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Friedrich Trendelenburg, 1844�1924, successively Professor of Surgery at Rostock (1875�1882), Bonn (1822�1895) and Leipzig, (1895�1911), Germany. The leaves of parotid fascia (arrows) have been raised exposing the underlying glandular parenchyma that accommodates the tumour. The image exhibits the remaining parotid bed with the facial nerve branch intact (arrows). Posterior mandible (upper arrow) and great vessels of the neck (lower arrow) are visible. It outcomes from harm to the autonomic innervation of the salivary gland with inappropriate regeneration of the postganglionic parasympathetic nerve fibres of the auriculotemporal nerve that aberrantly stimulate the sweat glands of the overlying pores and skin. The clinical options include sweating and erythema (flushing) over the area of surgical excision of the parotid gland as a consequence of autonomic stimulation of salivation by the smellor style of meals. This entails portray the affected space with iodine, which is allowed to dry earlier than making use of dry starch, which turns blue on publicity to iodine within the presence of sweat. These include: that involves parotid swelling, anterior uveitis, facial palsy and fever. These embody such circumstances as sialadenosis, adenomatoid hyperplasia and multifocal monomorphic adenomatosis. It usually happens in association with a wide range of conditions together with diabetes mellitus, alcoholism, different endocrine illnesses, being pregnant, medicine, bulimia and other consuming problems, and idiopathic diseases. When the parotid glands are affected, sufferers may complain of a hamster-like appearance. Drug-induced sialosis sternomastoid muscle flap; temporalis fascial flap; insertion of synthetic membranes between the skin and the parotid bed. All these strategies substitute the barrier between the skin and the parotid mattress to minimise inappropriate regeneration of autonomic nerve fibres. Granulomatous sialadenitis this is a group of rare conditions that affect the salivary glands producing a selection of signs and symptoms, particularly painless swellings of the parotid and/or submandibular glands. Tuberculosis and non-tuberculous sialadenitis sometimes present as a tumour-like swelling of the salivary gland. Preoperative investigations may be of some help, and the prognosis is just confirmed when the swelling has been excised by both submandibular gland excision or formal parotidectomy. Sarcoidosis can have an effect on the salivary tissue and presents with persistent salivary gland swelling that might be related to xerostomia. Occasionally, the patient will present with a localised tumour-like swelling in a single salivary gland, more commonly the parotid � the so referred to as sarcoid pseudotumour. In such circumstances, the prognosis is only more probably to be made following surgical excision for a presumed neoplasm. Christian Frederick Heerfordt, 1871�1953, Danish ophthalmologist, described this syndrome in 1909. Friedrich Wegener, 1907�1990, Professor of Pathology, L�beck, Germany, described this form of granulomatosis in 1939. Severe and prolonged malnutrition, as seen in eating problems, produces sialadenosis by a means of hypertrophy to compensate for swings in acid steadiness. The pathological mechanism of sialadenosis may be associated with a means of neuropathy, which interferes with salivary gland operate and subsequent acinar cell atrophy. This could be the case in diabetes mellitus, the place autonomic neuropathy is a recognised complication in addition to drug-induced sialosis. The therapy of sialosis is unsatisfactory, however remedy is aimed at correction of the underlying dysfunction. However, the symptoms are often extra severe, and the incidence of lymphomatous transformation (see below) within the major group is larger than that in the secondary group (Table 49. The glands are sometimes painful, and the affected person not often develops a bacterial sialadenitis due to ascending an infection from the related xerostomia. No recognized therapy modifies or improves the xerostomia or keratoconjunctivitis sicca. An ophthalmological evaluation is necessary, and synthetic tears are essential to preserve corneal operate.

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Inflamed peritoneum loses its glistening look and turns into reddened and velvety. Flakes of fibrin appear and trigger loops of intestine to turn into adherent to one another and to the parietes. There is an outpouring of serous inflammatory exudate wealthy in leukocytes and plasma proteins that soon becomes turbid; if localisation occurs, the turbid fluid turns into frank pus. Peristalsis is retarded in affected bowel and this helps to stop distribution of the an infection. The greater omentum, by enveloping and changing into adherent to inflamed buildings, often varieties a considerable barrier to the spread of an infection (see below). These organisms result in a thinning of cervical mucus and allow bacteria from the vagina into the uterus and oviducts, inflicting infection and inflammation. Klebsiella pneumoniae Other sources Chlamydia trachomatis Neisseria gonorrhoeae Haemolytic streptococci Staphylococci Streptococcus pneumoniae Mycobacterium tuberculosis and other species Fungal infections Speed of peritoneal contamination is a prime issue. If an infected appendix or different hollow viscus perforates before localisation has taken place, there shall be an efflux of contents into the peritoneal cavity, which can unfold over a big space virtually instantaneously. Perforation proximal to an obstruction or from sudden anastomotic separation is associated with severe generalised peritonitis and a high mortality price. Stimulation of peristalsis by the ingestion of food and even water hinders localisation. Violent peristalsis occasioned by the administration of a purgative or an enema might cause the widespread distribution of an an infection that may otherwise have remained localised. The virulence of the infecting organism may be so great as to render the localisation of an infection tough or impossible. Named after the 2 physicians, Thomas Fitz-Hugh, Jr and Arthur Hale Curtis who first reported this condition in 1934 and 1930, respectively. With acceptable therapy, localised peritonitis normally resolves; in about 20% of cases, an abscess follows. Conversely, in favourable circumstances, diffuse peritonitis can become localised, most regularly within the pelvis or at a number of sites throughout the abdominal cavity. When the peritoneum turns into inflamed, abdominal pain will worsen and in general temperature and pulse fee will rise. In instances of pelvic peritonitis arising from an infected appendix within the pelvic position or from salpingitis, the belly signs are often slight; there could also be deep tenderness of 1 or both lower quadrants alone, but a rectal or vaginal examination reveals marked tenderness of the pelvic peritoneum. It is first skilled on the site of the unique lesion and spreads outwards from this point. Tenderness and generalised guarding are discovered on palpation, when the peritonitis affects the anterior stomach wall. Infrequent bowel sounds should be heard for a few hours but they stop with the onset of paralytic ileus. A supine radiograph of the abdomen could affirm the presence of dilated gas-filled loops of bowel (consistent with a paralytic ileus), and sometimes present different gasfilled buildings which will help diagnosis. There is an abundance of recent printed proof to support its use in managing acute abdominal pain. Ultrasonography has undoubted worth in certain conditions similar to pelvic peritonitis in girls and localised proper upper quadrant peritonism. Management (b) General care of the affected person the care of critically unwell surgical sufferers is described in detail in Chapters 2, 17 and 20. Nutritional help is roofed in Chapter 19, and anaesthesia and pain relief in Chapter 18. Depending on diploma (localised/generalised), duration and severity, patients will require some or the entire following. Special measures could also be wanted for cardiac, pulmonary and renal help, especially if septic shock is current (see Chapter 2), together with central venous stress monitoring in sufferers with concurrent illness. A nasogastric tube is often passed to permit drainage � aspiration until paralytic ileus has resolved. If acceptable expertise is available, epidural infusion could present wonderful analgesia. Freedom from pain allows early mobilisation and enough physiotherapy in the postoperative interval, which helps to stop basal pulmonary collapse, deep vein thrombosis and pulmonary embolism. The use of a big volume of saline (typically 3 litres) containing dissolved antiseptic or antibiotic has been proven to be efficient.

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Minimising the production of ischaemic tissue by cautious surgical approach, together with meticulous management of bleeding, stay, nevertheless, probably the most crucial ideas. The evolution of laparoscopic bowel surgery has been proven by collective evaluate knowledge to end in lowered adhesion-related readmissions for a number of belly and pelvic procedures. Adept (4% icodextrin solution) is a solution utilized contained in the stomach on the time of surgical procedure; it has been proven to scale back the extent and severity of adhesion formation in animal models. In a evaluate of seven randomised trials taking a glance at an analogous Peritoneal unfastened bodies (peritoneal mice) Peritoneal loose our bodies (peritoneal mice) may be confused with a small tumour however almost by no means trigger symptoms. These hyaline our bodies attain the scale of a pea or bean and comprise saponified fats surrounded by fibrin. An inflammatory response ensues with cell migration, release of cytokines and activation of the coagulation cascade. The activation of the coagulation system ends in thrombin formation, which is important for the conversion of fibrinogen to fibrin. Such obstacles, when positioned round bowel anastomosis, also led to a significant enhance in the anastomotic leaks. The peritoneal cavity turns into obliterated as a end result of gross subserosal thickening by fibrosis, resulting in bowel obstruction and other sequelae. Although non-metastasising, and stated to be benign, it might possibly however show widely invasive, compressing and infiltrating surrounding tissues such as the bowel and mesentery with complications thereof. For occasion, an acutely infected appendix is commonly found wrapped in omentum, and this saves many patients from creating diffuse peritonitis. Some sufferers of herniae are additionally significantly indebted to this structure, as a end result of it usually plugs the neck of a hernial sac and prevents a coil of gut from getting into and changing into strangulated. The omentum is normally involved in tuberculous peritonitis and carcinomatosis of the peritoneum. This occurs throughout a vehicular collision when a seatbelt is being worn with sudden deceleration resulting in a torn mesentery. This possibility ought to be borne in mind, significantly as multiple accidents could distract consideration from this damage (the management of stomach trauma is covered in Chapter 27). Aside from management of any ongoing haemorrhage, related ischaemic or ruptured intestine would require resection. Torsion of the omentum Torsion of the omentum is a rare emergency and consequently is seldom identified appropriately. It may be major or secondary to adhesion of the omentum to an old focus of an infection or hernia. The blood supply having been jeopardised, the twisted mass generally becomes gangrenous, by which case bacterial peritonitis may comply with. Treatment is surgical; the pedicle above the twist is ligated securely and the mass removed. Ischaemia Torsion of the mesentery is covered beneath midgut volvulus and volvulus of the small gut (see Chapter 69). Embolism and thrombosis of mesenteric vessels resulting in intestinal ischaemia are also covered in Chapter sixty nine. Inflammation A variety of considerably miscellaneous circumstances are best described underneath this umbrella time period. The aetiology typically stays unknown, though some circumstances are associated with yersinia infection of the ileum. In about 25% of cases, a respiratory infection precedes an assault of non-specific mesenteric adenitis. Its significance thus primarily lies in its differential diagnosis with appendicitis in kids. The typical history is certainly one of brief attacks of central abdominal ache lasting from 10 min to 30 min, commonly related to vomiting. Abdominal tenderness is poorly localised and, when present, shifting tenderness is a valuable sign for differentiating the situation from appendicitis. There is often a leukocytosis of 10 000�12 000/�L (10�12 � 109/L) or more on the primary day of the attack, however this falls on the second day. The ileocaecal mesenteric lymph nodes are enlarged, and may be seen and felt between the leaves of the mesentery. In sufferers with acute stomach illness, misty mesentery could additionally be thought of a function of the underlying illness.

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Large hamangiomata can trap platelets leading to thrombocytopenia (Kasabach�Merritt syndrome). Friedrich Sigmud Merkel, 1845�1919, Professor of Anatomy successively at Rostock, Koningsberg (now Kaliningrad in Russia) and G�ttingen, Germany. Stasis can lead to a localised, consumptive coagulopathy in giant venous malformations. Low-flow malformations may trigger skeletal hypoplasia, while high-flow malformations could cause hypertrophy. It is brought on by an area of persistent fetal dermal circulation, which usually disappears at 1 year. They appear at start as flat, clean, intensely purple-stained areas, most regularly on the head and neck, often inside the maxillary and mandibular dermatomes of the trigeminal nerve. Whites pores and skin is affected most commonly and ladies are affected 3 times greater than boys. Heinrich Hoyer, 1834�1907, Professor of Histology, Embryology and Anatomy, the Central Medical School, the Polish University, Warsaw, Poland. The lymphangiosarcoma variant arises from lymphatic endothelium and may develop in lymphoedematous tissue, significantly an extremity. Treatment depends on the severity of the presentation, however often entails plastic surgery. Parry�Romberg illness Parry�Romberg disease is an uncommon and poorly understood progressive, hemifacial atrophy of skin, soft tissue and bone. Its incidence is unknown and its inheritance unsure, however it impacts women extra generally than males. Once secure, plastic surgical strategies may be employed alone or together to reconstruct an aesthetic contour. Spina bifida Failure of closure of the caudal neuropore in the course of the 4th week in utero leads to incomplete improvement of some or all the structural parts posterior to the spinal wire. Management ideally entails a multidisciplinary strategy and is directed in course of defending the spinal cord, stopping cerebrospinal fluid contamination and secondary hydrocephalus and meningitis. Acquired Pressure sores these begin with tissue necrosis at a stress level and develop into a cone-shaped volume of necrotic loss. As many as 10% of acute hospital in-patients will suffer some extent of pressure sore. The majority have an effect on the elderly and patients with spinal harm or decreased sensibility; 80% of paraplegics will get a stress sore and 8% die in consequence. Moricz K Kaposi, 1837�1902, Austrian dermatologist, described xeroderma pigmentosum in 1874. Moritiz Heinrich Romberg, 1795�1873, German neurologist, Director of the University Hospital, Berlin, Germany. In the paraplegic affected person recurrence is in all probability going, so administration should contain a multidisciplinary method. Primary treatment includes relieving pressure (special mattress; nursing care; reduction of muscle spasm and contractures); optimising nutrition; correcting anaemia; and preventing infection and dressings. Surgery includes thorough debridement to promote therapeutic and plastic surgery to reconstruct the defect. It is characterised by destruction of the surface epithelium and a granulating base. For particular management of the disease conditions, please discuss with the appropriate chapter. This communication or tract could also be lined by granulation tissue, however may become epithelialised in persistent circumstances. Management of a fistula is directed at the underlying aetiology (see the suitable chapters). Final model of the American Joint Committee on Cancer staging system for cutaneous melanoma. In the United Kingdom (with its inhabitants of 65 million), each year round a hundred seventy five 000 folks go to accident and emergency (A&E) departments suffering from burns, of whom about 13 000 must be admitted. About one thousand have severe burns requiring fluid resuscitation, and half of the victims are beneath 16 years of age. The majority of burns in children are scalds brought on by accidents with kettles, pans, scorching drinks and bathtub water.

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The sudden onset happens commonly but not completely during exertion, and could additionally be related to seizure (10%), unresponsiveness (50%) and vomiting (70%). They are then at excessive risk of succumbing to early complications, particularly a rebleed. A painful third nerve palsy is often the results of compression from a posterior communicating artery aneurysm. Papilloedema must be sought, however will not be evident early in the midst of a creating hydrocephalus. Sometimes mesh stents may be used to help safe the metal coils throughout the aneurysm sac as a part of this procedure. Class 1 proof suggesting a decrease risk of poor outcomes, a minimal of for small anterior circulation aneurysms, has pushed the uptake of coiling. For this reason, and to permit optimum management of vasospasm, the present consensus favours early intervention, regardless of the surgical challenges presented by mind swelling and blood load. Treated aneurysms can regrow and rebleed, especially after coiling, so that a programme of surveillance is critical. Unruptured aneurysms symbolize a thorny management downside: incidentally detected small anterior circulation aneurysms represent a minimal bleeding danger. Medical administration Patients should be positioned on bed rest with hourly neuro observations. They require strict input�output monitoring and intravenous fluid replacement with regular saline initially. Oral nimodipine at a dose of 60 mg each 4 hours reduces the speed of poor consequence (see Vasospasm below). Analgesics, laxatives, anti-emetics, gastric protection and compression stockings are additionally more doubtless to be essential. After resuscitation, the priorities in subarachnoid haemorrhage are: 1 to forestall rebleeding by identifying and controlling any underlying lesion; 2 to recognise and manage: neurological problems, particularly vasospasm (or delayed ischaemic neurologic deficit) and hydrocephalus; systemic complications, together with electrolyte imbalance, severe hypertension, cardiac infarct and arrhythmia, and neurogenic pulmonary oedema. These targets are greatest served by early switch of the patient to a neurosurgical centre. Note the only displaced coil passing into the distal inside carotid artery after which the center cerebral artery. Neurological deterioration should immediate a repeat scan to exclude proof of rebleeding and of hydrocephalus. This is usually the speaking sort, which is a typical sequela of haemorrhage. The process is attributed to cerebral vasospasm in response to , and correlating with, the blood load. This process can be visualised angiographically, and the rate of bloodflow within the cerebral vasculature, measured utilizing transcranial Doppler ultrasound, supplies an oblique assessment of the degree of stenosis. Outcomes are optimised by the prophylactic administration of nimodipine and upkeep of fluid volume, usually with 2. In established vasospasm, the goal is to preserve cerebral perfusion by administration of fluid and inotropes. Young patients with haematomas close to the cortical floor, demonstrating progressive neurological deterioration, characterize good surgical candidates. Posterior fossa clot can be a strong indication for surgical procedure due to the potential for fast deterioration due to brainstem compression and hydrocephalus. A substantial minority of intracerebral bleeds are attributable to focal vascular lesions (see above). This have to be thought-about when planning any surgery, and could also be a sign for acute vascular imaging in dialogue with neurovascular specialists. Delayed follow-up imaging is usually beneficial to exclude underlying tumour as a trigger for bleed. The majority happen within the context of hypertension or amyloid angiopathy, or as a complication of ischaemic stroke. Coagulation issues, particularly sufferers being handled with warfarin, are a significant danger factor. They require reversal of anticoagulation, ongoing hourly neuro observations and blood strain monitoring. High blood pressure may be longstanding and related to diversifications to autoregulation, so makes an attempt at decreasing it acutely with intravenous antihypertensives should be made only if the values are very high.

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There is often little correlation between the histological appearance of the breast tissue and the signs. Nodularity Frequency An various concept means that periductal inflammation is the primary situation and, indeed, anaerobic bacterial infection is present in some instances. A marked association between recurrent periductal inflammation and smoking has been demonstrated. This was thought by some to indicate that arteriopathy is a contributing think about its aetiology, though others consider that smoking will increase the virulence of the commensal bacteria. It is definitely clear that cessation of smoking increases the prospect of a long-term treatment. Antibiotic remedy could additionally be tried, probably the most acceptable agents being co-amoxiclav or flucloxacillin and metronidazole. It is especially important to shave the again of the nipple to be positive that all terminal ducts are removed. Pathology the disease consists essentially of four options which will differ in extent and degree in anyone breast. Fat and elastic tissues disappear and are changed with dense white fibrous trabeculae. Hyperplasia of epithelium in the lining of the ducts and acini may occur, with or with out atypia. The epithelial hyperplasia may be so intensive that it ends in papillomatous overgrowth within the ducts. Aberrations of regular growth and involution Nomenclature the nomenclature of benign breast disease is complicated. This is as a result of during the last century quite so much of clinicians and pathologists have chosen to describe a mixture of physiological adjustments and illness processes according to quite lots of medical, pathological and aetiological terminology. As well as leading to confusion, patients had been usually unduly alarmed or overtreated by ascribing a pathological name to a variant of physiological development. Lumpiness may be bilateral, commonly in the higher outer quadrant or, much less commonly, confined to one quadrant of 1 breast. The adjustments could also be cyclical, with an increase in each lumpiness and often tenderness before a menstrual interval. It should be distinguished from referred pain, for example a musculoskeletal disorder. About 5% of breast cancers exhibit pain at presentation, but not often as the sole presenting feature. It is probably worthwhile reviewing the affected person at a different point in the menstrual cycle, for example 6 weeks after the initial go to as typically the medical indicators may have resolved by that point. There is a tendency for women with lumpy breasts to be rendered unnecessarily anxious and to be submitted to multiple random biopsies as a outcome of the clinician lacks the courage of his or her convictions. Rapid referral into the secondary well being care sytem usually means patients are assessed without an intervening menstrual cycle and this may result in extra concerns. Acknowledgement that this is a actual symptom, a non-dismissive angle and an evidence of the aetiology are all helpful in managing this condition. In the primary instance, an appropriately becoming and supportive bra ought to be worn all through the day and a gentle bra (such as a sports activities bra) worn at night time. Avoiding caffeine drinks is said to help, though the author remains unconvinced. A affected person symptom diary will help her to chart the pattern of pain throughout the month and thus decide whether this is cyclical mastalgia. This allows the majority of patients to modify to the concept of a cyclical nature of their drawback however, if reassurance is insufficient, then a planned escalation of treatment (Table fifty three. It seems to achieve greater response charges in those over forty years of age somewhat than younger girls. For those with intractable symptoms, an antigonadotrophin, corresponding to danazol, or a prolactin inhibitor, such as bromocriptine, may be tried. For non-cyclical mastalgia you will need to exclude extramammary causes such as chest wall ache (Tietze syndrome). It is seldom needed today to perform a biopsy on a really localised tender space that may be harbouring a subclinical most cancers as imaging is so significantly better.

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The blood provide to the proper lobe of the liver may be partly or utterly equipped by a right hepatic artery arising directly from the superior mesenteric artery, rather than the coeliac trunk. This vessel passes posterior to the uncinate course of and head of the pancreas, and runs to the liver on the posterior wall of the bile duct. Similarly, the arterial blood provide to the left lobe of the liver could additionally be derived from a department of the left gastric artery. This vessel runs between the lesser curve of the abdomen and the left lobe of the liver within the lesser omentum. The right triangular ligament fixes the entire proper lobe of the liver to the undersurface of the right hemidiaphragm. Division of this ligament allows the liver to be mobilised from underneath the diaphragm and rotated to the left. Another major supporting structure is the falciform ligament (remnant of the umbilical vein), which runs from the umbilicus to the liver between the proper and left lobes, passing into the interlobar fissure. From the fissure, it passes anteriorly on the floor of the liver, attaching it to the posterior facet of the anterior stomach wall. The ultimate peritoneal reflection is between the Structures within the hilum of the liver the porta hepatis, a transverse fissure on the visceral floor of the liver, is the hilum of the liver. The hepatic artery, portal vein and bile duct are present throughout the free edge of the lesser omentum (the hepatoduodenal ligament) and together with nerves and lymphatics enter the liver at the porta hepatis. The frequent hepatic artery branches at a variable stage inside the ligament, with the best hepatic artery crossing the bile duct either anteriorly or posteriorly earlier than giving rise to the cystic artery. Multiple small hepatic arterial branches provide blood to the bile duct, predominantly from the proper hepatic artery. The portal vein arises from the confluence of the splenic vein and the superior mesenteric vein behind the neck of the pancreas. It has some important tributaries, including the left gastric vein, which joins just above the pancreas. The proper and left hepatic ducts arise from the hepatic parenchyma and join to kind the frequent hepatic duct. Once inside the liver parenchyma, the duct accompanies the branches of the hepatic artery and portal vein within a fibrous sheath. The portal vein usually provides off two giant branches to the right lobe, that are usually outside the liver for a short length, before giving a left portal vein department that runs behind the left hepatic duct. The right hepatic vein could be exposed absolutely exterior the liver, but the center and left veins often be a part of throughout the liver parenchyma. Each of those segments could be thought-about as a functional unit, with a department of the hepatic artery, portal vein and bile duct, and drained by a department of the hepatic vein. Couinaud, a French surgeon, There are two anatomical lobes with separate blood provide, bile duct and venous drainage Dual blood supply (20% hepatic artery and 80% portal vein) the liver regenerates fully after partial resection Resection is predicated on anatomical traces to preserve maximal functioning liver Claude Couinaud, 1922�2008, French surgeon and anatomist, described the segmental anatomy of the liver in his seminal guide Le Foie: �tudes anatomiques et chirurgicales. Sir James Cantlie, 1851�1926, Scottish born doctor who cofounded the Hong Kong College of Medicine for Chinese (now Hong Kong University School of Medicine). Resections can be carried out of individual segments or of the whole of the left or proper hemiliver. These comprise plates of liver cells separated by the hepatic sinusoids, large, thin-walled venous channels that carry blood to the central vein, a tributary of the hepatic vein, from the portal tracts, which comprise branches of the hepatic artery and portal vein. During passage via the sinusoids, the many features of the liver happen, including bile formation, which is channelled in an other way to the blood flow to drain via the bile duct tributaries throughout the portal tracts. Embryology the liver is a foregut structure and forms as a small endodermal bud early in gestation. The cell population is bipotential, and cells may become hepatocytes or intrahepatic ductal cells. The liver endothelium is derived from the vitelline and umbilical veins, which merge with the endodermal bud to type the liver sinusoids. The supporting connective tissue, haemopoietic cells, and Kupffer cells are derived from the mesoderm of the septum transversum, which is a mass of mesenchymal connective tissue. Increased levels may be related to increased haemoglobin breakdown, hepatocellular dysfunction leading to impaired bilirubin transport and excretion or biliary obstruction. In patients with known parenchymal liver disease, progressive elevation of bilirubin within the absence of a secondary complication suggests deterioration in liver perform.


  • Day MR, Armstrong DG: Factors associated with methicillin resistance in diabetic foot infections, J Foot Ankle Surg 36:322-325, 1997 discussion 31.
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