Alcoholic Liver Cirrhosis

I. PERSONAL DATA

Name: Baby D.G.

Address: Umilag, Lamut, Ifugao

Age: 1 yr 9 mos

Birthdate: December 31, 2004

Birthplace: Umilag, Lamut, Ifugao

Religion: Evangelical

Date and Time of Diagnosis: September 25,2006; 4 PMAdmitting Diagnosis: S/P Untreated Meningitis with Hydrocephalus

, R/O TB Meningitis, 4th degree Malnutrition

Attending Physician: Dr. Benzon

II. HISTORY OF PRESENT ILLNESS

Before the delivery, DGs mother did not have any prenatal check-up, she is confident enough since her 4 kids were delivered normal. The mother decided to deliver her baby via (NSD) normal spontaneous delivery.

Our patient was born on a G5P4 mother in their home and was assisted by her husband and a neighbor. The baby was normal upon delivery. The baby was a girl and the cord was primitively cut with bamboo sticks by her husband with no check-up was done.

It has been a year since birth and DG had not received any immunizations , which were supposedly given right after delivery, when in fact their house was just near the Brgy. Health Center. No vaccination was given due to negligence.

Three months after birth, the baby suffered cough and fever for five days. With her mothers instinct of experience with her 4 children, she bought over-the-counter drugs (Ambroxol and Paracetamol) to treat the illness. For almost a year, baby didnt experience any health problem.

It was March of this year that baby suffered from fever, cough, vomiting and loose, watery- mucoid stools occurring about 4-5 times/day, for three days. The mother was so worried that she went to Dr. Balisan for consultation. Medication was given to treat the diarrhea last March 10, 2006. Above symptoms persisted with fever.

They then went to Panupdupan Hospital on March 16, 2006 and the baby was diagnosed with blood infection as claimed by the mother. She was given Ampicillin, Chloramphenicol, and Cefuroxime during the entire hospitalization, which lasted for two weeks. The fever and cough became worst. No improvements were noted hence they opted to transfer at Ifugao Provincial Hospital and DG was diagnosed with Meningitis on March 29, 2006. Upon admission patient was febrile and drowsy. Lumbar tap was done for CSF analysis. She was started with Ceftriaxone and Mannitol. During babys stay at the hospital, an NGT was inserted for oral feeding since she had difficulty sucking her moms breast. Baby also had seizure episodes and muscle spasms. Diazepam was ordered and administered. To further support the diagnosis, CSF analysis and total cell count was done. Result was increased WBC, decreased RBC, decreased sugar and positive CHON. Head CT scan was also requested but was not done due to financial problems.

After a day or two, mother noticed that babys lumbar area was swollen. Mother decided that the baby should be taken home to consult a manghihilot to treat the swollen back. A HAMA form was signed by mother to end their 1 month stay in hopital. They went home with NGT still inserted to baby DG. Milk was introduced via NGT to sustain the child.

The NGT was only removed by the mother last July 2006 when mother decided to introduce soft food and baby DG was able to tolerate it. Baby was fed lugaw as her staple food for three months.

First week of September, baby again suffered from dysphagia, cough, vomiting and diarrhea for three weeks. A week after, no intake of food and not even fluids was noted by her mother. She went to Dra. Quilang and requested for NGT insertion. The following day, mother sought consultation at Dra. Padres clinic and pleaded her to do everything to improve babys status. Dra. Padre diagnosed the baby with S/P Untreated Meningitis with Hydrocephalus, r/o TB meningitis, Cerebral Palsy, 4th degree malnutrition and referred baby DG to Veterans Regional Hospital.

III. ENVIRONMENTAL DATA

Their house is a semi-concrete 20x20m excluding the kitchen. Their source of water is from a spring and is directly delivered through rubber tubings. They usually drink directly from it and sometimes boil the water for the babys formula. They have an open type toilet. They have a vegetable garden and three hogs to support the family expenses. It was only during the hospitalization that almost all resources were depleted. It takes one hour to travel to Lagawe Poblacion, since the family needed to cross two rivers before they could reach Lagawe.

IV. SOCIO-ECONOMIC DATA

Due to meager resources the family seldom eat balanced and nutritious foods. The familys usual diet is usually composed of instant noodles, sardines, vegetable tops, rice and, sometimes, coffee serves as their viand. The eldest, age 11, and the second child, age 9 are both in the fourth grade. The third child is in the first grade and the fourth child is supposedly in day care but wasnt well-managed to go to school due to the hospitalization of the youngest sibling. To augment the financial aspect of the family the father and the mother works at the relatives rice field.

V. PRE-CLINICAL GROWTH AND DEVELOPMENTALS STATUS:VI. BREIF DESCRIPTION OF THE ILLNESSA. Cerebral Palsy

Definition

Cerebral palsy (CP) is a group of motor problems and physical disorders related to a brain injury. CP causes uncontrolled reflex movements and muscle tightness (spasticity) that may affect a part, a side, or the entire body, with varying severity. Several conditions, such as mental retardation, seizures, or vision and hearing problems, are often also associated with cerebral palsy.

Types:

1. Athetoid/Dyskinetic Cerebral PalsyThis type of cerebral palsy is usually characterized by slow uncontrollable movements which usually affect the muscles in legs, hands, feet, and in some cases face or throat, which can result in drooling or grimacing. Such symptoms are most visible during times of emotional stress and are virtually invisible during sleep. In addition, this type of cerebral palsy can cause speech disorders. Athetoid or Dyskinetic cerebral palsy falls in to roughly 10-20 per cent of all cases.

2. Spastic Cerebral Palsy Spastic cerebral palsy is the most common type of cerebral palsy, accounting for nearl 80 percent of all cerebral palsy cases. Children with this type of cerebral palsy have one or more tight muscle groups which limit movement. Children with spastic cerebral palsy have stiff and jerky movements. They often have a hard time moving from one position to another. They may also have a hard time holding and letting go of objects.3. Ataxic Cerebral PalsyThis form is cerebral palsy usually results in very shaky or unsteady movements as well as weak sense of balance, poor coordination, and depth perception in children. Children affected with ataxic cerebral palsy usually take longer to complete certain tasks as a result of such shaky movements and poor coordination. This type of condition occurs in about 5-10 percent of all cases.

4. Mixed Cerebral PalsyIn some cases, more than one of the above symptoms are present and most often include but are not limited to the combination of athetoid movements and spasticity.Causes

Cerebral palsy is caused by a brain injury or problem that occurs during fetal growth, birth, or within the first 2 to 3 years of life. CP can result from: Complications related to prematurity Being deprived of blood, oxygen, or other nutrients before or during birth. A serious head injury. Developing a serious infection that can affect the brain, such as meningitis. Some conditions that are passed from parent to child (genetic conditions) that are linked to abnormal brain development.

In many cases, the exact cause of the injury is not known.

Symptoms problems with body movement and posture, although the degree of physical disability varies

slight limp or an uncoordinated walk

have little or no control over their arms and legs or other parts of their body, such as their mouths and tongues

seizures or mental retardation.

Babies born with severe CP often have an irregular posture; their bodies may be either very floppy or very stiff. Birth defects, such as an irregularly shaped spine, small jawbone, or small head, sometimes occur along with cerebral palsy.

Diagnosis

Cerebral palsy (CP) usually takes several months to several years to diagnose. However, most children with CP are diagnosed by about 18 months of age. If a child is born with a severe form of CP, a health professional may be able to diagnose the condition within the first few weeks of life. However, parents and caregivers usually are the first to notice that a baby has developmental delays that may be early signs of CP.]

Usually a health professional diagnoses cerebral palsy based on a baby's medical history (including parents' observations of developmental delays), physical examination, and results of screening tests.

Additional tests, such as developmental questionnaires, computed tomography (CT) scan or magnetic resonance image (MRI) of the head, or an ultrasound of the brain may be done. These tests can help a health professional determine the cause of CP.

Treatment

There is no cure for cerebral palsy. Treatment is often needed throughout life to help manage symptoms, prevent complications, and maximize abilities. Although CP does not get worse over time, new challenges can develop as the child grows and develops. Medications, surgery, special equipment and devices, physical therapy, and individualized training may all be used.

B. Malnutrition (Marasmus)

Marasmus is one component of protein-energy malnutrition (PEM). It a severe form of malnutrition caused by inadequate intake of protein and calories, and it usually occurs in the first year of life, resulting in wasting and growth retardation.The major factors that cause a deficit of caloric and protein intake

1. the transition from breastfeeding to nutrition-poor foods in infancy2. acute infections of the gastrointestinal tract, 3. and chronic infections such as HIV or tuberculosis..

The physiologic response to a negative energy balance is to reduce energy consumption. Children who suffer from marasmus display decreased activity, lethargy, behavioral changes, slowed growth, and weight loss. The subsequent effects on the body are wasting and a loss of subcutaneous fat and muscle, resulting in growth retardation. The majority of children who suffer from marasmus never return to age-appropriate growth standards.

The cornerstone of therapy for marasmus is to supply the body with the necessary nutritional requirements. The nutritional needs of children in the rehabilitation stage require at least 150 kilocalories per kilogram per day. Dehydration must be addressed with oral rehydration therapy, while micronutrient deficiencies, such as vitamin A deficiency, require supplementation. Immunizations must be reviewed and given as necessary to reduce the burden of infectious diseases on children's bodies. Finally, family education must be ongoing to improve behavioral responses to such conditions. Some ready-to-use formulas and foods have also been developed. Such a broad approach must be taken to help reduce the morbidity and mortality caused by this condition.C. HYDROCEPHALUS

Hydrocephalus is the most common problem faced by the pediatric neurosurgeon and may be due to a variety of conditions (congenital, posthemorrhagic in premature infants, postmeningitic, obstruction by tumors or cysts, etc.). Hydrocephalus may cause injury to the brain by raising the intracranial pressure (ICP).

As cerebral blood perfusion is determined by the difference between mean arterial pressure and ICP, an elevated ICP may result in widespread ischemia. Additional injury occurs when the enlarged ventricles associated with hydrocephalus disrupt the axons that course around them. Finally, hydrocephalus also causes disruption of the ependymal surface of the ventricles with periventricular white matter showing axonal degeneration and gliosis.

The clinical consequences of brain injury resulting from untreated hydrocephalus include widespread neurologic and cognitive dysfunction, blindness and a massively enlarged head if the process begins in an infant with open sutures.

The most common causes of acquired hydrocephalus are hemorrhage, infection (meningitis) and tumors. Hemorrhage and meningitis have similar mechanisms for causing obstruction: particular matter occludes the aqueduct or arachnoid granulations or the inflammatory response causes adhesions in the CSF pathways (usually at the base of the brain) that obstruct flow. Tumors cause hydrocephalus by growing into the CSF pathways or by causing brain shifts that impede CSF flow.Clinical FeaturesInfants

1. Increasing head circumference.

2. Irritability, lethargy, poor feeding, and vomiting.

3. Bulging anterior fontanelle.

4. Widened cranial sutures.

5. McEwen's cracked pot sign with cranial percussion.

6. Scalp vein dilation (increased collateral venous drainage).

7. Sunset sign (forced downward deviation of the eyes, a neurologic sign almost unique with hydrocephalus).

8. Epidsodic bradycardia and apnea.

Medical

Four principal modes of medical therapy are used.

1. Remove CSF.

2. Decrease CSF production.

3. Decrease cerebral water content.

4. Increase CSF absorption.D. MeningitisV. Anatomy and PhysiologyRespiratory SystemHuman Anatomy

Respiratory System, in anatomy and physiology are organs that deliver oxygen to the circulatory system for transport to all body cells. Oxygen is essential for cells, which use this vital substance to liberate the energy needed for cellular activities. In addition to supplying oxygen, the respiratory system aids in removing of carbon dioxide, preventing the lethal buildup of this waste product in body tissues. Day-in and day-out, without the prompt of conscious thought, the respiratory system carries out its life-sustaining activities. If the respiratory systems tasks are interrupted for more than a few minutes, serious, irreversible damage to tissues occurs, followed by the failure of all body systems, and ultimately, death.

While the intake of oxygen and removal of carbon dioxide are the primary functions of the respiratory system, it plays other important roles in the body. The respiratory system helps regulate the balance of acid and base in tissues, a process crucial for the normal functioning of cells. It protects the body against disease-causing organisms and toxic substances inhaled with air. The respiratory system also houses the cells that detect smell, and assists in the production of sounds for speech.

The respiratory and circulatory systems work together to deliver oxygen to cells and remove carbon dioxide in a two-phase process called respiration. The first phase of respiration begins with breathing in, or inhalation. Inhalation brings air from outside the body into the lungs. Oxygen in the air moves from the lungs through blood vessels to the heart, which pumps the oxygen-rich blood to all parts of the body. Oxygen then moves from the bloodstream into cells, which completes the first phase of respiration. In the cells, oxygen is used in a separate energy-producing process called cellular respiration, which produces carbon dioxide as a byproduct. The second phase of respiration begins with the movement of carbon dioxide from the cells to the bloodstream. The bloodstream carries carbon dioxide to the heart, which pumps the carbon dioxide-laden blood to the lungs. In the lungs, breathing out, or exhalation, removes carbon dioxide from the body, thus completing the respiration cycle.

STRUCTURE

The organs of the respiratory system extend from the nose to the lungs and are divided into the upper and lower respiratory tracts. The upper respiratory tract consists of the nose and the pharynx, or throat. The lower respiratory tract includes the larynx, or voice box; the trachea, or windpipe, which splits into two main branches called bronchi; tiny branches of the bronchi called bronchioles; and the lungs, a pair of saclike, spongy organs. The nose, pharynx, larynx, trachea, bronchi, and bronchioles conduct air to and from the lungs. The lungs interact with the circulatory system to deliver oxygen and remove carbon dioxide.

A Nasal Passages Anatomy of the Nose

The uppermost portion of the human respiratory system, the nose is a hollow air passage that functions in breathing and in the sense of smell. The nasal cavity moistens and warms incoming air, while small hairs and mucus filter out harmful particles and microorganisms

The flow of air from outside of the body to the lungs begins with the nose, which is divided into the left and right nasal passages. The nasal passages are lined with a membrane composed primarily of one layer of flat, closely packed cells called epithelial cells. Each epithelial cell is densely fringed with thousands of microscopic cilia, fingerlike extensions of the cells. Interspersed among the epithelial cells are goblet cells, specialized cells that produce mucus, a sticky, thick, moist fluid that coats the epithelial cells and the cilia. Numerous tiny blood vessels called capillaries lie just under the mucous membrane, near the surface of the nasal passages. While transporting air to the pharynx, the nasal passages play two critical roles: they filter the air to remove potentially disease-causing particles; and they moisten and warm the air to protect the structures in the respiratory system.

Filtering prevents airborne bacteria, viruses, other potentially disease-causing substances from entering the lungs, where they may cause infection. Filtering also eliminates smog and dust particles, which may clog the narrow air passages in the smallest bronchioles. Coarse hairs found just inside the nostrils of the nose trap airborne particles as they are inhaled. The particles drop down onto the mucous membrane lining the nasal passages. The cilia embedded in the mucous membrane wave constantly, creating a current of mucus that propels the particles out of the nose or downward to the pharynx. In the pharynx, the mucus is swallowed and passed to the stomach, where the particles are destroyed by stomach acid. If more particles are in the nasal passages than the cilia can handle, the particles build up on the mucus and irritate the membrane beneath it. This irritation triggers a reflex that produces a sneeze to get rid of the polluted air.

The nasal passages also moisten and warm air to prevent it from damaging the delicate membranes of the lung. The mucous membranes of the nasal passages release water vapor, which moistens the air as it passes over the membranes. As air moves over the extensive capillaries in the nasal passages, it is warmed by the blood in the capillaries. If the nose is blocked or stuffy due to a cold or allergies, a person is forced to breath through the mouth. This can be potentially harmful to the respiratory system membranes, since the mouth does not filter, warm, or moisten air.

In addition to their role in the respiratory system, the nasal passages house cells called olfactory receptors, which are involved in the sense of smell. When chemicals enter the nasal passages, they contact the olfactory receptors. This triggers the receptors to send a signal to the brain, which creates the perception of smell.

B Pharynx

Air leaves the nasal passages and flows to the pharynx, a short, funnel-shaped tube about 13 cm (5 in) long that transports air to the larynx. Like the nasal passages, the pharynx is lined with a protective mucous membrane and ciliated cells that remove impurities from the air. In addition to serving as an air passage, the pharynx houses the tonsils, lymphatic tissues that contain white blood cells. The white blood cells attack any disease-causing organisms that escape the hairs, cilia, and mucus of the nasal passages and pharynx. The tonsils are strategically located to prevent these organisms from moving further into the body. One tonsil, called the adenoids, is found high in the rear wall of the pharynx. A pair of tonsils, the palatine tonsils, is located at the back of the pharynx on either side of the tongue. Another pair, the lingual tonsils, is found deep in the pharynx at the base of the tongue. In their battles with disease-causing organisms, the tonsils sometimes become swollen with infection. When the adenoids are swollen, they block the flow of air from the nasal passages to the pharynx, and a person must breathe through the mouth.

C Larynx

Air moves from the pharynx to the larynx, a structure about 5 cm (2 in) long located approximately in the middle of the neck. Several layers of cartilage, a tough and flexible tissue, comprise most of the larynx. A protrusion in the cartilage called the Adams apple sometimes enlarges in males during puberty, creating a prominent bulge visible on the neck.

While the primary role of the larynx is to transport air to the trachea, it also serves other functions. It plays a primary role in producing sound; it prevents food and fluid from entering the air passage to cause choking; and its mucous membranes and cilia-bearing cells help filter air. The cilia in the larynx waft airborne particles up toward the pharynx to be swallowed.

Food and fluids from the pharynx usually are prevented from entering the larynx by the epiglottis, a thin, leaflike tissue. The stem of the leaf attaches to the front and top of the larynx. When a person is breathing, the epiglottis is held in a vertical position, like an open trap door. When a person swallows, however, a reflex causes the larynx and the epiglottis to move toward each other, forming a protective seal, and food and fluids are routed to the esophagus. If a person is eating or drinking too rapidly, or laughs while swallowing, the swallowing reflex may not work, and food or fluid can enter the larynx. Food, fluid, or other substances in the larynx initiate a cough reflex as the body attempts to clear the larynx of the obstruction. If the cough reflex does not work, a person can choke, a life-threatening situation. The Heimlich maneuver is a technique used to clear a blocked larynx. A surgical procedure called a tracheotomy is used to bypass the larynx and get air to the trachea in extreme cases of choking.

D Trachea, Bronchi, and Bronchioles

Air passes from the larynx into the trachea, a tube about 12 to 15 cm (about 5 to 6 in) long located just below the larynx. The trachea is formed of 15 to 20 C-shaped rings of cartilage. The sturdy cartilage rings hold the trachea open, enabling air to pass freely at all times. The open part of the C-shaped cartilage lies at the back of the trachea, and the ends of the C are connected by muscle tissue.

The base of the trachea is located a little below where the neck meets the trunk of the body. Here the trachea branches into two tubes, the left and right bronchi, which deliver air to the left and right lungs, respectively. Within the lungs, the bronchi branch into smaller tubes called bronchioles. The trachea, bronchi, and the first few bronchioles contribute to the cleansing function of the respiratory system, for they, too, are lined with mucous membranes and ciliated cells that move mucus upward to the pharynx.

E Alveoli

Human Lungs

Though the right lung has three lobes, the left lung, with a cleft to accommodate the heart, has only two. The two branches of the trachea, called bronchi, subdivide within the lobes into smaller and smaller air vessels. They terminate in alveoli, tiny air sacs surrounded by capillaries. When the alveoli inflate with inhaled air, oxygen diffuses into the blood in the capillaries to be pumped by the heart to the tissues of the body, and carbon dioxide diffuses out of the blood into the lungs, where it is exhaled.

The bronchioles divide many more times in the lungs to create an impressive tree with smaller and smaller branches, some no larger than 0.5 mm (0.02 in) in diameter. These branches dead-end into tiny air sacs called alveoli. The alveoli deliver oxygen to the circulatory system and remove carbon dioxide. Interspersed among the alveoli are numerous macrophages, large white blood cells that patrol the alveoli and remove foreign substances that have not been filtered out earlier. The macrophages are the last line of defense of the respiratory system; their presence helps ensure that the alveoli are protected from infection so that they can carry out their vital role.

The alveoli number about 150 million per lung and comprise most of the lung tissue. Alveoli resemble tiny, collapsed balloons with thin elastic walls that expand as air flows into them and collapse when the air is exhaled. Alveoli are arranged in grapelike clusters, and each cluster is surrounded by a dense hairnet of tiny, thin-walled capillaries. The alveoli and capillaries are arranged in such a way that air in the wall of the alveoli is only about 0.1 to 0.2 microns from the blood in the capillary. Since the concentration of oxygen is much higher in the alveoli than in the capillaries, the oxygen diffuses from the alveoli to the capillaries. The oxygen flows through the capillaries to larger vessels, which carry the oxygenated blood to the heart, where it is pumped to the rest of the body.

Carbon dioxide that has been dumped into the bloodstream as a waste product from cells throughout the body flows through the bloodstream to the heart, and then to the alveolar capillaries. The concentration of carbon dioxide in the capillaries is much higher than in the alveoli, causing carbon dioxide to diffuse into the alveoli. Exhalation forces the carbon dioxide back through the respiratory passages and then to the outside of the body.

III REGULATION

Diaphragm and Respiration As the diaphragm contracts and moves downward, the pectoralis minor and intercostal muscles pull the rib cage outward. The chest cavity expands, and air rushes into the lungs through the trachea to fill the resulting vacuum. When the diaphragm relaxes to its normal, upwardly curving position, the lungs contract, and air is forced out.

The flow of air in and out of the lungs is controlled by the nervous system, which ensures that humans breathe in a regular pattern and at a regular rate. Breathing is carried out day and night by an unconscious process. It begins with a cluster of nerve cells in the brain stem called the respiratory center. These cells send simultaneous signals to the diaphragm and rib muscles, the muscles involved in inhalation. The diaphragm is a large, dome-shaped muscle that lies just under the lungs. When the diaphragm is stimulated by a nervous impulse, it flattens. The downward movement of the diaphragm expands the volume of the cavity that contains the lungs, the thoracic cavity. When the rib muscles are stimulated, they also contract, pulling the rib cage up and out like the handle of a pail. This movement also expands the thoracic cavity. The increased volume of the thoracic cavity causes air to rush into the lungs. The nervous stimulation is brief, and when it ceases, the diaphragm and rib muscles relax and exhalation occurs. Under normal conditions, the respiratory center emits signals 12 to 20 times a minute, causing a person to take 12 to 20 breaths a minute. Newborns breathe at a faster rate, about 30 to 50 breaths a minute.

The rhythm set by the respiratory center can be altered by conscious control. The breathing pattern changes when a person sings or whistles, for example. A person also can alter the breathing pattern by holding the breath. The cerebral cortex, the part of the brain involved in thinking, can send signals to the diaphragm and rib muscles that temporarily override the signals from the respiratory center. The ability to hold ones breath has survival value. If a person encounters noxious fumes, for example, it is possible to avoid inhaling the fumes.

A person cannot hold the breath indefinitely, however. If exhalation does not occur, carbon dioxide accumulates in the blood, which, in turn, causes the blood to become more acidic. Increased acidity interferes with the action of enzymes, the specialized proteins that participate in virtually all biochemical reaction in the body. To prevent the blood from becoming too acidic, the blood is monitored by special receptors called chemoreceptors, located in the brainstem and in the blood vessels of the neck. If acid builds up in the blood, the chemoreceptors send nervous signals to the respiratory center, which overrides the signals from the cerebral cortex and causes a person to exhale and then resume breathing. These exhalations expel the carbon dioxide and bring the blood acid level back to normal.

A person can exert some degree of control over the amount of air inhaled, with some limitations. To prevent the lungs from bursting from overinflation, specialized cells in the lungs called stretch receptors measure the volume of air in the lungs. When the volume reaches an unsafe threshold, the stretch receptors send signals to the respiratory center, which shuts down the muscles of inhalation and halts the intake of air.

THE DIGESTIVE SYSTEM

The Digestive System is a series of connected organs whose purpose is to break down, or digest, the food we eat. Food is made up of large, complex molecules, which the digestive system breaks down into smaller, simple molecules that can be absorbed into the bloodstream. The simple molecules travel through the bloodstream to all of the body's cells, which use them for growth, repair, and energy.

All animals have a digestive system, a feature that distinguishes them from plants. Plants produce their own food in a process called photosynthesis, during which they use sunlight to convert water and carbon dioxide into simple sugars. But animals, including humans, must take in food in the form of organic matter, such as plants or other animals.

Digestion generally involves two phases: a mechanical phase and a chemical phase. In the mechanical phase, teeth or other structures physically break down large pieces of food into smaller pieces. In the chemical phase, digestive chemicals called enzymes break apart individual molecules of food to yield molecules that can be absorbed and distributed throughout the body. These enzymes are secreted (produced and released) by glands in the body.

The digestive system of most animals consists mainly of a long, continuous tube called the alimentary canal, or digestive tract. This canal has a mouth at one end, through which food is taken in, and an anus at the other end, through which digestive wastes are excreted. Muscles in the walls of the alimentary canal move the food along. Most digestive organs are part of the alimentary canal. However, two accessory digestive organs, the liver and pancreas, are located outside the alimentary canal. These organs contribute to chemical digestion by releasing digestive juices into the canal through tubes called ducts.

THE HUMAN DIGESTIVE SYSTEM

The human digestive system consists of a series of organs and structures that help break down food and absorb nutrients for use throughout the body. Food enters the digestive system through the mouth and passes through the esophagus, stomach, small intestine, large intestine, and rectum. Other organs, such as the liver, further aid in the breakdown of food, absorption of nutrients, and elimination of undigestible materials from the body

If a human adults digestive tract were stretched out, it would be 6 to 9 m (20 to 30 ft) long. In humans, digestion begins in the mouth, where both mechanical and chemical digestion occur. The mouth quickly converts food into a soft, moist mass. The muscular tongue pushes the food against the teeth, which cut, chop, and grind the food. Glands in the cheek linings secrete mucus, which lubricates the food, making it easier to chew and swallow. Three pairs of glands empty saliva into the mouth through ducts to moisten the food. Saliva contains the enzyme ptyalin, which begins to hydrolyze (break down) starcha carbohydrate manufactured by green plants.

Once food has been reduced to a soft mass, it is ready to be swallowed. The tongue pushes this masscalled a bolusto the back of the mouth and into the pharynx. This cavity between the mouth and windpipe serves as a passageway both for food on its way down the alimentary canal and for air passing into the windpipe. The epiglottis, a flap of cartilage, covers the trachea (windpipe) when a person swallows. This action of the epiglottis prevents choking by directing food from the windpipe and toward the stomach.

A The Esophagus

The presence of food in the pharynx stimulates swallowing, which squeezes the food into the esophagus. The esophagus, a muscular tube about 25 cm (10 in) long, passes behind the trachea and heart and penetrates the diaphragm (muscular wall between the chest and abdomen) before reaching the stomach. Food advances through the alimentary canal by means of rhythmic muscle contractions (tightenings) known as peristalsis. The process begins when circular muscles in the esophagus wall contract and relax (widen) one after the other, squeezing food downward toward the stomach. Food travels the length of the esophagus in two to three seconds.

A circular muscle called the esophageal sphincter separates the esophagus and the stomach. As food is swallowed, this muscle relaxes, forming an opening through which the food can pass into the stomach. Then the muscle contracts, closing the opening to prevent food from moving back into the esophagus. The esophageal sphincter is the first of several such muscles along the alimentary canal. These muscles act as valves to regulate the passage of food and keep it from moving backward.

B The Stomach

The stomach, located in the upper abdomen just below the diaphragm, is a saclike structure with strong, muscular walls. The stomach can expand significantly to store all the food from a meal for both mechanical and chemical processing. The stomach contracts about three times per minute, churning the food and mixing it with gastric juice. This fluid, secreted by thousands of gastric glands in the lining of the stomach, consists of water, hydrochloric acid, an enzyme called pepsin, and mucin (the main component of mucus). Hydrochloric acid creates the acidic environment that pepsin needs to begin breaking down proteins. It also kills microorganisms that may have been ingested in the food. Mucin coats the stomach, protecting it from the effects of the acid and pepsin. About four hours or less after a meal, food processed by the stomach, called chyme, begins passing a little at a time through the pyloric sphincter into the duodenum, the first portion of the small intestine.

C The Small Intestine

Most digestion, as well as absorption of digested food, occurs in the small intestine. This narrow, twisting tube, about 2.5 cm (1 in) in diameter, fills most of the lower abdomen, extending about 6 m (20 ft) in length. Over a period of three to six hours, peristalsis moves chyme through the duodenum into the next portion of the small intestine, the jejunum, and finally into the ileum, the last section of the small intestine. During this time, the liver secretes bile into the small intestine through the bile duct. Bile breaks large fat globules into small droplets, which enzymes in the small intestine can act upon. Pancreatic juice, secreted by the pancreas, enters the small intestine through the pancreatic duct. Pancreatic juice contains enzymes that break down sugars and starches into simple sugars, fats into fatty acids and glycerol, and proteins into amino acids. Glands in the intestinal walls secrete additional enzymes that break down starches and complex sugars into nutrients that the intestine absorbs. Structures called Brunners glands secrete mucus to protect the intestinal walls from the acid effects of digestive juices.

The small intestines capacity for absorption is increased by millions of fingerlike projections called villi, which line the inner walls of the small intestine. Each villus is about 0.5 to 1.5 mm (0.02 to 0.06 in) long and covered with a single layer of cells. Even tinier fingerlike projections called microvilli cover the cell surfaces. This combination of villi and microvilli increases the surface area of the small intestines lining by about 150 times, multiplying its capacity for absorption. Beneath the villis single layer of cells are capillaries (tiny vessels) of the bloodstream and the lymphatic system. These capillaries allow nutrients produced by digestion to travel to the cells of the body. Simple sugars and amino acids pass through the capillaries to enter the bloodstream. Fatty acids and glycerol pass through to the lymphatic system.

D The Large Intestine

A watery residue of indigestible food and digestive juices remains unabsorbed. This residue leaves the ileum of the small intestine and moves by peristalsis into the large intestine, where it spends 12 to 24 hours. The large intestine forms an inverted U over the coils of the small intestine. It starts on the lower right-hand side of the body and ends on the lower left-hand side. The large intestine is 1.5 to 1.8 m (5 to 6 ft) long and about 6 cm (2.5 in) in diameter.

The large intestine serves several important functions. It absorbs waterabout 6 liters (1.6 gallons) dailyas well as dissolved salts from the residue passed on by the small intestine. In addition, bacteria in the large intestine promote the breakdown of undigested materials and make several vitamins, notably vitamin K, which the body needs for blood clotting. The large intestine moves its remaining contents toward the rectum, which makes up the final 15 to 20 cm (6 to 8 in) of the alimentary canal. The rectum stores the feceswaste material that consists largely of undigested food, digestive juices, bacteria, and mucusuntil elimination. Then, muscle contractions in the walls of the rectum push the feces toward the anus. When sphincters between the rectum and anus relax, the feces pass out of the body.

IV REGULATION OF THE DIGESTIVE PROCESS

The body coordinates the various steps of digestion so that the process proceeds smoothly and cells obtain a steady supply of nutrients and energy. The central nervous system and various glands control activities that regulate the digestive process, such as the secretion of enzymes and fluids. For example, the presence of food in the esophagus, stomach, or intestines triggers peristalsis. Food entering the stomach also stimulates the central nervous system to initiate the release of gastric juice. And as hydrochloric acid passes from the stomach, the small intestine produces secretin, a substance that simulates secretion of pancreatic juice.

Nervous SystemNervous System

is the master controlling and communicating system of the body

its functions are:

a. it uses its million of sensory receptors to monitor changes (stimuli) occurring both inside and outside the body ( sensory input)

b. it processes and interprets the sensory input and makes decisions about what should be done at each moment ( integration)

c. it then effects a response by activating muscles or glands ( motor output)

Meninges

- connective tissue layers which covers and protects the CNS structures

Three (3) Meninges of the Brain

a. Dura mater

- outer layer is tough white fibrous connective tissue

b. Arachnoid

- middle layer of meninges, which resembles a cobweb in appearance, is a thin

layer with numerous threadlike strands that attach it to the innermost layer

c. Pia mater

the innermost layer of meninges

thin, delicate membrane that is tightly bound to the surface of the brain and spinal cord and cannot be dissected away without damaging the surface

Motor Neurons

A. Upper motor Neurons nerve cells in the cerebral cortex that help make up the following nerve tracts:

a. Corticospinal Tract

The Corticospinal Tract is the largest descending pathway in man. It originates in part from the pyramidal cells in the cortex of each cerebral hemisphere and courses through the internal capsule, then through the medullary pyramids. At this point some 80% of the fibres from each hemisphere, decussate in the pyramidal decussation, and continue to descend in the lateral white column of the opposite side. The remaining 20% continue down ipsilaterally, in the ventro-medial white column, to innervate bilaterally, the more medially located motor neurones of the axial and proximal muscles.

The crossed fibres in the lateral white columns comprise both sensory axons (from post-central gyrus and parietal association areas), and motor axons (from precentral gyrus and prefrontal areas). The sensory axons project into the dorsal horn of the grey matter, to effect feedback regulation of the input pathways. The motor axons terminate on motor neurons of the distal muscles, either directly or indirectly via interneurons.

There is some controversy as to the exact contribution of different areas of cerebral cortex to the corticospinal tracts. Two proposed schemes are illustrated below, but authorities vary widely.

b. Corticobulbar Tract

The corticobulbar (or corticonuclear) tract is a white matter pathway connecting the cerebral cortex to the brainstem (the term "bulbar" referring to the brainstem).

The 'bulb' is an archaic term for the medulla oblongata. In clinical usage, it includes the pons as well.

The muscles of the face, head and neck are controlled by the corticobulbar system, which terminates on motor neurons within brainstem motor nuclei. This is in contrast to the corticospinal tract, which connects the cerebral cortex to spinal motor neurons, and controls movement of the torso, upper and lower limbs.B. Lower Motor Neurons

Lower motor neurons (LMNs) are the motor neurons connecting the brainstem and spinal cord to muscle fibers, bringing the nerve impulses from the upper motor neurons out to the muscles.

Anatomy and Physiology of Cerebrospinal Fluid

The CSF is clear colorless fluid which has minimal content of protein. It is contained in the ventricular system as well as the subarachnoid spaces surrounding the brain and the spinal cord. The CSF is in hydrostatic equilibrium with the interstitial tissue of the brain and can permeate across the brain tissue in both directions. It is expected that the brain tissue and the CSF would have the same hydrostatic pressure in any part of the brain. As much as the brain tissue is protected by a blood brain barrier from changes outside the central nervous system, the CSF has the same protection and does not change biochemically as a result of changes in the systemic circulation. These barriers are at the level of the endothelium of brain capillaries, at the level of the epithelium of the choroid plexuses and the outer layers of arachnoid matter. These barriers protect the brain and the subarachnoid spaces from damaging influences outside the brain.

Cerebrospinal Fluid Volume and Distribution

The cerebrospinal fluid fills the cavity of the ventricles and the subarachnoid spaces. The subarachnoid spaces are wide in certain areas and these are called cisterns. At the cerebellomedullary area the cistern is called cisterna magna. We have also the pre-pontine cistern surrounding the basilar artery and the interpeduncular cistern surrounding the circle of Willis. The subarachnoid space extends caudally around the spinal cord and ends in lumbar -sacral dural sac where it surrounds the cauda equina.

The average volume of intracranial cerebrospinal fluid is 125 mls with 89 mls in the subarachnoid space. The volume of CSF in the lumbar sac is about 30 mls.Cerebrospinal Fluids Formation

The majority of CSF is produced by the choroid plexuses, there are assumptions that some CSF is formed outside the choroid plexuses, from the brain substance. This is estimated to be about 10 to 15% of the whole volume of CSF.

It is believed that CSF is formed at a rate of .5 ml per minute. It is believed that there is a persistent and steady production of CSF irrespective of systemic changes. It is independent of the mean arterial blood pressure until this is reduced below 60 mmHg. However it is believed that the perfusion pressure influenced the production of CSF i.e. CSF production is reduced at a higher threshold of systemic blood pressure when the CSF pressure is raised. Reduction of perfusion pressure might act by diminishing choroid plexus blood flow and the supply of necessary material for CSF secretion.

CSF Circulation and Drainage

From the lateral ventricles CSF passes through the foramen of Munro to the 3rd ventricle(fig 1). From there it passes through the aqueduct of the Sylvius to the 4th ventricle. With the CSF formed by the choroid plexus in the 4th ventricle it exits through the roof of the 4th ventricle. From there it passes along the outer surface of the cerebellum and through the basal cisterns. It passes through the hiatus of the tent to the Sylvian fissures and from there to the para-sagittal area. It is excreted by the arachnoid villi into the venous sinus, mainly the sagittal sinus. It is believed that CSF takes one to two hours to reach the basal cisterns, 3 to 4 hours to reach the sylvian fissure and 10 to 12 hours to spread over the cerebral subarachnoid space. By 24 hours it started to be cleared into the superior sagittal sinus. The mechanism by which the CSF is secreted through the arachnoid villi is still not clear.

Normal CSF Pressure

In children and babies CSF pressure is low. In infants it is estimated to be 40 to 50 mms of water and in children from 40 - 100 mms of water. In older age group it remains constant of about 150 mms of water or 15 mm of Mercury. Pressures above 200 mms mms of water or 20 mms of Mercury are considered abnormal.

The cerebral spinal fluid pressure is dependent on intracranial venous pressure; it is usually about 40 to 50 mms of water above the intracranial venous pressure. The difference in pressure is related to the continuous production of CSF and resistance to its secretion.

There are fluctuations in the CSF pressure, these are influenced by ventilation and cardiac contraction .CSF pressure falls with inspiration and rises during expiration, a variation of about 40 mms of water.

VI. LABORATORY

BLOOD CHEMISTRY

TEST09/25/0610/06/06NORMAL VALUES

Creatinine0.2mg/dL0.4 1.5mg/dL

AST402U/L51U/L16-35U/L

Glucose(RBS)247mg/dL