consequences of dumping syndrome

Arterial supply of the upper and lower leg

muscles
Functions of the different nuclei of the
hypothalamus
ECG findings consistent with left and right
axis deviations
PO2, O2 sat and O2 content changes with
exercise
Physiological mechanisms and
consequences of dumping
syndrome
 Dumping Syndrome
• Complaints: bloating, nausea, diarrhea, dizziness, weakness,
sweating, and rapid heartbeat; may occur 30 to 60 minutes
after eating a meal and then again, 2 to 3 hours after eating
• Cause of early symptoms: concentrated sugar passes too rapidly
from the stomach into the intestine → the body dilutes this
sugar mixture by bringing fluid from body tissues into the
intestine → sense of fullness, cramping, and occasionally,
diarrhea.
• Loss of water from tissues → temporary drop in blood pressure, with
resulting weakness and faintness → sympathetic baroreflex → ↑ HR,
CO, vasoconstriction
 Dumping Syndrome
• Cause of later symptoms: rapid absorption of sugar into the
bloodstream → ↑ blood sugar level → ↑ insulin production →
drive blood sugar levels down → the weakness, hunger, and
rapid heart rate that may occur about two to three hours after
eating
• TX: Anti-Dumping or Post-Gastrectomy Diet - regular diet with
frequent small meals and reduced simple sugars
• Depending on the type and extent of gastric surgery performed, poor
absorption of nutrients, vitamins, and minerals may occur to a
significant degree.
• Some patients may become deficient in iron, calcium, folate, and B-12
so may need to prescribe vitamin/mineral supplementation and B-12
injections
Arterial supply of the upper and lower leg muscles
 Heart (left ventricle)

Aorta

Common Iliac a.

External Iliac a. Internal iliac a.

Femoral a. Obturator a.

Gluteal aa.
 Heart (right atrium)

Inferior vena cava

Common Iliac v.

External Iliac v. Internal iliac v.

Femoral v. Obturator v.

Great
Gluteal vv.
saphenous v.
Vasculature of Thigh
Compartment Muscle Function Nerve Artery

Hip flexion; Femoral a.

Anterior Femoral n.
knee extension (Vastus lateral m.) Perforating br., deep femoral a.

Medial Hip adduction Obturator n. Obturator a.

(Add. magnus m.) Perforating br., deep femoral a.

Hip extension;
Posterior knee flexion Sciatic n. Deep femoral a., including perforating br.
Femoral Triangle
Boundaries of femoral triangle
• Superior – inguinal ligament
• Medial – adductor longus m.
• Lateral – sartorius m.

Contains the femoral nerve, artery, vein; and the

deep inguinal lymph nodes.
 Deep Femoral A.
• AKA profunda femoris a.
• Branches from femoral a. within the femoral triangle
• Gives off the medial and lateral circumflex femoral
branches.
• Perforating branches (4) supply all three
compartments
• Vastus lateralis m., anterior compartment
• Adductor magnus m., medial compartment
• Hamstring mm., posterior compartment
Circumflex Femoral Arteries
Medial circumflex femoral a. (MCFA)
• Major artery of femoral neck & head

Lateral circumflex femoral a. (LCFA)

• Ascending br. to lateral hip
• Trochanteric anastomosis of hip
• Transverse br. to lateral hip
• Cruciate anastomosis of thigh
• Descending br. to lateral knee
• Genicular anastomosis (superior lateral genicular a.)
Arterial Anastomoses of Hip & Thigh
 Cruciate Anastomosis
Supplies the superior thigh.

In the event of a external iliac or

femoral a. blockage, blood can reach
popliteal artery (leg) through branches
of the internal iliac a.
 Cruciate Anastomosis
Formed by:
1. Inferior gluteal a.
2. Medial femoral circumflex a.
(from deep femoral a.)
3. Lateral femoral circumflex a.
(from deep femoral a.)
4. First perforating branch
(from deep femoral a.)
 Cruciate Anastomosis
Formed by:
1. Inferior gluteal a. 1

2. Medial femoral circumflex a.

(from deep femoral a.)
3. Lateral femoral circumflex a.
(from deep femoral a.) 2 3

4. First perforating branch

(from deep femoral a.)

4
Trochanteric Anastomosis
Supplies the hip joint.

Formed by:
• Deep femoral a.
• Medial femoral circumflex branch (MCFB)
• Retinacular aa. to head & neck of the femur
• Lateral femoral circumflex branch (LCFB)
• Obturator artery
• Acetabular branch
(AKA artery to the head of the femur)
• Superior gluteal artery (deep br.)
• Inferior gluteal artery
 Vasculature of Leg
Arterial supply: femoral a. becomes
popliteal a. after passing through
adductor hiatus
• Genicular aa.
• Anterior tibial a.
• Dorsal pedal a.
• Posterior tibial a.
• Fibular a.
• Plantar aa.

Posterior Anterior
 Knee Joint (Genicular Anastomoses)
Femoral a.
• Deep femoral a.
• Descending br., lateral circumflex femoral a. (1)
• Descending genicular a. (2)
• Popliteal a.
• Superior medial genicular a. (3)
• Superior lateral genicular a. (4)
• Middle genicular* a.
• Inferior medial genicular a. (5)
• Inferior lateral genicular a. (6)
• Anterior tibial a.
• Posterior* and anterior tibial (7) recurrent aa.
• Posterior tibial a.
*not shown• Fibular circumflex a*
Popliteal Artery Occlusion
Causes:
• Atherosclerosis (common site)
• Knee dislocation

Symptoms:
• Claudication (intermittent cramping)
• Cyanosis, decreased temperature
• Loss of distal pulses
• Pain and numbness
• Atrophic changes to nails, skin, muscles in leg
Popliteal Artery Occlusion
How is arterial blood bypassing this
popliteal a. blockage?
Compartment Muscle Function Nerve Artery

Anterior Ankle dorsiflexion; digit extension Deep fibular n. Anterior tibial a.

Lateral Foot eversion Superficial fibular n. Fibular a.

Posterior Ankle plantarflexion; digit flexion Tibial n. Posterior tibial a.

Functions of the different nuclei of the
hypothalamus
Helpful Hints
• This link has more explanations,
http://epomedicine.com/medical-students/nuclei-hypothalamus-mn
emonic/
ECG findings consistent with left and right axis
deviations
 QRS Axis (of Depolarization)
Note: the location of the positive electrode for each lead

+ +
+

+ +
 Axis Determination

Rapid Approach:

• Lead I: if positive, mean axis vector is toward left

• AVF: If positive, mean axis vector is downward

• Many other approaches…..think about other general

trends that give you a rapid insight
 Axis Determination
Rapid Approach:

• Lead I: if positive, vector is toward left

• AVF: If positive, vector is downward
 Axis Determination
Rapid Approach:

• Lead I: if negative, vector is toward right

• AVF: If positive, vector is downward
 Axis Determination
Rapid Approach:

• Lead I: if positive, vector is toward left

• AVF: If negative, vector is upward
 Axis Determination

Abberant Axes (Deviations):

• Left Axis Deviation: QRS negative in AVF, positive in I

(mean axis < -30 )

• Right axis deviation: QRS negative in I

(mean axis > +110)

• Change of axis may provide diagnostic insight

Right Axis Deviation
RV Hypertrophy Due to Pulmonary
Stenosis

Guyton, Textbook of Medical Physiology, 7 ed

Left Axis Deviation Due to Systemic
Hypertension

Guyton, Textbook of Medical Physiology, 7 ed

Left Axis Deviation
Left Bundle Branch Block

Guyton, Textbook of Medical Physiology, 7 ed

Helpful Hints
• If you’re struggling w/ determining axis deviation, I would NOT look at
Smith’s explanation. The EKG book in the bible is helpful, youtube is
great. Ask a friend, anything but the ppt!

• L. Axis Deviation: systemic HTN

• R. Axis Deviation: pulmonary HTN, RV Hypertrophy, anything
pulmonary (more or less)
PO2, O2 sat and O2 content changes with exercise
Questions
• A patient with hypotension (BP = 90/60) will have
(↑, ↓, same) size of zone 1 blood flow compared
with a patient with normotension (BP = 120/80).
• During exercise a patient would have greater
capillary perfusion in which zone?
• During resting conditions a normal patient would
exhibit a (large, small) volume of zone 1 blood
flow.
Diffusion of Oxygen
• PO2 of RBC as enters pulmonary capillary
(40).

• O2 travels down the large pressure gradient

and PO2 of RBC  to ~100 mmHg.

• If alveolar wall thickened,  diffusion of O2.

• Thus “Abnormal” diffusion

• Exercise  cardiac output and  time RBC in

capillary.
 Metabolism & O2 Extraction

• The metabolism in the tissues leads to oxygen being extracted

from the blood

• Thus, PO2 decreases as blood moves from the artery to vein

• The a-v O2 difference is therefore a measure of O2 extraction

• Normally, O2 extraction is ~ 5 ml/dL at rest

• **** O2 extraction increases progressively with exercise

What happens during dynamic (aerobic) exercise?

• Think through the components of the alveolar gas equation

(previous slides)

• Explain what changes must be occurring to explain why

1)At mild exercise PaCO2 does not change

2)At intense exercise PaCO2 decreases (hyperventilation)

Exercise: Ventilatory (lactate) Threshold
[normally occurs at workloads above 70% of maximum]

Ventilation

Alveolar Ventilation
threshold (breakpoint)

Drives for ventilation:

Maximal workload
Below Ventilatory threshold
“Central command” signals from motor cortex
Reflex from muscles & tendons –
VCO2 & VA increase in direct proportion and
thus PaCO2 remains constant
Exercise Workload
(VO2) Above Ventilatory threshold
Additional contribution from acidosis
stimulating chemoreceptors—
VA increases disproportionately more than
VCO2 & thus PaCO2 is decreased