abbreviations for cardiac tests and procedures with the explanations/descriptions that follow. BNP CRT cTnI or cTnT ECHO ECMO ETT ETT-MIBI ICD LDL LVAD RFA

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TEE 1. serum cardiac enzyme test for myocardial infarction _____________________ 2. booster pump implanted in the abdomen with a cannula leading to the heart as a "bridge to transplant" _____________________ 3. ultrasound of the heart using a transducer inside the esophagus ________________________ 4. device implanted in the chest that detects and corrects arrhythmias by shocking the heart _____________________ 5. Application of a high-frequency current catheter to damage a small portion of the heart muscle and reverse an abnormal heart rhythm _____________________ 6. Procedure for determine the heart's response to physical exertion (stress) ___________________ 7. cardiac imaging using high-frequency sound waves pulsed through the chest wall and rebounded off cardiac structures _____________________ 8. radioactive stress test of cardiac function _____________________ 9. technique using a developmental heart-lung machine to draw blood from the heart and lungs while the heart is being repaired _______ _____________ 10. biventricular pacemaker to correct severe abnormal ventricular rhythms _____________________ 11. lipoprotein sample is measured _____________________ 12. brain chemistry is measured to identify patients at risk of complications after myocardial infarction and with CPI

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_____________________ O Spell the term correctly from its definition. 1. pertaining to the heart: __________________________ ario 2. abnormal heart rhythm: arr __________________________ 3. abnormal blue condition: __________________________ osis 4. relaxation phase of heartbeat: __________________________ tole 5. chest pain: __________________________ pectoris 6. inflammation of a vein: __________________________ itis 7. dilation of a vessel: vas __________________________ 8. dilation of the heart: cardio __________________________ 9. hardening of the arteries with fatty plaques: __________________________ sclerosis 10. swollen veins in the rectal area: __________________________ oids P Combine the terms listed for cardiovascular procedures with the following meanings/descriptions. aneurysmorrhaphy atherectomy BNP test CABG catheter ablation embolectomy

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endarterectomy PCI pericardiocentesis STEMI thrombolytic therapy valvotomy 1. incision of a heart valve __________________________ 2. removal of a clot that has moved into a blood vessel and suddenly caused occlusion __________________________ 3. coronary artery bypass grafting (to relieve ischemia) __________________________ 4. surgical puncture to remove fluid from the pericardial space __________________________ 5. inserting a balloon-tipped catheter and stents into a coronary artery 6. removing the inner lining of an artery to widen it __________________________ 7. suturing (repairing) a portion with a balloon in an artery __________________________ 8 .plaque removal from an artery __________________________ 9. type of acute coronary syndrome __________________________ 10. use of streptokinase and tPA to dissolve clots __________________________ 11. brief application of radiofrequency energy to dislodge to destroy areas of cardiac tissue or for the treatment of arrhythmias __ ________________________

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12. measures an elevated peptide in patients with heart failure __________________________ Q Select the terms in bold that best complete each sentence. 1. Bill was experiencing chest pain that radiated to his neck and arm. He called the family doctor, who thought Bill should report to the local hospital emergency department (ED) immediately. The first test performed in the emergency department was a/an (stress test, ECG, CABG). 2. Dr. Kelly explained to the family that observing the bluish color of baby Charles' skin helped her diagnose a defect (thrombotic, aneurysmal, septal) in the baby's heart that required immediate attention. 3. Mr. Duggan had a fever of unknown origin. When the doctors completed an echocardiogram and saw vegetations on his mitral valve, they suspected (bacterial endocarditis, hypertensive heart disease, angina). 4. Claudia's fingers turned white or bluish whenever she was outside in the cold or stressed. Her doctor considered it prudent to have her evaluated (varicose veins, Raynaud's syndrome, intermittent claudication). 5. Daisy's heart seemed to beat faster every time she drank coffee. Her doctor suggested that she wear one (Holter monitor, LVAD, CABG) for 24 hours to assess the nature of the arrhythmia. 6. Paola's father and grandfather died of heart attacks. Her doctor tells her that she has inherited a

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tendency to accumulate fat in the bloodstream. Blood tests reveal elevated levels of (enzymes, lipids, nitroglycerin). Talking to her about her family history (gynecologist, hematologist, cardiologist), he understands that she has relatives (hypocholesterolemia, hypercholesterolemia, cardiomyopathy). 7. During the exercise, Bernard felt a pain (cramp) in his calf muscle. The pain disappeared when he was resting. After performing (Holter monitoring, Doppler ultrasound, echocardiography) on his leg to assess blood flow, Dr. Shaw found (stenosis, fibrillation, endocarditis) indicating poor circulation. He recommended a daily exercise program, low-fat diet, careful foot care, and antiplatelet therapy to treat Bernard's complication (palpitations, hypertension, claudication). 8. Carol noticed that her son Louis, 6 weeks old, had a slightly bluish skin tone or (jaundice, cyanotic, diastolic). She consulted a pediatrician (dermatologist, hematologist, cardiologist), who performed (echocardiography, PET, endarterectomy) and diagnosed Louis's condition as (endocarditis, congestive heart disease, tetralogy of Fallot). 9. John Smith, age 78, has had coronary artery disease and high blood pressure for the past 10 years. His history included acute heart attack or (MI, PDA, CABG). He often felt tired and complained of (dyspnea, nausea, migraine) and swollen ankles. His doctor has diagnosed his condition as (aorta

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panneurysm, congestive heart failure, congenital heart disease) and a restricted intake of salt, diuretics and a (ACE inhibitor, antibiotic, analgesic) are recommended. 10. Sarah had a routine checkup that included (auscultation, vasoconstriction, vasodilation) of the chest with (catheter, stent, stethoscope) to listen to the heart. Her doctor noted a characteristic mid-systolic murmur of (DVT, MVP, LDL). An echocardiogram confirmed the diagnosis.

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Answers to exercises A 1. tricuspid valve 2. capillary 3. pulmonary vein 4. aorta 5. superior vena cava 6. atrium 7. pulmonary artery 8. arteriole 9. mitral valve 10. inferior vena cava 11. venule 12. ventricle B one . right atrium 2. tricuspid valve 3. right ventricle 4. pulmonary valve 5. pulmonary artery 6. pulmonary capillaries 7. pulmonary veins

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8. left atrium 9. mitral valve 10. left ventricle 11. aortic valve 12. aorta C 1. sinoatrial (SA) node 2. pericardium 3. interatrial septum 4. diastole 5. atrioventricular bundle or bundle of His 6. endocardium 7. systole 8. carbon dioxide (CO2) 9. atrioventricular (AV) node 10. visceral pericardium (outer lining is the parietal pericardium) 11. murmur 12. D-pulse 1. arteriosclerosis 2. cardiomyopathy 3. cardiomegaly

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4. phlebitis 5. tachycardia 6. bradycardia 7. hypercholesterolemia 8. valvuloplasty 9. hypoxia 10. atrial 11. mitral stenosis 12. thrombolysis E 1. bluish discoloration of the skin due to lack of oxygen in the blood 2. incision of a vein 3. new connection between arteries 4. circulatory failure due to heart malfunction 5. mass of yellowish plaque (fake substance) 6. abnormal heart rhythm 7. instrument for measuring blood pressure 8. instrument for listening to sounds inside the chest 9. inflammation of the mitral valve 10. hardening of the arteries with a yellowish-yellow substance (plaque) 11. narrowing of a vessel 12. dilation of a vessel

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F 1. endocarditis 2. flu er 3. atrial septal defect 4. mitral valve prolapse 5. coronary artery disease 6. hypertensive heart disease 7. fibrillation 8. pericarditis 9. congestive heart failure 10. tetralogy of Fallot 11. coarctation of the aorta 12. Patent ductus arteriosus G 1. Inability to adequately conduct impulses through the AV node into the atrioventricular bundle (bundle of His) 2. Sudden and unexpected arrest of heart action 3. Associated uncomfortable chest sensations with arrhythmias 4. Heartbeat operated device worn on the chest and wired to deliver electrical current to the heart to establish normal sinus rhythm 5. Vessel obstruction by a clot

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6. chest pain as a result of insufficient oxygen supply to the heart muscle (ischemia) 7. area of necrosis (tissue death in the heart muscle; heart attack) 8. abnormal death state (dead tissue) 9. tissue damage or death due to oxygen deprivation 10. blood is retained in an area of the body 11. nitrate drug used to treat angina 12. drug that treats arrhythmias and strengthens the heartbeat 13. abnormal sound (murmur) heard on auscultation 14. vibration felt in the chest palpation 15. consequences of plaque rupture in the coronary arteries; AMI and unstable angina 16. Scraping or grinding noise on auscultation of the heart; indicates pericarditis 17. clot formation in a large vein, usually in the lower extremity 18. device that allows the ventricles to beat in unison; cardiac resynchronization therapy H 1. vegetations 2. emboli 3. petechiae 4. murmur

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5. auscultation 6. rheumatic heart disease 7. essential hypertension 8. secondary hypertension 9. Raynaud's disease 10. aneurysm 11. claudication 12. peripheral arterial disease I 1. beta-blockers, ACE inhibitors, statins, aspirin, channel blockers calcium 2. varicose veins 3. hemorrhoids 4. a. pulmonary artery stenosis b. ventricular septal defect c. aortic deviation to the right d. right ventricular hypertrophy J 1. endarterectomy 2. defibrillation 3. lipid tests (profile) 4. stress test 5. cardiac biomarkers

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6. angiography (arteriography) 7. electrocardiography 8. thallium 201 scan 9. echocardiography 10. lipoprotein electrophoresis 11. coronary artery bypass grafting 12. cardiac magnetic resonance imaging 1. Video equipment and a computer produce X-ray images of the blood vessels by taking two photographs (without and with contrast) and subtracting the first image (without contrast) from the second. 2. A donor's heart is transferred to a recipient. 3. Exercise tolerance test combined with a radioactive tracer scan. 4. An instrument that focuses sound waves into a blood vessel to measure blood flow. 5. A compact version of an electrocardiograph is used over a 24-hour period to detect cardiac arrhythmias. 6. Treatment with drugs (streptokinase and tPA) to dissolve clots after a heart attack. 7. A heart-lung machine is used to divert blood away from the heart and lungs during surgery. The machine oxygenates the blood and returns it to the bloodstream.

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8. A catheter (tube) is inserted into an artery or vein and threaded into the chambers of the heart. Contrast can be injected to take X-ray images, blood flow patterns can be detected, and blood pressure can be measured. 9. A balloon-tipped catheter is inserted into a coronary artery to open the artery; stents are placed. 10. Stents are expandable slanted tubes that are placed in the arteries during PCI. They release polymers that prevent plaque formation. 11. Electron beams and CT identify calcium deposits in and around coronary arteries to diagnose CAD. 12. X-ray images of the heart and coronary arteries obtained using CT technology. L 1. atrial fibrillation 2. ventricular tachycardia 3. ventricular fibrillation 4. ventricular premature contraction 5. atrial premature contraction M 1. congestive heart failure 2. ventricular septal defect 3. myocardial infarction 4. patent ductus arteriosus

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5. Mitral valve prolapse 6. Aortic stenosis 7. Coronary artery disease 8. Atrial septal defect N 1. cTnI or cTnT: cardiac troponin-I and troponin-T 2. LVAD: left ventricular assist device 3. TEE: transesophageal echocardiography 4 ICD: implantable cardioverter-defibrillator 5. RFA: radiofrequency catheter ablation 6. ET: exercise tolerance test 7. ECHO: echocardiography 8. TTE-MIBI: exercise tolerance test with sestamibi scan 9. ECMO: oxygenation by extracorporeal membrane 10. CRT: cardiac resynchronization therapy 11. LDL: low density lipoprotein; high levels indicate risk of CAD 12. BNP: brain natriuretic peptide O 1. coronary 2. arrhythmia 3. cyanosis 4. diastole

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5. angina pectoris 6. phlebitis 7. vasodilation 8. cardiomegaly 9. atherosclerosis 10. P hemorrhoids 1. valvotomy 2. embolectomy 3. CABG 4. pericardiocentesis 5. PCI 6. endarterectomy 7. aneurysmography 8. atherectomy 9. STEMI ST elevation of myocardial infarction) 10. Thrombolytic therapy 11. Catheter ablation 12. BNP Q test 1. ECG 2. Septal 3. Bacterial endocarditis

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4. Raynaud's 5. Holter monitor 6. lipids; cardiologist; hypercholesterolemia 7. Doppler ultrasound; stenosis; 8. cyanotic lameness; cardiologist; echocardiography; Tetralogy of Fallot 9. MI; dyspnoea; congestive heart failure; ACE inhibitor 10. auscultation; stethoscope; MVP Answers to Practical Applications Operating Room Schedule

1. E 2. C 3. H 4. I 5. D 6. A 7. B 8. J 9. G 10. F Clinical Cases: What is your Diagnosis?

Case 1 1.b

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Case 2 1. d 2. a 3. b Case 3 1. d 2. a Pronunciation of terms

Vocabulary and Terminology

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TERM angiogram angioplasty anoxia aorta aortic stenosis vertex of heart arrhythmia arterial anastomosis arteriography arteriola arteriosclerosis arterial atherectomy atheroma atherosclerosis atrioatrioventricular bundle atrioventricular nodule; please atrium brachial artery capillary bradycardia His bundle carbon dioxide cardiogenic shock cardiomegaly cardiomyopathy coronary arteries cyanosis deoxygenated blood diastole electrocardiogram endocardium endothelium hypercholesterolemia hypoxia interventricular septum mitral valve mitral valvulitis myxoma normal sinus rhythm oxygen pacemaker pericardiocentesis pericardium phlebotomy pulmonary artery pulmonary circulation pulmonary valve pulse come to

PRONUNCIATION AN-je-o-gram AN-je-o-plas-te ah-NOK-se-ah a-OR-tah a-OR-tik steh-NO-sis A-pex of the heart a-RITH-me - ah ar-TE-re-al ah-nas-to-MO-sis ar-TE-re-OG-rah-fe ar-TE-re-ohl ar-te-re-o-skleh-RO-sis AR - teh-re ath-eh-REK-to-me ath-er-O-mah ath-er-o-skleh-RO-sis A-tre-al a-tre-o-ven-TRIK-u-lar BUN - say a-three-or-ten-TRIK-u-lar not A-three-um; A-tre-ah BRA-ke-al AR-ter-e bra-de-KAR-de-ah BUN-dil of hiss KAP-ih-lah-re KAR-bon di-OX-ide kar-de-o- JEN-ik choque kar-de-o-MEG-ah-le kar-de-o-mi-OP-ah-the KOR-o-nair-e AR-teh-reez si-ah-NO-sis de-OX -ih-jeh-NA-ted sangue di-AS-to-le eh-lik-tro-KAR-de-o-gram en-do-KAR-de-um en-do-THE-le-um hi-per -ko-les-ter-ol-E-me-ah hi-POX-e-ah in-ter-ven-TRIK-u-lar SEP-tum MI-tral valve MI-tral val-vu-LI-tis mi -o-KAR-de-um mik-SO-mah NOR-mal SI-nus RIH-thim OX-ih-jen PACE-ma-ker peh-rih-kar-de-o-sen- TE-sis peh-rih -KAR-de-um fleeh-BOT-o-me PUL-mo-nair-e AR-teh-re PUL-mo-nair-e ser-ku-LA-shun PUL-mo-nair-e valve PUL-mo -nair-e videira pulse

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TERM septum; please sinoatrial node septum sphygmomanometer stethoscope systemic circulation systole tachycardia thrombolysis thrombophlebitis tricuspid valve valvotomy valve valvuloplasty vascular vasoconstriction vasodilation vena cava; please vena cava venipuncture ventricle venule venule

PRONUNCIATION SEP-objective; SEP-ta si-no-A-tres-al nodo sfig-mo-mah-NOM-eh-ter STETH-o-scope sis-TEM-ik see-ku-LA-shun SIS-to-le tah-ke- KAR-de-ah throm-BOL-ih-sis throm-bo-fieh-BI-tis tri-KUS-pid valve valve val-VOT-o-me val-vu-lo-PLAS-te VAS-ku-lar vaz -o-kon-STRIKE-shun vaz-o-di-LA-shun vine VE-nah KA-vah; VE-ne KA-ve ve-nih-PUNK-chur VE-nus VE-trih-kel VE-ule

Pathology, Laboratory Tests and Clinical Procedures

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TERM ACE inhibitor acute coronary syndromes aneurysm angina angiography atrial fibrillation atrioventricular block auscultation beta blocker biventricular pacemaker BNP testing calcium channel blocking murmur cardiac arrest cardiac biomarkers cardiac catheterization cardiac MRI cardiac tamponade cardioversion catheter ablation claudication coarctation of the aorta tomography computed angiography heart disease congenital congestive heart failure coronary artery bypass grafting coronary artery disease deep vein thrombosis defibrillation digital subtraction angiography digoxin Doppler ultrasound arrhythmia echocardiography electrocardiography electron beam computed tomography embolism; please emboli endarterectomy endocarditis cardiopulmonary bypass fibrillation fluorescence heart block heart transplant hemorrhoids Holter monitoring hypertension hypertensive heart disease cardioverter implantable defibrillator infarction ischemia

PRONUNCIATION ACE in-HIB-ih-tor a-KYOOT KOR-o-nair-e SIN-drohms AN-yoo-rih-zim an-JI-nah an-je-OG-rah-fe A-tre-al fib- . rih-LA-shun a-tre-o-ven-TRIK-u-lar block aw-school-TA-shun BA-tah BLOCK-er bi-ven-TRIK-u-lar PACE-maker GDP Test BRU- e ENG -se-um CHA-nel BLOCK-er KAR-de-ak KAR-de-ak BI-o-mar-kerz KAR-de-ak kath-eh-ter-ih-ZA-shun KAR-de-ak KAR - de-ak tam-po-NADE kar-de-o-VER-zhun KATH-eh-ter ab-LA-shun klaw-deh-KA-shun ko-ark-TA-shun do a-OR-tah come- PU -ted to-MOG-rah-fe an-je-OG-rah-fe con-JEN-ih-tal heart dih-ZEEZ con-JES-tiv heart FAIL-your KOR-o-nair-e AR- son BI -pass GRAF-something KOR-o-nair-e AR-son dih-ZEEZ wine deep throm-BO-sis of-fib-rih-LA-shun DIJ-ih-tal sub-TRAK-shun an-je- OG - . rah-fe dih-JOK-sin DOP-ler UL-trah-sound dis-RITH-me-ah ek-o-kar-de-OG-rah-fe eh-lek-tro-kar- de-OG- rah - fe eh-LEK-throne haz come-PU-ted a-MOG-rah-fe EM-bo-lus; EM-bo-li en-dar-ter-EK-to-me en-do-kar-DI-tis ex-trah-chor-POR-e-all see-cow-LA-shun fib-rih-LA-shun FLUH-ter heart block heart tranz-plan-TA-shun HEM-uh-roydz HOL-ter MON-ih-teh-ring hi-per-TEN-shun hi-per-TEN-siv heart dih-ZEEZ im-PLANT- ah-bul kar-de-o-VER-ter de-FIB-rihla-tor in-FARK-shun is-KE-me-ah

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TERM left ventricular assist device lipid test lipoprotein electrophoresis mitral stenosis mitral valve prolapse murmur myocardial infarction nitrates nitroglycerin occlusion palpitations patent ductus arteriosus percutaneous coronary intervention pericardial rub pericarditis peripheral arterial disease petechiae positron emission tomography of the heart Raynaud's disease rheumatic cardiac septal defects statins 99m Tc stress test sestamibi telemetry scan tetralogy of Fallot thallium 201 emotion scan transcatheter thrombolytic therapy thrombotic occlusion aortic valve replacement varicose veins vegetations

PRONUNCIATION ven-TRIH-ku-lar esquerdo ah-SIST de-show LIH-pid testes li-po-PRO-teen eh-lek-tro-for-E-sis MI-tral steh-NO-sis MI-tral valve PRO -laps MUR-mer mi-o-KAR-de-al in-FARK-shun ni-TRAYTS ni-tro-GLIS-er-in o-KLU-zhun pal-pih-TA-shunz PA-tent PA-tent DUK -tus ar-te-re-O-sus per-ku-TA-ne-us KOR-in-air-e in-ter-VEN-shun peh-rih-KAR-de-al FRIK-shun rub peh-rih -kar-DI-tis peh-RIH-fer-al ar-TE-re-al dih-ZEEZ peh-TE-ke-i pos-ih-tron e-MIH-shun to-MOG-rah-faith of the heart ra -NO dih-ZEEZ ru-MAT-ik hard dih-ZEEZ SEP-number DE-facts STAT-inz STRESS test take-NE-she-um Tc99m ses-tah-MIH-be scan tel-EM-et-re teh - TRAH-lo-je of fah-LO THAL-e-um 201 scan thril throm-bo-LIT-ik THERE-ah-pe throm-BOT-ik o-KLU-zhun tranz-KATH-eh-ter a-OR - . .tick valve re-PLAYS-ment VAR-ih-cost vines road-eh-TA-shunz

revision sheet

Write the meanings of each part of the word in the space provided. Check your answers with the information in the chapter or in the Glossary (Parts of Medical Words—English) at the end of the book.

match shapes

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COMBINED FORM aneurysm/o angio/o aort/o arter/o, arteri/o ather/o atri/o axill/o brachi/o cardio/o cholesterol/o coron/o cyan/o isch/o my/o myx/ the ox/the pericardi/the phlebo/the lung/the rhythm/the sphygmo/the steth/the thrombus/the valv/the valve/the vas/the vascul/the ven/the, ven/i ventricul/o

Suffixes SUFFIX -constriction -dilation -emia -graphy -lysis -megaly -metro -oma -ose -plasty -sclerosis -stenosis -tomy

prefixes

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PREFIXO a-, anbradydedysendohyperhypointerperitachytetratri-

Use the cardiovascular anatomy terms listed to complete the accompanying chart.

aorta inferior vena cava left atrium left ventricle pulmonary capillaries mitral valve pulmonary artery pulmonary vein right atrium right ventricle superior vena cava tricuspid valve

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CHAPTER 12

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Respiratory System CHAPTER SECTIONS: Introduction 432 Anatomy and Physiology of Respiration 432 Vocabulary 436 Terminology 437 Pathology 443 Clinical Procedures 450 Abbreviations 455 Practical Applications 457 Face-to-Face: Recurrent Pneumonia 458 Exercises 459 Answers to Exercises 466 Pronunciation of Terms 468 Review Sheet 471

CHAPTER OBJECTIVES • Name the organs of the respiratory system and their location and function. • Identify pathological conditions that affect the respiratory system. • Learn medical terms related to breathing. • Describe important clinical procedures related to the respiratory system and recognize relevant abbreviations. • Apply your new knowledge to understand medical terms in their proper contexts, such as medical reports and records.

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Introduction We tend to think of respiration as the mechanical process of breathing, the exchange of air between the lungs and the external environment. This exchange of air in the lungs is called external respiration. During inhalation, oxygen passes from the environment (inhaled air contains about 21%) to the alveoli of the lungs and the blood capillaries of the lungs. Simultaneously, during exhalation, carbon dioxide, a waste gas produced when oxygen and food combine in cells, passes from the capillary blood vessels to the alveoli in the lungs to be exhaled. While external respiration takes place between the external environment and the capillary blood in the lungs, another form of respiration takes place between the individual cells of the body and the tiny capillary blood vessels that surround them. This is internal (cellular) respiration, which involves gas exchange at the cell level within all organs of the body. Here, oxygen passes from the capillaries of the tissues to the cells of the body. At the same time, carbon dioxide passes from the cells of the body into the capillaries of the tissues to travel to the lungs and be exhaled. See Figure 12-1.

FIGURE 12-1

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Anatomy and Physiology of Respiration Review Figure 12-2 as you read the following paragraphs that describe the respiratory organs and their functions.

FIGURE 12-2 Organs of the respiratory system.

Air enters the body through the nose[1] through two openings called the nostrils or nostrils. The air then passes through the nasal cavity [2], which is lined with a mucous membrane and fine hairs (cilia) to help filter out foreign bodies, as well as warm and humidify the air. The paranasal sinuses [3] are hollow, air-containing spaces within the skull that communicate with the nasal cavity. They also have a mucous membrane lining. In addition to producing mucus, a lubricating fluid, the sinuses light up the bones of the skull and help make sound. After passing through the nasal cavity, the air reaches the pharynx (throat). There are three divisions of the pharynx. The first is the nasopharynx [4]. It contains the pharyngeal tonsils or adenoids [5], which are collections of lymphatic tissue. They are more prominent in children and, if enlarged, can obstruct the airway. Below the nasopharynx and closer to the mouth is the second division of the pharynx, the oropharynx [6]. The palatine tonsils [7], two rounded masses of lymphatic tissue, are found in the oropharynx. The third division of the pharynx, the laryngopharynx [8],

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it serves as a common passage for food from the mouth and air from the nose. It is divided into the larynx (voice box) [9] and the esophagus [10]. The esophagus leads to the stomach and carries food to be digested. The larynx contains the vocal cords and is surrounded by pieces of cartilage to support itself and keep the airways open. The thyroid cartilage is the largest and is commonly called the Adam's apple in men. As the expelled air passes through the vocal cords, they vibrate to produce sound. The tension of the vocal cords determines the high or low pitch of the voice. Since food entering the mouth and air entering the nose mix in the pharynx, what prevents food or drink from entering the larynx and respiratory system during swallowing? Even if a small amount of solid or liquid matter enters the airways, swallowed food can irritate the lungs and stop breathing. The epiglottis is [11], a flap of cartilage located at the root of the tongue, which prevents choking or aspiration of food. It acts as a cover over the laryngeal opening. During swallowing, when food and liquids pass down the throat, the epiglottis closes over the larynx, preventing material from entering the lungs. Figure 12-3 shows the larynx from above.

FIGURE 12-3 The larynx, viewed from above (superior view).

On its way to the lungs, air passes through the larynx into the trachea (windpipe) [12], a vertical tube about 2.5 cm long and 2.5 cm in diameter. The trachea is held open by 16 to 20 C-shaped rings of cartilage separated by fibrous connective tissue that stiffens the front and sides of the tube. The mediastinum [13] is a space in the center of the chest. In the mediastinal region, the trachea divides into two branches, the right and left bronchi, or bronchi [14] (singular: bronchus). The bronchi are tubes composed of a delicate epithelium surrounded by cartilaginous rings and a muscular wall. Each bronchus leads to a separate lung [15], where it divides and subdivides into smaller, thinner tubes, a bit like the branches of a tree. The small bronchial branches are the bronchioles. Each terminal bronchiole [16] narrows into alveolar ducts, which terminate in collections of air sacs called alveoli [17] (singular: alveolus). It is estimated that around 300 million alveoli are present in both lungs. The total area of the alveoli is about the size of a tennis court. Each alveolus is lined by a layer of epithelium one cell thick. This very thin wall allows gas exchange between the alveolus and the capillary [18] that surrounds it. The blood flowing through the capillary accepts oxygen from the alveoli while depositing carbon dioxide in the alveoli. Red blood cells [19] in the blood carry oxygen from the lungs to all parts of the body and carbon dioxide back to the lungs for exhalation.

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Each lung is covered by a double-layered membrane called the pleura. The outer layer of this membrane, closest to the ribs, is the parietal pleura [20], and the inner layer, closest to the lung, is the visceral pleura [21]. A serous discharge (thin, watery fluid) moistens the pleura and facilitates movement of the lungs within the chest (thorax). The two lungs are not mirror images of each other. The slightly larger right lung is divided into three lobes, while the smaller left lung has two lobes. A lobe of the lung can be removed without significantly compromising lung function. The upper part of the lung is the apex and the lower part is the base. The hilum of the lung is the midline region where blood vessels, nerves, lymphatic tissue, and bronchi enter and exit. The lungs extend from the clavicle to the diaphragm [22] in the thoracic cavity. The diaphragm is a muscular partition that separates the thoracic cavity from the abdominal cavity and helps in the breathing process. It contracts and falls with each inhalation (inspiration) and relaxes and rises with each exhalation (exhalation). The downward movement of the diaphragm increases the area of the chest cavity, lowering the internal air pressure so that air flows into the lungs to equalize the pressure. When the lungs are full, the diaphragm relaxes and rises, decreasing the area of the chest cavity, thus increasing the air pressure in the chest. Air is then forced out of the lungs to equalize the pressure; this is exhalation (exhalation). Figure 12-4 shows the position of the diaphragm during inspiration and expiration.

FIGURE 12-4 Position of the diaphragm during inspiration (inspiration) and expiration (expiration).

Figure 12-5 is a flow diagram of the air path from the nose, where air enters the body, to the capillaries in the lungs, where oxygen enters the bloodstream.

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FIGURE 12-5 Air path from the nose to the capillaries of the lungs.

Vocabulary

This list reviews the terminology introduced in the previous section. Brief definitions and additional information will reinforce your understanding. See Pronouncing Terms on page 468 for help with difficult or unfamiliar words.

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adenoids alveolus (plural: alveoli) apex of lung base of lung bronchioles bronchi (plural: bronchi) carbon dioxide (CO2) cilia

Lymphatic tissue in the nasopharynx; pharyngeal tonsils. Air bag in the lung. Tip or upper portion of the lung. A vertex is the point of a structure. Apical means belonging to or situated at the apex. Lower portion of the lung; from the Greek base, foundation. Basilar means located at or at the base. Lesser branches of the bronchi. The terminal bronchioles lead to the alveolar ducts. Branch of the windpipe (windpipe) which is a passage for the lung; bronchial tube. Gas produced by cells in the body when oxygen and carbon atoms in food combine; exhaled through the lungs.

A few fine hairs ached on the epithelium of the mucous membrane lining the respiratory tract. They remove bacteria and foreign substances from the lung. Cigarette and smoke impair the function of the eyelashes. Diaphragm Muscle that separates the thorax and abdomen. It contracts to draw air into the lungs and relaxes to expel air. The epiglottis is an eyelid-like piece of cartilage that covers the larynx and prevents food from entering the larynx and trachea during swallowing. exhalation Expiration; Due date. glo is a slit-like opening to the larynx. midline hilum where bronchi, blood vessels, and nerves enter and leave the lungs. Lung hilar means belonging to (in) the hilum. inhalation Inhalation; inspiration. larynx voice box; containing the vocal cords. Division of the lobe of a lung. Mediastinum Region between the lungs in the thoracic cavity. Contains the trachea, heart, lymph nodes, major blood vessels, esophagus, and bronchi. nostrils Openings through the nose that carry air into the nasal cavities; nostrils oxygen (O2) Gas that makes up 21% of the air we breathe. It passes into the bloodstream in the lungs and travels to every cell in the body. palatine One of a pair of almond-shaped masses of lymphatic tissue in the oropharynx (palatine means tonsil belonging to the roof of the mouth). paranasal One of the air spaces in the bones near the nose. parietal sinus Outer layer of pleura located closest to the ribs and chest wall. pleura pharynx Throat; including nasopharynx, oropharynx, and laryngopharynx. pleura Double-layered membrane that surrounds each lung. pleural Space between the layers of the pleura. lung cavity Essential parts of the lung, responsible for respiration; bronchioles and alveoli. parenchymal respiration Exchange of gases (oxygen and carbon dioxide) in the pulmonary capillaries (external respiration or respiration) and in the tissue capillaries (internal respiration). windpipe windpipe visceral Inner layer of the pleura located closest to the lung tissue. pleura

Terminology

Write the meanings of the medical terms in the spaces provided.

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MATCHING FORM OF MEANING adenoid/the adenoids alveolus/the bronchus/the bronchi/the

bronchus/the capn/the coni/the cyan/the epiglomus/the larynx/the

lob/o mediastino/o nas/o orth/o

ox/the chest/the pharynx/the fono/the wood/the pleuro/the

alveolus, air bag, bronchial tube, bronchus

bronchiole, small bronchus carbon dioxide dust

TERMINOLOGY

SENSE

adenoidectomy _________________________________ adenoid hypertrophy _________________________________ alveolar _________________________________ bronchospasm _________________________________ This narrowing of the bronchi and smaller bronchial tubes (bronchioles) is one of the main features of bronchitis. bronchiectasis __________________________________ Caused by weakening of the bronchial wall due to infection. bronchodilator __________________________________ This medication causes the opening of a bronchus or bronchiole to dilate or widen to improve ventilation of the lungs. An example is albuterol, administered through an inhaler. bronchopleural __________________________________ A bronchopleural fistula is an abnormal connection between the bronchial tube and the pleural cavity (space). Occurring as a result of lung disease or a surgical complication, this can cause an air leak into the pleural space. bronchiolitis __________________________________ This is an acute viral infection that occurs in children less than 18 months of age. hypercapnia __________________________________

pneumoconiosis __________________________________ See page 447. blue cyanosis __________________________________ Caused by a deficiency of oxygen in the blood. The epiglottis is the epiglottis __________________________________ It is characterized by fever, sore throat, and a swollen, erythematous epiglottis. larynx, laryngeal voice __________________________________ laryngospasm picture __________________________________ Spasm of the laryngeal muscles that closes the larynx. lobectomy laryngitis __________________________________ lung Figure 12-6 shows four different types of lung resections. mediastinum mediastinoscopy __________________________________ An endoscope is inserted through an incision in the chest. sinuses __________________________________ Para- means to close in this term. See Figure 12-7. nasogastric intubation __________________________________ straight, orthopnea __________________________________ in upright position An abnormal condition in which breathing (-pnea) is easier in an upright position. One of the main causes of orthopnea is congestive heart failure. Clinicians assess the degree of orthopnea by the number of pillows a patient needs to sleep comfortably (eg, two-pillow orthopnea). oxygen hypoxia __________________________________ Tissues have a reduced amount of oxygen and cyanosis may occur. chest sputum _____________________________________ Elimination of secretions from the respiratory tract when coughing or sneezing. This sputum may contain mucus, blood, cell debris, pus, and microorganisms. pharynx, pharynx __________________________________ voice hoarseness in the throat _________________________________ Hoarseness or other impairment of the voice. diaphragm phrenic nerve __________________________________ The motor nerve of the diaphragm. pleura pleurodynia __________________________________ The suffix -dynia means pain. The intercostal muscles or the pleura become inflamed, causing pain during breathing. Pleural effusion __________________________________ An effusion is the leakage of fluid from blood or lymphatic vessels into a cavity or tissue spaces.

793

COMBINED FORM OF MEANING pneumon/o, air, lung pneumon/o

lung

kidney/the sinus/the spiro/the

telephone

thorax/tonsil/trachea/

TERMINOLOGY

SENSE

pneumothorax __________________________________ The suffix -thorax means chest. Due to a hole in the lung, air accumulates in the pleural cavity, between the layers of the pleura (Fig. 12.8).

Pneumonectomy Pulmonary __________________________________ __________________________________ The pulmonary circulation carries oxygen-poor (deoxygenated) blood from the heart to the lungs and then returns the oxygenated blood to the heart for transport throughout the body. nasal rhinoplasty _________________________________ rhinorrhea __________________________________ Commonly known as “runny nose”. sinusitis, sinusitis __________________________________ respiratory spirometer _________________________________ expiration __________________________________ Note that the s is omitted (when preceded by an x). breathing __________________________________ Cheyne-Stokes respirations are marked by rhythmic changes in the depth of breathing (rapid breathing then no breathing). The default value occurs every 45 seconds to 3 minutes. The cause could be heart failure or brain injury, both of which affect the respiratory center of the brain. complete atelectasis __________________________________ Collapsed lung; incomplete expansion (-ectasia) of a lung (Fig. 12-9). Atelectasis can occur after surgery when the patient is in pain and does not breathe deeply, preventing full expansion of the lungs. thoracotomy thoracotomy __________________________________ thoracic __________________________________ tonsillectomy __________________________________ The oropharyngeal (palatine) tonsils are removed. trachea, tracheostomy __________________________________ tracheal stenosis tracheal __________________________________ Injuries to the trachea from trauma, burns, or severe infection can cause scarring and contractions that obstruct airflow. For example, having an endotracheal tube in place for a long period of time can lead to tracheal injury or scar tissue formation. lung

794

FIGURE 12-6 Lung resections. A, A wedge resection is the removal of a small, localized area of diseased tissue near the surface of the lung. Lung function and structure remain relatively unchanged after healing. B, Segmental resection is the removal of a bronchiole and its alveoli (one or more lung segments). The remaining lung tissue expands to fill the previously occupied space. C, Lobectomy is the removal of an entire lobe of the lung. After lobectomy, the remaining lung is enlarged to fill the space in the chest cavity. D, Pneumonectomy is the removal of an entire lung. Techniques such as rib removal and diaphragm elevation are used to reduce the size of the empty chest space.

795

FIGURE 12-7 Paranasal sinuses. These are 4 pairs, filled with air, spaced on the bones of the skull around the nasal cavity. Sinusitis is inflammation of the sinuses due to viral, bacterial or fungal infections or allergic reactions.

FIGURE 12-8 Pneumothorax. Air accumulates in the pleural cavity, causing the lung to collapse. When this happens, the lung cannot fill with air, breathing becomes more difficult, and the body receives less oxygen. The onset of pneumothorax is characterized by sudden sharp chest pain with shortness of breath.

796

FIGURE 12-9 Two forms of atelectasis. A, Bronchial obstruction prevents air from reaching the distal airways, and the alveoli collapse. The most frequent cause is the obstruction of a bronchus by a mucous or mucopurulent plug (containing pus), as can occur in the postoperative period. B, Collections of fluid, blood, or air within the pleural cavity collapse the lung. This can occur with congestive heart failure (poor circulation leads to fluid buildup in the pleural cavity), pneumonia, trauma, or pneumothorax.

Suffixes SUFFIX MEANING TERMINOLOGY MEANING -ema condition empyema ______________________________________ Em- at the beginning of this term means inside. Empyema (pyothorax) is an accumulation of pus in the pleural cavity. -olfactory osmia anosmia ______________________________________ -pnea respiratory apnea __________________________________________ Sleep apnea is the sudden cessation of breathing during sleep. Hypoxia can occur, leading to cognitive impairment, hypertension, and arrhythmias. Obstructive sleep apnea (OSA) involves narrowing or occlusion of the upper airways. Continuous positive airway pressure (CPAP) is a gentle ventilatory support used to keep the airway open (Figure 1210). dyspnea ___________________________________ Dis- means abnormal here and is associated with shortness of breath (SOB). Patients with congestive heart failure may experience paroxysmal (sudden) nocturnal (night) dyspnea when lying in bed. Patients often describe the sensation as "hunger for air." hyperpnea __________________________________ An increase in the depth of respiration, which occurs normally with exercise and abnormally with any condition in which the oxygen supply is inadequate. tachypnea __________________________________________ Tachy- means fast. Excessively rapid and shallow breathing; hyperventilation. -ptis spiing hemoptysis ______________________________________ Blood is ejected from the bronchi and lungs; it occurs with bronchitis or pneumonia, but also with tuberculosis, cancer, bronchiectasis and pulmonary embolism. pulse asphyxia __________________________________________ sphyxia Literally meaning absence of a pulse, this condition is severe hypoxia leading to hypoxemia, hypercapnia, unconsciousness, and death. -chest hemothorax pleural ______________________________________ cavity, pyothorax ________________________________________________ thorax Empyema of the thorax.

797

FIGURE 12-10 This man is sleeping with a nasal CPAP (continuous positive airway pressure) mask on. The pressure supplied by air from the compressor opens the oropharynx and nasopharynx.

798

Pathology Diagnostic Terms Auscultation

percussion

year pleural

rales (crackles) snoring (singular: snoring) sputum

stridor

wheezing

Listen to sounds inside the body. This procedure, performed with a stethoscope, is used primarily to listen for air moving in and out of the lungs and to listen to heart sounds. It is useful in diagnosing conditions of the lungs, pleura, heart, and abdomen, as well as in determining the status of the fetus during pregnancy. Touch a surface to determine the difference in density from the underlying structure. Playing on a solid organ produces a muffled sound with no resonance. Playing the drum on an air-filled structure, such as the lung, produces a resonant, hollow note. When the lungs or pleural space fill with fluid and become denser, as in pneumonia, the resonance is replaced by numbing. A harsh sound produced by the pleural surfaces rubbing against each other. Pleural rubbing (also called rubbing) occurs when the pleurae are stiff and thickened by inflammation, infection, scarring, or neoplastic cells. It is heard on auscultation and can be palpated by placing fingers on the chest wall. Fine crackling sounds heard on auscultation (during inhalation) when there is fluid in the alveoli. These clicks or clicks can be heard in patients with pneumonia, bronchiectasis, or acute bronchitis. The French word rale means rale. Loud noises are heard on auscultation of bronchi obstructed by sputum. These harsh rumbling sounds resemble snoring and are usually caused by secretions in the larger bronchi. Material expelled from the bronchi, lungs, or upper respiratory tract when sneezing. Purulent sputum (containing pus) is usually green or brown. It is the result of an infection and can be seen in asthma. Blood-tinged sputum suggests tuberculosis or malignancy. For a sputum culture, the sample is kept in a nutrient medium to promote the growth of a pathogen. The culture and susceptibility (C&S) test identifies the pathogen in the sputum and determines which antibiotic will be effective in destroying or reducing its growth. High-pitched, tense sound heard on inspiration caused by an obstruction in the pharynx or larynx. Common causes of stridor include throat abscess, airway injury, croup, allergic reaction or epiglottitis, and laryngitis. Continuous and high-pitched whistling produced during breathing. Wheezing is heard when air is forced through a narrowed or obstructed airway. Patients with asthma or emphysema often experience wheezing when the bronchi become narrow and constricted.

Upper respiratory tract disorders

799

diphtheritic croup

epistaxis

whooping cough

Acute viral infection of infants and children with laryngeal obstruction, accompanied by intense cough and stridor. The most common causative agents are influenza viruses or respiratory syncytial virus (RSV). Acute infection of the throat and upper respiratory tract caused by the diphtheria bacterium (Corynebacterium). Inflammation occurs and an opaque leathery membrane (from the Greek diphthera, leathery membrane) forms in the pharynx and trachea. Immunity to diphtheria (through antibody production) is induced by administration of weakened toxins (antigens) from the sixth to eighth week of life. These injections are usually given as a combination vaccine with pertussis and tetanus toxins and are therefore called DPT injections. nosebleeds Epistaxis is a Greek word meaning drooping. It is usually the result of irritation of the nasal mucous membranes, trauma, vitamin K deficiency, obstruction abnormalities, anticoagulant medications (such as aspirin and warfarin), or hypertension. whooping cough; highly contagious bacterial infection of the pharynx, larynx, and trachea caused by Bordetella pertussis. Whooping cough is characterized by paroxysmal (sudden, violent) coughing spasms ending in loud “whooping” breathing.

bronchial disorders asthma

Chronic inflammatory disorder with airway obstruction due to bronchial and bronchiolar edema and constriction. Signs and symptoms associated with asthma are breathlessness, wheezing, increased mucus production, and coughing. The etiology may involve allergy or infection. Triggers for asthma attacks include exercise, strong odors, cold air, stress, allergens (for example, tobacco smoke, pet dander, dust, mold, pollen, food ) and medications (aspirin, beta blockers). Asthma treatments are: • Fast-acting agents for acute symptoms; example is an albuterol inhaler (bronchodilator). • Long-acting agents for long-term control; some examples are glucocorticoids (inhaled), oral steroids (anti-inflammatory drugs), and leukotriene blockers such as montelukast (Singulair). Other conditions, such as gastroesophageal reflux disease (GERD), sinusitis, and allergic rhinitis, can exacerbate asthma. bronchiectasis Chronic dilation of a bronchus, usually secondary to infection. This condition is caused by a chronic infection with loss of elasticity in the bronchi. The secretions form a pool and do not drain normally. Signs and symptoms are cough, fever, and expectoration of fetid, purulent sputum (containing pus). Treatment is palliative (not curative) and includes antibiotics, mucolytics, bronchodilators, respiratory therapy, and surgical resection if other therapies are not effective. Chronic inflammation of the bronchi that persists for a long time; type of lung disease chronic obstructive bronchitis (COPD). Infection and smoking are etiological factors. Signs and symptoms include excessive discharge of often infected mucus, productive cough, and airway obstruction. Chronic bronchitis and emphysema (a lung disease in which air exchange in the alveoli is severely affected) are types of chronic obstructive pulmonary disease (COPD). cystic fibrosis An inherited disorder of the exocrine glands that produces thick mucinous secretions in the airways (UC) that do not drain normally. This is a genetic disease caused by a mutation in a gene. It can be diagnosed by newborn screening blood test, sweat test, and genetic test. CF affects the epithelium (cellular lining) of the airways, causing chronic airway obstruction, infection, bronchiectasis, and sometimes respiratory failure. It also involves exocrine glands such as the pancreas (insufficient secretion of digestive enzymes leads to poor growth) and sweat glands (salty-tasting skin). There is no known cure, but therapy includes antibiotics, aerosol medications, chest physiotherapy, and pancreatic enzyme replacement. A new medication called ivacaftor (Kalydeco) helps prevent the buildup of thick mucus in the lungs. Lung transplantation becomes necessary for some patients. It can restore lung function and prolong life.

lung disorders

800

atelectasis

collapsed lung; incomplete expansion of the alveoli (Figure 12-9, page 441). In atelectasis, the bronchioles and alveoli (lung parenchyma) resemble a collapsed balloon. emphysema Hyperinflation of the alveoli with destruction of the alveolar walls (Fig. 12-11A and B). Loss of elasticity and rupture of the alveolar walls result in expiratory flow limitation. There is a strong association between smoking and emphysema. As a result of the destruction of the lung parenchyma, including the blood vessels, the pressure in the pulmonary artery increases, and the right side of the heart has to work harder to pump blood. This leads to right ventricular hypertrophy and right heart failure (cor pulmonale). Emphysema and chronic bronchitis are forms of COPD. lung cancer A malignant tumor originating in the lungs and bronchi (Fig. 12.12). This group of cancers, often associated with smoking and smoking, is the most common fatal neoplasm. Lung cancers fall into two general categories: non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC). NSCLC accounts for 90% of lung cancers and comprises three main types: adenocarcinoma (derived from mucus-secreting cells), squamous cell carcinoma (derived from cells lining the upper respiratory tract), and large cell lung cancer. When lung cancer is diagnosed, doctors evaluate the stage of the tumor (determined by its size, lymph node involvement, and any distant areas of spread) to design a treatment protocol. For localized tumors, surgery can be curative. Staging of NSCLC by evaluation of the mediastinal lymph nodes is essential. If the nodes are negative and there are no other medical problems, the patient is a good candidate for surgery. If the lymph nodes are positive, multimodality treatment (chemotherapy and irradiation), with or without surgery, may be an option. Doctors treat metastatic disease (in the liver, brain, and bone) with palliative chemotherapy or radiation therapy. In some patients, usually non-smokers, NSCLC can be caused by a mutation (change) in the epithelial lung tissue. An example is a mutation in the epidermal growth factor receptor (EGFR), which is sensitive to treatment with EGFR inhibitors (Iressa and Tarceva). This is an example of targeted drug therapy for cancer. Examples of tumors treatable by interference with mutated gene products are increasing. SCLC is derived from small round cells ("oat cells") found in the lung epithelium. It grows rapidly and spreads rapidly outside the lung. Treatment with surgery, radiotherapy and/or chemotherapy can lead to remissions. pneumoconiosis An abnormal lung condition caused by exposure to certain dusts; with chronic inflammation, infection, and bronchitis (Fig. 12.13A). Various forms are named according to the type of dust particle inhaled: anthracosis: coal dust (antrac) (black lung disease); asbestosis: particles of asbestos (asbestos) (in naval and civil construction); silicosis: silica (silica/o = stones) or glass (Grinder's disease). pneumonia Acute inflammation and infection of the alveoli, which fill with pus or products of the inflammatory reaction. The etiologic agents are pneumococci, staphylococci, and other bacteria, fungi, or viruses. The infection damages the alveolar membranes so that an exudate (fluid, blood cells, and debris) consolidates the alveoli (the sacs “stick together,” making air exchange less effective). An infiltrate is a fluid-filled area within the lungs, as seen on a chest X-ray or CT scan. Lobar pneumonia (see Figure 12-13B) affects an entire lobe of the lung. Bronchopneumonia is a limited form of infection that produces patchy consolidation (abscesses) in the lung parenchyma. Treatment includes appropriate antibiotics and, if necessary, oxygen and mechanical ventilation in severe cases. See In Person: Recurrent Pneumonia, page 458. Community-acquired pneumonia is the result of a contagious respiratory infection caused by a variety of viruses and bacteria (including pneumococci and Mycoplasma bacteria). It is usually treated at home with oral antibiotics. Hospital-acquired pneumonia or nosocomial pneumonia is acquired during hospitalization (from the Greek nosokomeion meaning hospital). For example, patients can contract pneumonia during mechanical ventilation or as a hospital-acquired infection. Aspiration pneumonia is caused by material, such as food or vomit, lodged in the bronchi or lungs. It is a danger to the elderly, Alzheimer's disease patients, stroke victims, and people with esophageal reflux and feeding tubes. X-ray images of a normal chest and a chest with pneumonia are on page 450. pulmonary Large collection of pus (bacterial infection) in the lungs. Lung abscess Fluid in the alveoli and bronchioles. edema. This condition is usually caused by the heart's inability to pump blood (congestive heart failure). Blood collects in the pulmonary blood vessels and fluid

801

pulmonary embolism (PE)

sarcoidosis fibrosis pulmonar

tuberculosis (TB)

penetrates the alveoli and bronchioles. Acute pulmonary edema requires immediate medical attention, including medications (diuretics), high-concentration oxygen, and keeping the patient in a lying position (to decrease venous return to the heart). Clots or other materials become lodged in the vessels of the lung (Fig. 12.14A and B). The clot (embolus) travels from distant veins, usually in the legs. The occlusion may produce an area of dead (necrotic) tissue; this is a pulmonary infarction. PE usually causes acute pleuritic chest pain (pain on inspiration) and may be associated with blood in the sputum, fever, and respiratory failure. CT angiography is the main diagnostic tool for pulmonary embolism. Formation of scar tissue in the connective tissue of the lungs. This condition can be primary (idiopathic) or secondary as a result of chronic inflammation or irritation caused by tuberculosis, pneumonia, or pneumoconiosis. A chronic inflammatory disease in which small nodules (granulomas) develop in the lungs, lymph nodes, and other organs. The cause of sarcoidosis is unknown. Bilateral hilar lymphadenopathy or pulmonary involvement is visible on chest radiography in most cases. Many patients are asymptomatic and maintain adequate lung function. Sarcoidosis can affect the brain, heart, liver, and other organs. Other patients have more active disease and impaired lung function. Glucocorticoids are used to prevent disease progression. Infectious disease caused by Mycobacterium tuberculosis; the lungs are usually involved, but any organ in the body can be affected. Rod-shaped bacteria called bacilli invade the lungs and produce small tubercles (from the Latin tubercle, swelling) of infection. Early tuberculosis is usually asymptomatic and is detected on routine chest x-rays. Signs and symptoms of advanced disease are cough, weight loss, night sweats, hemoptysis, and pleuritic pain. Tuberculosis chemotherapy (isoniazid, rifampicin) is effective in most cases. Immunocompromised patients are particularly susceptible to antibiotic-resistant TB. It is important and often necessary to treat TB with several drugs at the same time to prevent drug resistance. The PPD skin test (see page 454) is administered to most hospital staff and physicians because tuberculosis is highly contagious. A positive PPD test indicates TB exposure, and treatment with isoniazid will be necessary even in the absence of pulmonary infection.

FIGURE 12-11 A. Normal lung tissue. B, Emphysema. Note the hyperinflation of the alveoli and the destruction of the alveolar walls.

802

FIGURE 12-12 Lung cancer. Grayish-white tumor tissue is seeping into the substance of the lung. This tumor was identified as a squamous cell carcinoma. Squamous cell carcinomas arise in the main bronchi and spread to local hilar lymph nodes.

FIGURE 12-13 A, Anthracosis or black lung disease. Note the dark black deposits of carbon dust throughout the lung. B, Lobar pneumonia (at autopsy). Keep in mind that the condition affects one lobe of the lung. The patient's signs and symptoms included fever, chills, cough, dark sputum, rapid and shallow breathing, and hypoxia. If the diagnosis is made early, antibiotic therapy is successful.

803

FIGURE 12-14 Pulmonary embolism (A and B).

Common causes of atelectasis • Bronchial obstruction: from secretions or tumor • Complications after surgery: difficulty breathing • Chest wounds: air (pneumothorax), fluid (pleural effusion), or blood (hemothorax) accumulates in the pleural cavity

Pleural disorders mesothelioma pleural effusion pleurisy (pleurisy) pneumothorax

Rare malignant tumor arising in the pleura. Mesotheliomas are derived from the mesothelium, which forms the lining of the pleural surface. These tumors are usually caused by exposure to asbestos. Abnormal accumulation of fluid in the pleural space (cavity). Two types of pleural effusions are exudates (fluid from tumors and infections) and transudates (fluid from congestive heart failure or cirrhosis). Inflammation of the pleura. This condition causes pleurodynia and dyspnea and, in chronic cases, pleural effusion. Accumulation of air in the pleural space. Pneumothorax can occur in the course of lung disease (emphysema, carcinoma, tuberculosis, or lung abscess) when a break in the lung surface releases air into the pleural space. This allows communication between an alveolus or bronchus and the pleural cavity. It can also occur after trauma and perforation of the chest wall or a prolonged flow of oxygen delivered by a ventilator in an intensive care unit (ICU). Pleurodesis (-desis means to join) is the artificial production of adhesions between the parietal and visceral pleura for the treatment of persistent pneumothorax and severe pleural effusion. This is done using talcum powder or medications such as antibiotics that cause irritation and scarring of the pleura.

study section

Practice spelling each term and learn its meaning.

804

anthracosis asbestosis bacilli (singular: bacillus) chronic obstructive pulmonary disease (COPD) exudates cor pulmonale

Coal dust accumulates in the lungs. Asbestos particles accumulate in the lungs. Rod-shaped bacteria.

Chronic condition of persistent obstruction of airflow through the bronchi and lungs. COPD is caused by smoking, air pollution, chronic infections and, in a minority of cases, asthma. Patients with predominantly chronic bronchitis COPD may be referred to as “blue puffers” (robust, cyanotic conformation), while those with predominant emphysema may be referred to as “pink breathers” (difficulty breathing, but near blood oxygen levels). normal and no change in skin color). Inability of the right side of the heart to pump enough blood to the lungs due to underlying lung disease. Fluid, cells, and other substances (pus) leaking from cells or capillaries into lesions or areas of inflammation. infiltrate A collection of fluid or other material within the lung, as seen on a chest x-ray, CT scan, or other radiological image. palliative Relieves the symptoms, but does not cure the disease. paroxysmal Pertaining to a sudden event, such as a spasm or convulsion; oxismo/o means sudden. lung Area of necrosis (death of lung tissue). Purulent infarct containing pus. silicosis Disease caused by silica or glass dust in the lungs; occurs in mining occupations.

805

Clinical procedures X-ray examinations Chest x-ray (CXR) Computed tomography (CT) of the chest

Radiographic image of the chest cavity (chest film). Chest radiographs are taken in the frontal (coronal) plane as posteroanterior (PA) or anteroposterior (AP) views and in the sagittal plane as lateral views. Figures 12-15A and B show a normal chest radiograph and a chest radiograph with pneumonia. A series of computer generated X-ray images show thoracic structures in cross sections and other planes. This test is to diagnose lesions that are difficult to assess by conventional X-ray studies, such as those of the lungs, mediastinum, and pleura. CT pulmonary angiography (CTPA) is a combination of computed tomography and angiography. Examination of the pulmonary circulation is useful in diagnosing pulmonary embolism.

FIGURE 12-15 A, Normal appearance of a chest radiograph. The image is taken from the posteroanterior (PA) view (the x-ray goes from back to front). The inverted L in the upper corner is placed on the film to indicate the left side of the patient's chest. A, Diaphragm; B, costophrenic angle; C, left ventricle of the heart; D, right atrium of the heart; E, aortic arch; F, superior vena cava; G, trachea. Air-filled lung spaces appear black. B, Pneumonia of the right lung shown on a chest X-ray image.

MRI Magnetic resonance imaging (MRI) of the chest

Magnetic waves create detailed images of the chest in the frontal, lateral (sagial), and transverse (axial) planes. This test is useful in defining mediastinal tumors (such as those of Hodgkin's disease) that are difficult to evaluate by computed tomography.

Nuclear Medicine Tests

806

lung ventilation and perfusion (V/Q) positron emission tomography (PET)

Radioactive glucose is injected, and images reveal metabolic activity in the lungs. This scanning technique can identify malignant tumors, which have increased metabolic activity. It is also used to evaluate small nodules seen on a CT scan. The detection device records radioactivity in the lung after intravenous injection of a radioisotope and inhalation of a small amount of radioactive gas (xenon). This test can identify areas of the lung that do not receive adequate airflow (ventilation) or blood flow (perfusion), as well as areas where there is a mismatch between airflow (V) and blood flow ( Q). Airflow without compatible blood flow suggests pulmonary embolism.

Other Procedures

807

bronchoscopy

Fiberoptic endoscopic examination of the bronchi. A doctor places the bronchoscope through the throat, larynx, and trachea into the bronchi for diagnosis, biopsy, or collection of secretions. In bronchoalveolar lavage (bronchial lavage), fluid is injected and withdrawn. In bronchial brushing, a brush is inserted through the bronchoscope and used to scrape tissue (Figure 12-16). Endobronchial ultrasound (EBUS) is performed during bronchoscopy to diagnose and stage lung cancer. An EBUS-guided biopsy allows sampling of small (

Solution Key The Language of Medicine 12th Edition (2023)

References