Word Parts

Medical terms are built from word parts. Those word parts are prefix, word root, suffix, and combining form vowel. When a word root is combined with a combining form vowel the word part is referred to as a combining form.

Identifying Word Parts in Medical Terms

By the end of this resource, you will have identified hundreds of word parts within medical terms.  Let’s start with some common medical terms that many non-medically trained people may be familiar with.

Language Rules

Language rules are a good place to start when building a medical terminology foundation.  Many medical terms are built from word parts and can be translated literally. At first, literal translations sound awkward. Once you build a medical vocabulary and become proficient at using it, the awkwardness will slip away. For example, suffixes will no longer be stated and will be assumed. The definition of intravenous then becomes within the vein.

Since you are at the beginning of building your medical terminology foundation stay literal when applicable. It should be noted that as with all language rules there are always exceptions and we refer to those as rebels. So let’s begin by analyzing the language rules for medical terminology.

Language Review

Before we begin analyzing the rules let’s complete a short language review that will assist with pronunciation and spelling. In class, you will practice pronunciation with your Instructor.

Language Rules for Building Medical Terms

1. When combining two combining forms you keep the combining form vowel.
2. When combining a combining form with a suffix that begins with a consonant you keep the combining form vowel.

   Examples

   Gastr/o/enter/o/logy – The study of the stomach and the intestines

   • Following rule 1, when we join combining form gastr/o (meaning stomach) with the combining form enter/o (meaning intestines) we keep the combining form vowel o.
   • Following rule 2, when we join the combining form enter/o (meaning intestines) with the suffix -logy (that starts with a suffix and means the study of) we keep the combining form vowel o.
3. When combining a combining form with a suffix that begins with a vowel you drop the combining form vowel.
4.  A prefix goes at the beginning of the word and no combining form vowel is used.

   Examples

   Intra/ven/ous – Pertaining to within the vein

   • Following rule 3, notice that when combining the combining form ven/o (meaning vein) with the suffix -ous ( that starts with a vowel and means pertaining to) we drop the combining form vowel o.
   • Following rule 4, the prefix intra- (meaning within) is at the beginning of the medical term with no combining form vowel used.
5. When defining a medical word, start with the suffix first and then work left to right stating the word parts. You may need to add filler words. As long as the filler word does not change the meaning of the word you may use it for the purpose of building a medical vocabulary. Once you start to apply the word in the context of a sentence it will be easier to decide which filler word(s) to choose.

   Examples

   Intra/ven/ous – Pertaining to within the vein or Pertaining to within a vein.

   • Following rule 5, notice that I start with the suffix -ous (that means pertaining to) then we work left to right starting with the prefix Intra- (meaning within) and the combining form ven/o (meaning vein).
   • Notice that we have used two different definitions that mean the same thing.
   • In these examples we do not have the context of a full sentence. For the purpose of building a medical terminology foundation either definition is accepted.

Prefixes are located at the beginning of a medical term. The prefix alters the meaning of the medical term. It is important to spell and pronounce prefixes correctly.

Many prefixes that you find in medical terms are common to English language prefixes. A good technique to help with memorization is the following:

• Start by reviewing the most common prefixes.
• Consider common English language words that begin with the same prefixes.
• Compare them to the examples of use in medical terms.

Suffixes are word parts that are located at the end of words. Suffixes can alter the meaning of medical terms. It is important to spell and pronounce suffixes correctly.

Suffixes in medical terms are common to English language suffixes. Suffixes are not always explicitly stated in the definition of a word. It is common that suffixes will not be explicitly stated when defining a medical term in the workplace. However, when transcribing or reading medical reports the suffix is always clearly written. In order to properly spell and pronounce medical terms, it is helpful to learn the suffixes.

As you memorize the language components of medical terminology it is important to support that learning within the context of anatomy and physiology. Proceeding through the body system chapters you will learn word parts, whole medical terms, and common abbreviations. It is important to put into context where in the body the medical term is referencing, and then consider how it works within the body.

Anatomy focuses on structure and physiology focuses on function. Much of the study of physiology centers on the body’s tendency toward homeostasis .

Consider the structures of the body in terms of fundamental levels of organization that increase in complexity: subatomic particles, atoms, molecules, organelles, cells, tissues, organs, organ systems, organisms, and biosphere (Figure 5.1).

Figure 5.1 Levels of Structural Organization of the Human Body. The organization of the body often is discussed in terms of six distinct levels of increasing complexity, from the smallest chemical building blocks to a unique human organism. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

The Levels of Organization

• The smallest unit of any of these pure substances (elements) is an atom.
  • Atoms are made up of subatomic particles such as the proton, electron, and neutron.
• Two or more atoms combine to form a molecule, such as the water molecules, proteins, and sugars found in living things.
  • Molecules are the chemical building blocks of all body structures.
• A cell is the smallest independently functioning unit of a living organism.
  • Even bacteria, which are extremely small, independently-living organisms, have a cellular structure. Each bacterium is a single cell. All living structures of human anatomy contain cells, and almost all functions of human physiology are performed in cells or are initiated by cells
  • A human cell typically consists of flexible membranes that enclose cytoplasm, a water-based cellular fluid, together with a variety of tiny functioning units called organelles. In humans, as in all organisms, cells perform all functions of life.
• A tissue is a group of many similar cells (though sometimes composed of a few related types) that work together to perform a specific function.
• An organ is an anatomically distinct structure of the body composed of two or more tissue types. Each organ performs one or more specific physiological functions.

An organ system is a group of organs that work together to perform major functions or meet the physiological needs of the body.

Consider the breakdown into eleven distinct organ systems in the human body (Figure 5.2 and Figure 5.3). Assigning organs to organ systems can be imprecise since organs that “belong” to one system can also have functions integral to another system. In fact, most organs contribute to more than one system.

Figure 5.2. Organ Systems of the Human Body. Organs that work together are grouped into organ systems. From Betts, et al., 2013. Licensed under CC BY 4.0 [Image description.]

Figure 5.3. Organ Systems of the Human Body (continued). Organs that work together are grouped into organ systems. From Betts, et al., 2013. Licensed under CC BY 4.0 [Image description.]

The organism level is the highest level of organization. An organism is a living being that has a cellular structure and that can independently perform all physiologic functions necessary for life. In multicellular organisms, including humans, all cells, tissues, organs, and organ systems of the body work together to maintain the life and health of the organism.

Watch this video:

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Media 5.1. Introduction to Anatomy & Physiology: Crash Course A&P #1 [Online video]. Copyright 2015 by CrashCourse.

Anatomical Position

Anatomists and health care providers use terminology for the purpose of precision and to reduce medical errors. For example, is a scar “above the wrist” located on the forearm two or three inches away from the hand? Or is it at the base of the hand? Is it on the palm-side or back-side? By using precise anatomical terminology, we eliminate ambiguity. Anatomical terms derive from ancient Greek and Latin words.

To further increase precision, anatomists standardize the way in which they view the body. Just as maps are normally oriented with north at the top, the standard body “map,” or anatomical position, is that of the body standing upright, with the feet at shoulder width and parallel, toes forward. The upper limbs are held out to each side, and the palms of the hands face forward as illustrated.

Using this standard position reduces confusion. It does not matter how the body being described is oriented, the terms are used as if it is in anatomical position. For example, a scar in the “anterior (front) carpal (wrist) region” would be present on the palm side of the wrist. The term “anterior” would be used even if the hand were palm down on a table.

Figure 5.4. Regions of the Human Body. The human body is shown in anatomical position in an (a) anterior view and a (b) posterior view. The regions of the body are labeled in boldface. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

A body that is lying down is described as either prone or supine.  These terms are sometimes used in describing the position of the body during specific physical examinations or surgical procedures.

Directional Terms

Directional terms are essential for describing the relative locations of different body structures. For instance, an anatomist might describe one band of tissue as “inferior to” another or a physician might describe a tumor as “superficial to” a deeper body structure. Commit these terms to memory to avoid confusion when you are studying or describing the locations of particular body parts.

• Anterior (or ventral) describes the front or direction toward the front of the body. The toes are anterior to the foot.
• Posterior (or dorsal) describes the back or direction toward the back of the body. The popliteus is posterior to the patella.
• Superior (or cranial) describes a position above or higher than another part of the body proper. The orbits are superior to the oris.
• Inferior (or caudal) describes a position below or lower than another part of the body proper; near or toward the tail (in humans, the coccyx, or lowest part of the spinal column). The pelvis is inferior to the abdomen.
• Lateral describes the side or direction toward the side of the body. The thumb (pollex) is lateral to the digits.
• Medial describes the middle or direction toward the middle of the body. The hallux is the medial toe.
• Proximal describes a position in a limb that is nearer to the point of attachment or the trunk of the body. The brachium is proximal to the antebrachium.
• Distal describes a position in a limb that is farther from the point of attachment or the trunk of the body. The crus is distal to the femur.
• Superficial describes a position closer to the surface of the body. The skin is superficial to the bones.
• Deep describes a position farther from the surface of the body. The brain is deep to the skull.

Figure 5.5. Directional Terms Applied to the Human Body. Paired directional terms are shown as applied to the human body. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Practice these directional terms.

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Concept Check

• Find a partner and take turns choosing two body parts on your or your partner’s body.
• Using directional terms, describe the location of those body parts relative to one another.

Body Cavities and Serous Membranes

The body maintains its internal organization by means of membranes, sheaths, and other structures that separate compartments. The dorsal (posterior) cavity and the ventral (anterior) cavity are the largest body compartments (Figure 5.6). These cavities contain and protect delicate internal organs, and the ventral cavity allows for significant changes in the size and shape of the organs as they perform their functions. The lungs, heart, stomach, and intestines, for example, can expand and contract without distorting other tissues or disrupting the activity of nearby organs.

Figure 5.6. Dorsal and Ventral Body Cavities. The ventral cavity includes the thoracic and abdominopelvic cavities and their subdivisions. The dorsal cavity includes the cranial and spinal cavities. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Subdivisions of the Posterior (Dorsal) and Anterior (Ventral) Cavities

The posterior (dorsal) and anterior (ventral) cavities are each subdivided into smaller cavities:

The posterior (dorsal) cavity has two main subdivisions:

• In the posterior (dorsal) cavity, the cranial cavity houses the brain
  • Protected by the bones of the skulls and cerebrospinal fluid
• The spinal cavity (or vertebral cavity) encloses the spinal cord.
  • Protected by the vertebral column and cerebrospinal fluid

The anterior (ventral) cavity has two main subdivisions:

• The thoracic cavity is the more superior subdivision of the anterior cavity, and it is enclosed by the rib cage.
  • The thoracic cavity contains the lungs and the heart, which is located in the mediastinum.
  • The diaphragm forms the floor of the thoracic cavity and separates it from the more inferior abdominopelvic cavity.
• The abdominopelvic cavity is the largest cavity in the body.
  • No membrane physically divides the abdominopelvic cavity.
  • The abdominal cavity houses the digestive organs, the pelvic cavity, and the reproductive organs.

Practice locating cavities.

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Abdominal Regions and Quadrants

To promote clear communication, for instance about the location of a patient’s abdominal pain or a suspicious mass, health care providers typically divide up the cavity into either nine regions or four quadrants.

Practice locating the quadrants.

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Tissue Membranes

A tissue membrane is a thin layer or sheet of cells that covers the outside of the body (for example, skin), the organs (for example, pericardium), internal passageways that lead to the exterior of the body (for example, abdominal mesenteries), and the lining of the movable joint cavities. There are two basic types of tissue membranes: connective tissue and epithelial membranes (Figure 5.7).

Figure 5.7. Tissue Membranes. The two broad categories of tissue membranes in the body are (1) connective tissue membranes, which include synovial membranes, and (2) epithelial membranes, which include mucous membranes, serous membranes, and the cutaneous membrane, in other words, the skin. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Did you know?

Synovial membranes line cavities which hold synovial fluid.

Synovial fluid lubricates the joints for movement.

 

Connective Tissue Membranes

• The connective tissue membrane is formed solely from connective tissue.
  • These membranes encapsulate organs, such as the kidneys, and line our movable joints.
• A synovial membrane is a type of connective tissue membrane that lines the cavity of a freely movable joint.
  • For example, synovial membranes surround the joints of the shoulder, elbow, and knee.

Epithelial Membranes

• The epithelial membrane is composed of epithelium attached to a layer of connective tissue.
  • For example, your skin.
• The mucous membrane is also a composite of connective and epithelial tissues.
  • Sometimes called mucosae, these epithelial membranes line the body cavities and hollow passageways that open to the external environment, and include the digestive, respiratory, excretory, and reproductive tracts.
  • Mucus, produced by the epithelial exocrine glands, covers the epithelial layer.
  • The underlying connective tissue, called the lamina propria (literally “own layer”), help support the fragile epithelial layer.
• The skin is an epithelial membrane also called the cutaneous membrane.
  • It is a stratified squamous epithelial membrane resting on top of connective tissue. The apical surface of this membrane is exposed to the external environment and is covered with dead, keratinized cells that help protect the body from desiccation and pathogens.

Membranes of the Anterior (Ventral) Body Cavity

• A serous membrane (also referred to as serosa) is an epithelial membrane composed of mesodermally derived epithelium called the mesothelium that is supported by connective tissue.  These membranes line the coelomic cavities of the body and they cover the organs located within those cavities. They are essentially membranous bags, with mesothelium lining the inside and connective tissue on the outside.
  • Parietal layers: line the walls of the body cavity.
  • Visceral layer:  covers the organs (the viscera).
  • Between the parietal and visceral layers is a very thin, fluid-filled serous space.

Figure 5.8. Serous Membrane. Serous membrane lines the pericardial cavity and reflects back to cover the heart—much the same way that an underinflated balloon would form two layers surrounding a fist. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

There are three serous cavities and their associated membranes. Serous membranes provide additional protection to the viscera they enclose by reducing friction that could lead to inflammation of the organs.

• Pleura: surrounds the lungs in the pleural cavity and reduces friction between the lungs and the body wall.
• Pericardium:  surrounds the heart in the pericardial cavity and reduces friction between the heart and the wall of the pericardium.
• Peritoneum: surrounds several organs in the abdominopelvic cavity. The peritoneal cavity reduces friction between the abdominal and pelvic organs and the body wall.

Test Yourself

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References

[CrashCourse]. (2015, January 6). Introduction to anatomy & physiology: Crash course A&P #1 [Video]. YouTube. https://youtu.be/uBGl2BujkPQ

Image Descriptions

Figure 5.1 image description: This illustration shows biological organization as a pyramid. The chemical level is at the apex of the pyramid where atoms bond to form molecules with three dimensional structures. An example is shown with two white hydrogen atoms bonding to a red oxygen atom to create water. The next level down on the pyramid is the cellular level, as illustrated with a long, tapered, smooth muscle cell. At this level, a variety of molecules combine to form the interior fluid and organelles of a body cell. The next level down is the tissue level. A community of similar cells forms body tissue. The example given here is a section of smooth muscle tissue, which contains many smooth muscle cells closely bound side by side. The next level down is the organ level, as illustrated with the bladder and urethra. The bladder contains smooth muscle while the urethra contains skeletal muscle. These are both examples of muscle tissues. The next level down is the organ system level, as illustrated by the entire urinary system containing the kidney, ureters, bladder and urethra. At this level, two or more organs work closely together to perform the functions of a body system. At the base of the pyramid is the organismal level illustrated with a woman drinking water. At this level, many organ systems work harmoniously together to perform the functions of an independent organism. [Return to Figure 5.1].

Figure 5.2 image description: This illustration shows eight silhouettes of a human female, each showing the components of a different organ system. The integumentary system encloses internal body structures and is the site of many sensory receptors. The integumentary system includes the hair, skin, and nails. The skeletal system supports the body and, along with the muscular system, enables movement. The skeletal system includes cartilage, such as that at the tip of the nose, as well as the bones and joints. The muscular system enables movement, along with the skeletal system, but also helps to maintain body temperature. The muscular system includes skeletal muscles, as well as tendons that connect skeletal muscles to bones. The nervous system detects and processes sensory information and activates bodily responses. The nervous system includes the brain, spinal cord, and peripheral nerves, such as those located in the limbs. The endocrine system secretes hormones and regulates bodily processes. The endocrine system includes the pituitary gland in the brain, the thyroid gland in the throat, the pancreas in the abdomen, the adrenal glands on top of the kidneys, and the testes in the scrotum of males as well as the ovaries in the pelvic region of females. The cardiovascular system delivers oxygen and nutrients to the tissues as well as equalizes temperature in the body. The cardiovascular system includes the heart and blood vessels.[Return to Figure 5.2].

Figure 5.3 image description: The lymphatic system returns fluid to the blood and defends against pathogens. The lymphatic system includes the thymus in the chest, the spleen in the abdomen, the lymphatic vessels that spread throughout the body, and the lymph nodes distributed along the lymphatic vessels. The respiratory system removes carbon dioxide from the body and delivers oxygen to the blood. The respiratory system includes the nasal passages, the trachea, and the lungs. The digestive system processes food for use by the body and removes wastes from undigested food. The digestive system includes the stomach, the liver, the gall bladder (connected to the liver), the large intestine, and the small intestine. The urinary system controls water balance in the body and removes and excretes waste from the blood. The urinary system includes the kidneys and the urinary bladder. The reproductive system of males and females produce sex hormones and gametes. The male reproductive system is specialized to deliver gametes to the female while the female reproductive system is specialized to support the embryo and fetus until birth and produce milk for the infant after birth. The male reproductive system includes the two testes within the scrotum as well as the epididymis which wraps around each testis. The female reproductive system includes the mammary glands within the breasts and the ovaries and uterus within the pelvic cavity. [Return to Figure 5.3]

Figure 5.4 image description: This illustration shows an anterior and posterior view of the human body. The cranial region encompasses the upper part of the head while the facial region encompasses the lower half of the head beginning below the ears. The eyes are referred to as the ocular region. The cheeks are referred to as the buccal region. The ears are referred to as the auricle or otic region. The nose is referred to as the nasal region. The chin is referred to as the mental region. The neck is referred to as the cervical region. The trunk of the body contains, from superior to inferior, the thoracic region encompassing the chest, the mammary region encompassing each breast, the abdominal region encompassing the stomach area, the coxal region encompassing the belt line, and the pubic region encompassing the area above the genitals. The umbilicus, or naval, is located at the center of the abdomen. The pelvis and legs contain, from superior to inferior, the inguinal or groin region between the legs and the genitals, the pubic region surrounding the genitals, the femoral region encompassing the thighs, the patellar region encompassing the knee, the crural region encompassing the lower leg, the tarsal region encompassing the ankle, the pedal region encompassing the foot and the digital/phalangeal region encompassing the toes. The great toe is referred to as the hallux. The regions of the upper limbs, from superior to inferior, are the axillary region encompassing the armpit, the brachial region encompassing the upper arm, the antecubital region encompassing the front of the elbow, the antebrachial region encompassing the forearm, the carpal region encompassing the wrist, the palmar region encompassing the palm, and the digital/phalangeal region encompassing the fingers. The thumb is referred to as the pollux. The posterior view contains, from superior to inferior, the cervical region encompassing the neck, the dorsal region encompassing the upper back and the lumbar region encompassing the lower back. The regions of the back of the arms, from superior to inferior, include the cervical region encompassing the neck, acromial region encompassing the shoulder, the brachial region encompassing the upper arm, the olecranal region encompassing the back of the elbow, the antebrachial region encompasses the back of the arm, and the manual region encompassing the palm of the hand. The posterior regions of the legs, from superior to inferior, include the gluteal region encompassing the buttocks, the femoral region encompassing the thigh, the popliteus region encompassing the back of the knee, the sural region encompassing the back of the lower leg, and the plantar region encompassing the sole of the foot. Some regions are combined into larger regions. These include the trunk, which is a combination of the thoracic, mammary, abdominal, naval, and coxal regions. The cephalic region is a combination of all of the head regions. The upper limb region is a combination of all of the arm regions. The lower limb region is a combination of all of the leg regions. [Return to Figure 5.4].

Figure 5.5 image description: This illustration shows two diagrams: one of a side view of a female and the other of an anterior view of a female. Each diagram shows directional terms using double-sided arrows. The cranial-distal arrow runs vertically behind the torso and lower abdomen. The cranial arrow is pointing toward the head while the caudal arrow is pointing toward the tail bone. The posterior/anterior arrow is running horizontally through the back and chest. The posterior or dorsal arrow is pointing toward the back while the anterior, or ventral arrow, is pointing toward the abdomen. On the anterior view, the proximal/distal arrow is on the right arm. The proximal arrow is pointing up toward the shoulder while the distal arrow is pointing down toward the hand. The lateral-medial arrow is a horizontal arrow on the abdomen. The medial arrow is pointing toward the navel while the lateral arrow is pointing away from the body to the right. Right refers to the right side of the woman’s body from her perspective while left refers to the left side of the woman’s body from her perspective. [Return to Figure 5.5].

Figure 5.6 image description: This illustration shows a lateral and anterior view of the body and highlights the body cavities with different colors. The cranial cavity is a large, bean-shaped cavity filling most of the upper skull where the brain is located. The vertebral cavity is a very narrow, thread-like cavity running from the cranial cavity down the entire length of the spinal cord. Together the cranial cavity and vertebral cavity can be referred to as the dorsal body cavity. The thoracic cavity consists of three cavities that fill the interior area of the chest. The two pleural cavities are situated on both sides of the body, anterior to the spine and lateral to the breastbone. The superior mediastinum is a wedge-shaped cavity located between the superior regions of the two thoracic cavities. The pericardial cavity within the mediastinum is located at the center of the chest below the superior mediastinum. The pericardial cavity roughly outlines the shape of the heart. The diaphragm divides the thoracic and the abdominal cavities. The abdominal cavity occupies the entire lower half of the trunk, anterior to the spine. Just under the abdominal cavity, anterior to the buttocks, is the pelvic cavity. The pelvic cavity is funnel shaped and is located inferior and anterior to the abdominal cavity. Together the abdominal and pelvic cavity can be referred to as the abdominopelvic cavity while the thoracic, abdominal, and pelvic cavities together can be referred to as the ventral body cavity. [Return to Figure 5.6].

Figure 5.7 image description: This illustrations shows the silhouette of a human female from an anterior view. Several organs are showing in her neck, thorax, abdomen left arm and right leg. Text boxes point out and describe the mucous membranes in several different organs. The topmost box points to the mouth and trachea. It states that mucous membranes line the digestive, respiratory, urinary and reproductive tracts. They are coated with the secretions of mucous glands. The second box points to the outside edge of the lungs as well as the large intestine and states that serous membranes line body cavities that are closed to the exterior of the body, including the peritoneal, pleural and pericardial cavities. The third box points to the skin of the hand. It states that cutaneous membrane, also known as the skin, covers the body surface. The fourth box points to the right knee. It states that synovial membranes line joint cavities and produce the fluid within the joint.[Return to Figure 5.7]

Figure 5.8 image description: This diagram shows the pericardium on the left next to an analogy of a hand punching a balloon on the right. The pericardium is a two-layered sac that surrounds the entire heart except where the blood vessels emerge on the heart’s superior side. The pericardium has two layers because it folds over itself in the shape of the letter U. The inner layer that borders the heart is the visceral pericardium while the outer layer is the parietal pericardium. The space between the two layers is called the pericardial cavity. The heart sits in the cavity much like a fist punching into a balloon. The balloon surrounds the lower part of the fist with a two-layered sac, with the top of the balloon, where it contacts the fist, being analogous to the visceral pericardium. The bottom of the balloon, where it is tied off, is analogous to the parietal pericardium. The air within the balloon is analogous to the pericardial cavity. [Return to Figure 5.8].

Watch this video:

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Media 6.1. The Integumentary System, Part 1 – Skin Deep: Crash Course A&P #6 [Video]. Copyright 2015 by CrashCourse.

Practice integumentary system medical terms.

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Anatomy (Structures) of the Integumentary System

The skin and its accessory structures make up the integumentary system, which provides the body with overall protection. The skin is made of multiple layers of cells and tissues, which are held to underlying structures by connective tissue. The deeper layer of skin is well vascularized . It also has numerous sensory, and autonomic and sympathetic nerve fibers ensuring communication to and from the brain.

The skin is composed of two main layers:

1. The epidermis
2. The dermis
   1. Beneath the dermis lies the hypodermis

Figure 6.1 Layers of Skin. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Concept Check

• On the diagram above find the two layers of the skin; epidermis and dermis.
• The literal breakdown for hypodermis is below the dermis. On the diagram above where can you locate it?
• Can you find a hair follicle, hair root and hair shaft?
• Keep reading to find out what the arrector pili muscle does when you are frightened.

​​​​Epidermis

The epidermis is composed of keratinized, stratified squamous epithelium. It is made of four or five layers of epithelial cells, depending on its location in the body. It is avascular.

• Thin skin has four layers of cells. From deep to superficial, these layers are the stratum basale, stratum spinosum, stratum granulosum, and stratum corneum. Most of the skin can be classified as thin skin.
• Thick skin is found only on the palms of the hands and the soles of the feet. It has a fifth layer, called the stratum lucidum, located between the stratum corneum and the stratum granulosum (see Figure 6.2).

Figure 6.2 Thin Skin versus Thick Skin. These slides show cross-sections of the epidermis and dermis of (a) thin and (b) thick skin. Note the significant difference in the thickness of the epithelial layer of the thick skin. From top, LM × 40, LM × 40. (Micrographs provided by the Regents of University of Michigan Medical School © 2012). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

The cells in all of the layers except the stratum basale are called keratinocytes.  Keratin is an intracellular fibrous protein that gives hair, nails, and skin their hardness and water-resistant properties. The keratinocytes in the stratum corneum are dead and regularly slough away, being replaced by cells from the deeper layers (see Figure 6.3).

Figure 6.3 Epidermis. The epidermis is epithelium composed of multiple layers of cells. The basal layer consists of cuboidal cells, whereas the outer layers are squamous, keratinized cells, so the whole epithelium is often described as being keratinized stratified squamous epithelium. LM × 40. (Micrograph provided by the Regents of University of Michigan Medical School © 2012). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Dermis

The dermis contains blood and lymph vessels, nerves, and other structures, such as hair follicles and sweat glands. The dermis is made of two layers (papillary layer and reticular layer) of connective tissue that compose an interconnected mesh of elastin and collagenous fibers, produced by fibroblasts (see Figure 6.4).

Figure 6.4 Layers of the Dermis. This stained slide shows the two components of the dermis—the papillary layer and the reticular layer. Both are made of connective tissue with fibers of collagen extending from one to the other, making the border between the two somewhat indistinct. The dermal papillae extending into the epidermis belong to the papillary layer, whereas the dense collagen fiber bundles below belong to the reticular layer. LM × 10. (credit: modification of work by “kilbad”/Wikimedia Commons).  From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Papillary Layer

The papillary layer is made of loose, areolar connective tissue, which means the collagen and elastin fibers of this layer form a loose mesh. This superficial layer of the dermis projects into the stratum basale of the epidermis to form finger-like dermal papillae (see Figure 6.4). Within the papillary layer are fibroblasts, a small number adipocytes, and an abundance of small blood vessels. In addition, the papillary layer contains phagocytes, that help fight bacteria or other infections that have breached the skin. This layer also contains lymphatic capillaries, nerve fibers, and  Meissner corpuscles.

Reticular Layer

Underlying the papillary layer is the much thicker reticular layer, composed of dense, irregular connective tissue. This layer is well vascularized and has a rich sensory and sympathetic nerve supply. The reticular layer appears reticulated due to a tight meshwork of fibers. Elastin fibers provide some elasticity to the skin, enabling movement. Collagen fibers provide structure and tensile strength, with strands of collagen extending into both the papillary layer and the hypodermis. In addition, collagen binds water to keep the skin hydrated. Collagen injections and Retin-A creams help restore skin turgor by either introducing collagen externally or stimulating blood flow and repair of the dermis, respectively.

Hypodermis

The hypodermis serves to connect the skin to the underlying fascia of the bones and muscles. It is not strictly a part of the skin, although the border between the hypodermis and dermis can be difficult to distinguish. The hypodermis consists of well-vascularized, loose, areolar connective tissue and adipose tissue, which functions as a mode of fat storage and provides insulation and cushioning for the integument.

Practice labeling the layers of the skin.

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Physiology (Function) of the Integumentary System

The skin and accessory structures perform a variety of essential functions, such as protecting the body from invasion by microorganisms, chemicals, and other environmental factors; preventing dehydration; acting as a sensory organ; modulating body temperature and electrolyte balance; and synthesizing vitamin D. The underlying hypodermis has important roles in storing fats, forming a “cushion” over underlying structures, and providing insulation from cold temperatures.

Protection

The skin protects the body from wind, water, and UV sunlight. It acts as a protective barrier against water loss and it also is the first line of defense against abrasive activity such as grit, microbes, or harmful chemicals. Sweat excreted from sweat glands deters microbes from over-colonizing the skin surface by generating dermicidin, which has antibiotic properties.

Sensory Function

The skin acts as a sense organ because the epidermis, dermis, and the hypodermis contain specialized sensory nerve structures that detect touch, surface temperature, and pain. These receptors are more concentrated on the tips of the fingers, which are most sensitive to touch, especially the Meissner corpuscle, which responds to light touch, and the Pacinian corpuscle , which responds to vibration. Merkel cells, seen scattered in the stratum basale, are also touch receptors. In addition to these specialized receptors, there are sensory nerves connected to each hair follicle, pain and temperature receptors scattered throughout the skin, and motor nerves innervate the arrector pili muscles and glands. This rich innervation helps us sense our environment and react accordingly,

Thermoregulation

The integumentary system helps regulate body temperature through its tight association with the sympathetic nervous system. The sympathetic nervous system is continuously monitoring body temperature and initiating appropriate motor responses.

1.  When the body becomes warm sweat glands, accessory structures to the skin, secrete water, salt, and other substances to cool the body.
   1. Even when the body does not appear to be noticeably sweating, approximately 500 mL of sweat are secreted a day.
2. If the body becomes excessively warm due to high temperatures, vigorous activity, or a combination of the two, sweat glands will be stimulated by the sympathetic nervous system to produce large amounts of sweat.
   1. When the sweat evaporates from the skin surface, the body is cooled as body heat is dissipated.
   2. In addition to sweating, arterioles in the dermis dilate so that excess heat carried by the blood can dissipate through the skin and into the surrounding environment (Figure 2b).
   3. This accounts for the skin redness that many people experience when exercising.
3. When body temperatures drop, the arterioles constrict to minimize heat loss, particularly in the ends of the digits and tip of the nose.
   1. This reduced circulation can result in the skin taking on a whitish hue.
   2. Although the temperature of the skin drops as a result, passive heat loss is prevented, and internal organs and structures remain warm.
   3. If the temperature of the skin drops too much (such as environmental temperatures below freezing), the conservation of body core heat can result frostbite .

Figure 6.5 Thermoregulation. During strenuous physical activities, such as skiing (a) or running (c), the dermal blood vessels dilate and sweat secretion increases (b). These mechanisms prevent the body from overheating. In contrast, the dermal blood vessels constrict to minimize heat loss in response to low temperatures (b). (credit a: “Trysil”/flickr; credit c: Ralph Daily). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Concept Check

Can you describe the thermoregulation process between the integumentary system and the sympathetic system?

• When body temperature is too warm.
• When body temperature is too cold.

Vitamin D Synthesis

Did You Know?

Vitamin D is essential for general immunity against bacterial, viral and fungal infections.

The epidermal layer of human skin synthesizes Vitamin D when exposed to UV radiation. In the presence of sunlight, a form of Vitamin D₃ called cholecalciferol is synthesized from a derivative of the steroid cholesterol in the skin. The liver converts cholecalciferol to calcidiol, which is then converted to calcitriol (the active chemical form of the vitamin) in the kidneys.

• Vitamin D is essential for normal absorption of calcium and phosphorous, which are required for healthy bones.

• The absence of sun exposure can lead to a lack of vitamin D in the body, in children this can cause rickets.  Vitamin D deficiency in elderly individuals may lead to osteomalacia.

• In present day society, Vitamin D is added as a supplement to many foods, including milk and orange juice, compensating for the need for sun exposure. In addition to its essential role in bone health, Vitamin D is essential for general immunity against bacterial, viral, and fungal infections.

Watch this video:

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Accessory Structures

Accessory structures of the skin include hair, nails, sweat glands, and sebaceous glands. These structures embryologically originate from the epidermis and can extend down through the dermis into the hypodermis.

Hair

Hair is a keratinous filament growing out of the epidermis. It is primarily made of dead, keratinized cells. Strands of hair originate in an epidermal penetration of the dermis called the hair follicle. The hair shaft is the part of the hair not anchored to the follicle, and much of this is exposed at the skin’s surface. The rest of the hair, which is anchored in the follicle, lies below the surface of the skin and is referred to as the hair root. The hair root ends deep in the dermis at the hair bulb, and includes a layer of mitotically active basal cells called the hair matrix. The hair bulb surrounds the hair papilla, which is made of connective tissue and contains blood capillaries and nerve endings from the dermis (see Figure 6.6).

Figure 6.6 Hair. Hair follicles originate in the epidermis and have many different parts. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Hair Function

Did You Know?

When frightened, the arrector pili muscle is responsible for your hair standing on end. The same is true when  a cat’s fur is raised.

Hair serves a variety of functions, including protection, sensory input, thermoregulation, and communication. For example:

• Hair on the head protects the skull from the sun.
• Hair in the nose and ears, and around the eyes (eyelashes) defends the body by trapping and excluding dust particles that may contain allergens and microbes.
• Hair of the eyebrows prevents sweat and other particles from dripping into and bothering the eyes.

Hair also has a sensory function due to sensory innervation by a hair root plexus surrounding the base of each hair follicle. Hair is extremely sensitive to air movement or other disturbances in the environment, much more so than the skin surface. This feature is also useful for the detection of the presence of insects or other potentially damaging substances on the skin surface.

Each hair root is connected to a smooth muscle called the arrector pili that contracts in response to nerve signals from the sympathetic nervous system, making the external hair shaft “stand up.” The primary purpose for this is to trap a layer of air to add insulation. This is visible in humans as goose bumps and even more obvious in animals, such as when a frightened cat raises its fur. Of course, this is much more obvious in organisms with a heavier coat than most humans, such as dogs and cats.

Hair Growth, Loss and Colour

Hair grows and is eventually shed and replaced by new hair.  Hair typically grows at the rate of 0.3 mm per day. On average, 50 hairs are lost and replaced per day. Hair loss occurs if there is more hair shed than what is replaced and can happen due to hormonal or dietary changes. Hair loss can also result from the aging process, or the influence of hormones. Similar to the skin, hair gets its colour from the pigment melanin, produced by melanocytes in the hair papilla. Different hair color results from differences in the type of melanin. As a person ages, the melanin production decreases, and hair tends to lose its color and becomes gray and/or white.

Nails

The nail bed is a specialized structure of the epidermis that is found at the tips of our fingers and toes. The nail body is formed on the nail bed, and protects the tips of our fingers and toes as they are the farthest extremities and the parts of the body that experience the maximum mechanical stress (see Figure 6.7). The nail body forms a back-support for picking up small objects with the fingers. The nail body is composed of densely packed dead keratinocytes.

The epidermis in this part of the body has evolved a specialized structure upon which nails can form. The nail body forms at the nail root, which has a matrix of proliferating cells from the stratum basale that enables the nail to grow continuously. The lateral nail fold overlaps the nail on the sides, helping to anchor the nail body. The nail fold that meets the proximal end of the nail body forms the nail cuticle, also called the eponychium.

The nail bed is rich in blood vessels, making it appear pink, except at the base, where a thick layer of epithelium over the nail matrix forms a crescent-shaped region called the lunula (the “little moon”). The area beneath the free edge of the nail, furthest from the cuticle, is called the hyponychium. It consists of a thickened layer of stratum corneum.

Figure 6.7 Nails. The nail is an accessory structure of the integumentary system. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Sweat Glands

Sudoriferous Glands

When the body becomes warm, sudoriferous glands produce sweat to cool the body. Sweat glands develop from epidermal projections into the dermis and are classified as merocrine glands; that is, the secretions are excreted by exocytosis through a duct without affecting the cells of the gland. There are two types of sweat glands, each secreting slightly different products.

An eccrine sweat gland is type of gland that produces a hypotonic sweat for thermoregulation as described previously. These glands are found all over the skin’s surface, but are especially abundant on the palms of the hand, the soles of the feet, and the forehead (Figure 6.8). They are coiled glands lying deep in the dermis, with the duct rising up to a pore on the skin surface, where the sweat is released. This type of sweat, released by exocytosis, is hypotonic and composed mostly of water, with some salt, antibodies, traces of metabolic waste, and dermicidin, an antimicrobial peptide. Eccrine glands are a primary component of thermoregulation in humans and thus help to maintain homeostasis .

Figure 6.8 Eccrine Gland. Eccrine glands are coiled glands in the dermis that release sweat that is mostly water. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

An apocrine sweat gland is usually associated with hair follicles in densely hairy areas, such as armpits and genital regions. Apocrine sweat glands are larger than eccrine sweat glands and lie deeper in the dermis, sometimes even reaching the hypodermis, with the duct normally emptying into the hair follicle. In addition to water and salts, apocrine sweat includes organic compounds that make the sweat thicker and subject to bacterial decomposition and subsequent smell. The release of this sweat is under both nervous and hormonal control, and plays a role in the poorly understood human pheromone response. Most commercial antiperspirants use an aluminum-based compound as their primary active ingredient to stop sweat. When the antiperspirant enters the sweat gland duct, the aluminum-based compounds precipitate due to a change in pH and form a physical block in the duct, which prevents sweat from coming out of the pore.

Words not Easily Broken into Word Parts

Common Integumentary System Abbreviations

Many terms and phrases related to the integumentary system are abbreviated.  Learn these common abbreviations by expanding the list below.

Changes Due to Aging

All systems in the body accumulate subtle and some not-so-subtle changes as a person ages. Among these changes are reductions in cell division, metabolic activity, blood circulation, hormonal levels, and muscle strength (see Figure 6.9). In the skin, these changes are reflected in decreased mitosis in the stratum basale, leading to a thinner epidermis. The dermis, which is responsible for the elasticity and resilience of the skin, exhibits a reduced ability to regenerate, which leads to slower wound healing. The hypodermis, with its fat stores, loses structure due to the reduction and redistribution of fat, which in turn contributes to the thinning and sagging of skin.

Figure 6.9 Aging. Generally, skin, especially on the face and hands, starts to display the first noticeable signs of aging, as it loses its elasticity over time. (credit: Janet Ramsden). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Did You Know?

A reduced sweating ability can cause some elderly to be intolerant to extreme heat.

The accessory structures also have lowered activity, generating thinner hair and nails, and reduced amounts of sebum and sweat. A reduced sweating ability can cause some elderly to be intolerant to extreme heat. Other cells in the skin, such as melanocytes and dendritic cells, also become less active, leading to a paler skin tone and lowered immunity. Wrinkling of the skin occurs due to breakdown of its structure, which results from decreased collagen and elastin production in the dermis, weakening of muscles lying under the skin, and the inability of the skin to retain adequate moisture.

Disease and Disorders

The integumentary system is susceptible to a variety of diseases, disorders, and injuries. These range from annoying but relatively benign bacterial or fungal infections that are categorized as disorders, to skin cancer and severe burns, which can be fatal. In this section, you will learn several of the most common skin conditions.

One of the most talked about diseases is skin cancer. Most cancers are identified by the organ or tissue in which the cancer originates. One common form of cancer is skin cancer.

In general, cancers result from an accumulation of DNA mutations. These mutations can result in cell populations that do not die when they should and uncontrolled cell proliferation that leads to tumors. Although many tumors are benign, some metastasize. Cancers are characterized by their ability to metastasize.

It requires about 10 days after initial sun exposure for melanin synthesis to peak, which is why pale-skinned individuals tend to suffer sunburns of the epidermis initially. Dark-skinned individuals can also get sunburns, but are more protected than are pale-skinned individuals. Too much sun exposure can eventually lead to wrinkling due to the destruction of the cellular structure of the skin, and in severe cases, can cause sufficient DNA damage to result in skin cancer. When there is an irregular accumulation of melanocytes in the skin, freckles appear. Moles are larger masses of melanocytes, and although most are benign, they should be monitored for changes that might indicate the presence of cancer (see Figure 6.10).

Figure 6.10 Moles. Moles range from benign accumulations of melanocytes to melanomas. These structures populate the landscape of our skin. (credit: the National Cancer Institute). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Basal Cell Carcinoma (BCC)

Figure 6.11 Basal Cell Carcinoma. Basal cell carcinoma can take several different forms. Similar to other forms of skin cancer, it is readily cured if caught early and treated. (credit: John Hendrix, MD). From Betts, et al., 2013. Licensed under CC BY 4.0.

Basal cell carcinoma is a form of cancer that affects the mitotically active stem cells in the stratum basale of the epidermis. It is the most common of all cancers that occur in the United States and is frequently found on the head, neck, arms, and back, which are are as that are most susceptible to long-term sun exposure. Although UV rays are the main culprit, exposure to other agents, such as radiation and arsenic, can also lead to this type of cancer. Wounds on the skin due to open sores, tattoos, burns, etc. may be predisposing factors. Basal cell carcinomas start in the stratum basale and usually spread along this boundary. At some point, they begin to grow toward the surface and become an uneven patch, bump, growth, or scar on the skin surface (see Figure 6.11). Like most cancers, basal cell carcinomas respond best to treatment when caught early. Treatment options include surgery, freezing (cryosurgery), and topical ointments.

Squamous Cell Carcinoma (SCC)

Figure 6.12 Squamous Cell  Carcinoma Squamous cell carcinoma presents here as a lesion on a nose. (credit: the National Cancer Institute). From Betts, et al., 2013. Licensed under CC BY 4.0.

Squamous cell carcinoma is a cancer that affects the keratinocytes of the stratum spinosum and presents as lesions commonly found on the scalp, ears, and hands (see Figure 6.12). It is the second most common skin cancer. The American Cancer Society reports that two of 10 skin cancers are squamous cell carcinomas, and it is more aggressive than basal cell carcinoma. If not removed, these carcinomas can metastasize. Surgery and radiation are used to cure squamous cell carcinoma.

Melanoma

Figure 6.13 Melanoma. Melanomas typically present as large brown or black patches with uneven borders and a raised surface. (credit: the National Cancer Institute). From Betts, et al., 2013. Licensed under CC BY 4.0.

A melanoma is a cancer characterized by the uncontrolled growth of melanocytes, the pigment-producing cells in the epidermis. Typically, a melanoma develops from a mole. It is the most fatal of all skin cancers, as it is highly metastatic and can be difficult to detect before it has spread to other organs. Melanomas usually appear as asymmetrical brown and black patches with uneven borders and a raised surface (see Figure 6.13). Treatment typically involves surgical excision and immunotherapy.

ABCDE for Early Diagnosis

Doctors often give their patients the following ABCDE mnemonic to help with the diagnosis of early-stage melanoma. If you observe a mole on your body displaying these signs, consult a doctor.

Asymmetry – the two sides are not symmetrical
Borders – the edges are irregular in shape
Color – the color is varied shades of brown or black
Diameter – it is larger than 6 mm (0.24 in)
Evolving – its shape has changed

Some specialists cite the following additional signs for the most serious form, nodular melanoma:

Elevated – it is raised on the skin surface
Firm – it feels hard to the touch
Growing – it is getting larger

 Albinism

Albinism is a genetic disorder that affects (completely or partially) the coloring of skin, hair, and eyes. This is primarily due to the inability of melanocytes to produce melanin. Individuals with albinism tend to appear white or very pale due to the lack of melanin in their skin and hair. Recall that melanin helps protect the skin from the harmful effects of UV radiation. Individuals with albinism tend to need more protection from UV radiation, as they are more prone to sunburns and skin cancer. They also tend to be more sensitive to light and have vision problems due to the lack of pigmentation on the retinal wall (Betts, et al., 2013)

Treatment of this disorder usually involves addressing the symptoms, such as limiting UV light exposure to the skin and eyes. In vitiligo, the melanocytes in certain areas lose their ability to produce melanin, possibly due to an autoimmune reaction. This leads to a loss of color in patches (see Figure 6.14). Neither albinism nor vitiligo directly affects the lifespan of an individual (Betts, et al., 2013)

Figure 6.14 Vitiligo. Individuals with vitiligo experience depigmentation that results in lighter colored patches of skin. The condition is especially noticeable on darker skin. (credit: Klaus D. Peter). From Betts, et al., 2013. Licensed under CC BY 4.0.

Changes in Skin Colouration

Other changes in the appearance of skin colouration can be indicative of diseases associated with other body systems.

• Liver disease or liver cancer can cause the accumulation of bile and the yellow pigment bilirubin, leading to the skin appearing yellow or jaundiced.
• Tumors of the pituitary gland can result in the secretion of large amounts of melanocyte-stimulating hormone (MSH), which results in a darkening of the skin.
• Addison’s disease can stimulate the release of excess amounts of adrenocorticotropic hormone (ACTH), which can give the skin a deep bronze color
• A sudden drop in oxygenation can affect skin color, causing the skin to initially turn ashen (white).
• A prolonged reduction in oxygen levels, dark red deoxyhemoglobin becomes dominant in the blood, making the skin appear blue, a condition referred to as cyanosis. This happens when the oxygen supply is restricted, as when someone is experiencing difficulty in breathing because of asthma or a heart attack. However, in these cases the effect on skin color has nothing do with the skin’s pigmentation (Betts, et al., 2013)

Skin Disorders

Two common skin disorders are eczema and acne. Eczema is an inflammatory condition and occurs in individuals of all ages. Acne involves the clogging of pores, which can lead to infection and inflammation, and is often seen in adolescents. Other disorders, include seborrheic dermatitis (on the scalp), psoriasis, fungal infections, cold sores, impetigo, scabies, hives, and warts (Betts, et al., 2013).

Eczema

Figure 6.15 Eczema. Eczema is a common skin disorder that presents as a red, flaky rash. (credit: “Jambula”/Wikimedia Commons). From Betts, et al., 2013. Licensed under CC BY 4.0.

Eczema is an allergic reaction that manifests as dry, itchy patches of skin that resemble rashes (see Figure 6.15). It may be accompanied by swelling of the skin, flaking, and in severe cases, bleeding. Symptoms are usually managed with moisturizers, corticosteroid creams, and immunosuppressants (Betts, et al., 2013).

Acne

Figure 6.16. Acne. Acne is a result of over-productive sebaceous glands, which leads to formation of blackheads and inflammation of the skin. From Betts, et al., 2013. Licensed under CC BY 4.0.

Acne is a skin disturbance that typically occurs on areas of the skin that are rich in sebaceous glands (face and back). It is most common along with the onset of puberty due to associated hormonal changes, but can also occur in infants and continue into adulthood. Hormones, such as androgens, stimulate the release of sebum. An overproduction and accumulation of sebum along with keratin can block hair follicles. This plug is initially white. The sebum, when oxidized by exposure to air, turns black. Acne results from infection by acne-causing bacteria (Propionibacterium and Staphylococcus), which can lead to redness and potential scarring due to the natural wound healing process (see Figure 6.16) (Betts, et al., 2013).

Ringworm

Tinea or dermatophytosis is often referred to as ringworm. Ringworm presents as a circular rash that is itchy and red and can be found on various parts of the body. It is referred to by the location that it is found:

• • Tinea Pedis – feet or commonly referred to as athlete’s feet
  • Tinea Capitis – scalp
  • Tinea barbae – beard
  • Tinea manuum – hands
  • Tinea unguium – Toenails and fingernails also called onychomycosis
  • Tinea corporis – Body parts such as arms and legs (Center for Disease Control and Prevention, 2018a)

To learn more about ringworm, visit the Center for Disease Control and Prevention’s web page on fungal infections. 

Psoriasis

Psoriasis is a chronic autoimmune disorder that results in patches of thick red skin with the appearance of silvery scales. These patches can be found on elbows, knees, scalp, low back, face, feet, fingernails, toenails and even the mouth. Psoriasis can be confused with other skin disease so a dermatologist is the best physician to diagnosis psoriasis. Treatments may include creams, ointments, ultraviolet light therapy and medication (Center for Disease Control and Prevention, 2018).  To learn more, visit the Center for Disease Control and Prevention’s web page on psoriasis.

Injuries

Because the skin is the part of our bodies that meets the world most directly, it is especially vulnerable to injury. Injuries include burns, wounds, as well as scars and calluses. They can be caused by sharp objects, heat, or excessive pressure or friction to the skin (Betts, et al., 2013).

Skin injuries set off a healing process that occurs in several overlapping stages.

• The first step to repairing damaged skin is the formation of a blood clot that helps stop the flow of blood and scabs over with time. Many different types of cells are involved in wound repair, especially if the surface area that needs repair is extensive.
• Before the basal stem cells of the stratum basale can recreate the epidermis, fibroblasts mobilize and divide rapidly to repair the damaged tissue by collagen deposition, forming granulation tissue.
• Blood capillaries follow the fibroblasts and help increase blood circulation and oxygen supply to the area.
• Immune cells, such as macrophages, roam the area and engulf any foreign matter to reduce the chance of infection (Betts, et al., 2013).

Burns

A burn results when the skin is damaged by intense heat, radiation, electricity, or chemicals. The damage results in the death of skin cells, which can lead to a massive loss of fluid. Dehydration, electrolyte imbalance, and renal and circulatory failure follow, which can be fatal. Burn patients are treated with intravenous fluids to offset dehydration, as well as intravenous nutrients that enable the body to repair tissues and replace lost proteins. Another serious threat to the lives of burn patients is infection. Burned skin is extremely susceptible to bacteria and other pathogens, due to the loss of protection by intact layers of skin (Betts, et al., 2013).

Burn Classification

Burns are sometimes measured in terms of the size of the total surface area affected. This is referred to as the rule of nines, which associates specific anatomical areas with a percentage that is a factor of nine (see Figure 6.17) (Betts, et al., 2013).

Figure 6.17 Calculating the Size of a Burn. The size of a burn will guide decisions made about the need for specialized treatment. Specific parts of the body are associated with a percentage of body area. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Burns are also classified by the degree of their severity.

• A first-degree burn is a superficial burn that affects only the epidermis. Although the skin may be painful and swollen, these burns typically heal on their own within a few days. Mild sunburn fits into the category of a first-degree burn.
• A second-degree burn goes deeper and affects both the epidermis and a portion of the dermis. These burns result in swelling and a painful blistering of the skin. It is important to keep the burn site clean and sterile to prevent infection. If this is done, the burn will heal within several weeks.
• A third-degree burn fully extends into the epidermis and dermis, destroying the tissue and affecting the nerve endings and sensory function. These are serious burns that may appear white, red, or black; they require medical attention and will heal slowly without it.
• A fourth-degree burn is even more severe, affecting the underlying muscle and bone.

Oddly, third and fourth-degree burns are usually not as painful because the nerve endings themselves are damaged. Full-thickness burns cannot be repaired by the body, because the local tissues used for repair are damaged and require debridement, or amputation in severe cases, followed by grafting of the skin from an unaffected part of the body, or from skin grown in tissue culture for grafting purposes. Skin grafts are required when the damage from trauma or infection cannot be closed with sutures or staples (Betts et al., 2013).

Scars and Keloids

Most cuts or wounds, with the exception of ones that only scratch the epidermis, lead to scar formation. Scarring occurs in cases in which there is repair of skin damage, but the skin fails to regenerate the original skin structure. Fibroblasts generate scar tissue in the form of collagen, and the bulk of repair is due to the basket-weave pattern generated by collagen fibers and does not result in regeneration of the typical cellular structure of skin. Instead, the tissue is fibrous in nature and does not allow for the regeneration of accessory structures, such as hair follicles, sweat glands, or sebaceous glands (Betts, et al., 2013).

Sometimes, there is an overproduction of scar tissue, because the process of collagen formation does not stop when the wound is healed; this results in a keloid. In contrast, scars that result from acne and chickenpox have a sunken appearance and are called atrophic scars (Betts, et al., 2013)

Scarring of skin after wound healing is a natural process and does not need to be treated further. Application of mineral oil and lotions may reduce the formation of scar tissue. However, modern cosmetic procedures, such as dermabrasion, laser treatments, and filler injections have been invented as remedies for severe scarring. All of these procedures try to reorganize the structure of the epidermis and underlying collagen tissue to make it look more natural (Betts, et al., 2013).

Bedsores and Stretch Marks

Skin and its underlying tissue can be affected by excessive pressure. One example of this is called a bedsore. Bedsores, also called decubitus ulcers, are caused by constant, long-term, unrelieved pressure on certain body parts that are bony, reducing blood flow to the area and leading to necrosis . Bedsores are most common in elderly patients who have debilitating conditions that cause them to be immobile. Most hospitals and long-term care facilities have the practice of turning the patients every few hours to prevent the incidence of bedsores. If left untreated bedsores can be fatal if they become infected (Betts, et al., 2013)

The skin can also be affected by pressure associated with rapid growth. A stretch mark results when the dermis is stretched beyond its limits of elasticity, as the skin stretches to accommodate the excess pressure. Stretch marks usually accompany rapid weight gain during puberty and pregnancy. They initially have a reddish hue, but lighten over time. Other than for cosmetic reasons, treatment of stretch marks is not required. They occur most commonly over the hips and abdomen (Betts, et al., 2013).

Calluses

When you wear shoes that do not fit well and are a constant source of abrasion on your toes, you tend to form a callus at the point of contact. This occurs because the basal stem cells in the stratum basale are triggered to divide more often to increase the thickness of the skin at the point of abrasion to protect the rest of the body from further damage. This is an example of a minor or local injury, and the skin manages to react and treat the problem independent of the rest of the body. Calluses can also form on your fingers if they are subject to constant mechanical stress, such as long periods of writing, playing string instruments, or video games. A corn is a specialized form of callus. Corns form from abrasions on the skin that result from an elliptical-type motion (Betts, et al., 2013).

Medical Terms in Context

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An interactive or media element has been excluded from this version of the text. You can view it online here:
https://ecampusontario.pressbooks.pub/medicalterminology/?p=245

Medical Specialties and Procedures Related to the Integumentary System

A dermatologist is a medical doctor with specialized training in treating diseases, disorders and injuries related to the integumentary system and its accessory structures. There are many dermatologic subspecialties such as cosmetic dermatology, dermatopathology and pediatric dermatology. To learn more visit the Dermatology and Subspecialties section of the Canadian Dermatology Association website.

Dermatologists can be specially trained to perform a procedure called Mohs surgery. Mohs surgery excises skin cancers in thin layers until all cancer is removed from the tissue (Mayo Clinic Staff, 2017).

Integumentary System Vocabulary

Adipocytes

Fat cells.

Adipose tissue

Fat tissue.

Autonomic nerve fibers

Unconsciously regulates communication to and from the brain.

Avascular

Without blood vessels.

Benign

Noncancerous, harmless.

Cancer

A process where abnormal cells in the body divide uncontrollably.

Cyanosis

Abnormal condition of blue (bluish colour, lips and nail beds). Typically caused by low oxygenation.

Debridement

Excision of damaged tissue or foreign object.

Dehydration

Loss of fluids/water is greater than what is taken in.

Dermatologic

Pertaining to dermatology.

Dermatopathology

Study of diseases of the skin.

Dermis

The layer of skin that is made of dense, irregular connective tissue that houses blood vessels, hair follicles, sweat glands, and other structures.

Epidermis

Outer layer of skin, made of closely packed epithelial cells.

Excises

Remove by cutting out.

Exocytosis

Active transport of molecules out of the cell.

Fascia

Fibrous tissue.

Frostbite

Conservation of core body heat results in the skin actually freezing.

Hypodermis

Literally means below the dermis. The layer of skin below the dermis that is composed mainly of loose connective and fatty tissues.

Infection

Invasion by disease-causing organisms.

Intravenous

Pertaining to within the vein.

Jaundiced

Yellow-coloured.

Keloid

Formation of a raised or hypertrophic scar.

Keratinocytes

Cells that manufacture and store the protein keratin.

Meissner corpuscle

Tactile corpuscle that responds to light and touch, touch receptor.

Meissner corpuscles

Tactile corpuscle that responds to light and touch, touch receptors.

Melanocytes

Specialized cells that produce melanin which is a dark pigment responsible for colouration of skin and hair.

Metastasize

Production of cells that can mobilize and establish tumors in other organs of the body.

Necrosis

Tissue death.

Osteomalacia

Softening of the bones.

Pacinian corpuscle

Lamellated corpuscle that responds to vibration.

Pathogens

Disease-causing agents.

Phagocytes

Cells that engulf and absorb bacteria and cell particles.

Reticulated

Net like.

Rickets

A painful condition in children where bones are misshapen due to a lack of calcium, causing bow leggedness.

Scar

Collagen-rich skin formed after the process of wound healing that differs from normal skin.

Stratum Basale

Deepest layer of the epidermal.

Sympathetic nerve fibers

Flight or fight response determines communication to and from the brain.

Sympathetic Nervous System

Responsible for fight or flight responses.

Vascularized

Has numerous blood vessels.

Test Yourself

Respiratory System Word Parts

Click on prefixes, combining forms, and suffixes to reveal a list of word parts to memorize for the Respiratory System.

Introduction to the Respiratory System

The major structures of the respiratory system function primarily to provide oxygen to body tissues for cellular respiration, remove the waste product carbon dioxide, and help to maintain acid-base balance. Portions of the respiratory system are also used for non-vital functions, such as sensing odors, speech production, and for straining, such as coughing.

Figure 7.1 Major Respiratory Structures. The major respiratory structures span the nasal cavity to the diaphragm. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

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Respiratory System Medical Terms

Anatomy (Structures) of the Respiratory System

The Nose and its Adjacent Structures

The major entrance and exit for the respiratory system is through the nose. When discussing the nose, it is helpful to divide it into two major sections:

•  external nose
•  internal nose

The nares open into the nasal cavity, which is separated into left and right sections by the nasal septum (Figure 7.2). The nasal septum is formed anteriorly by a portion of the septal cartilage  and posteriorly by the perpendicular plate of the ethmoid bone and the thin vomer bones.

Each lateral wall of the nasal cavity has three bony projections the inferior conchae are separate bones and the superior and middle conchae are portions of the ethmoid bone. Conchae increase the surface area of the nasal cavity, disrupt the flow of air as it enters the nose, causing air to bounce along the epithelium, where it is cleaned and warmed. The conchae and meatuses  trap water during exhalation preventing dehydration.

The floor of the nasal cavity is composed of the hard palate and the soft palate. Air exits the nasal cavities via the internal nares and moves into the pharynx.

Figure 7.2 Upper Airway. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Paranasal sinuses, serve to warm and humidify incoming air and are lined with a mucosa which produces mucus. Paranasal sinuses are named for their associated bone:

• frontal sinus
• maxillary sinus
• sphenoidal sinus
• ethmoidal sinus

The nares and anterior portion of the nasal cavities are lined with mucous membranes, containing sebaceous glands and hair follicles that serve to prevent the passage of large debris, such as dirt, through the nasal cavity. An olfactory epithelium used to detect odors is found deeper in the nasal cavity.

Did You Know?

Cold air slows the movement of cilia that may result in the accumulation of mucus leading to rhinorrhea during cold weather.

The conchae, meatuses, and paranasal sinuses are lined by respiratory epithelium composed of pseudostratified ciliated columnar epithelium (Figure 7.3). The epithelium contains specialized epithelial cells that produce mucus to trap debris. The cilia of the respiratory epithelium help to remove mucus and debris with a constant beating motion, sweeping materials towards the throat to be swallowed.

This moist epithelium functions to warm and humidify incoming air. Capillaries located just beneath the nasal epithelium warm the air by convection. Serous and mucus-producing cells also secrete defensins, immune cells patrol the connective tissue providing additional protection.

Figure 7.3 Pseudostratified Ciliated Columnar Epithelium. Respiratory epithelium is pseudostratified ciliated columnar epithelium. Seromucous glands provide lubricating mucus. LM × 680. (Micrograph provided by the Regents of University of Michigan Medical School © 2012). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Pharynx

The pharynx is divided into three major regions: the nasopharynx, the oropharynx, and the laryngopharynx (see Figure 7.4).

Figure 7.4 Divisions of the Pharynx. The pharynx is divided into three regions: the nasopharynx, the oropharynx, and the laryngopharynx. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

At the top of the nasopharynx are the pharyngeal tonsils. The function of the pharyngeal tonsil is not well understood, but it contains a rich supply of lymphocytes and is covered with ciliated epithelium that traps and destroys invading pathogens that enter during inhalation. The pharyngeal tonsils are large in children, but tend to regress with age and may even disappear. The uvula and soft palate move like a pendulum during swallowing, swinging upward to close off the nasopharynx to prevent ingested materials from entering the nasal cavity. Auditory (Eustachian) tubes that connect to each middle ear cavity open into the nasopharynx. This connection is why colds often lead to ear infections.

The oropharynx is bordered superiorly by the nasopharynx and anteriorly by the oral cavity.  The oropharynx contains two distinct sets of tonsils:

• The palatine tonsils.
  • A palatine tonsil is one of a pair of structures located laterally in the oropharynx in the area of the fauces.
• The lingual tonsils.
  • The lingual tonsil is located at the base of the tongue.

Similar to the pharyngeal tonsil, the palatine and lingual tonsils are composed of lymphoid tissue, and trap and destroy pathogens entering the body through the oral or nasal cavities.

The laryngopharynx is inferior to the oropharynx and posterior to the larynx. It continues the route for ingested material and air until its inferior end, where the digestive and respiratory systems diverge. The stratified squamous epithelium of the oropharynx is continuous with the laryngopharynx. Anteriorly, the laryngopharynx opens into the larynx, whereas posteriorly, it enters the esophagus.

Larynx

The structure of the larynx is formed by several pieces of cartilage. Three large cartilage pieces form the major structure of the larynx.

• Thyroid cartilage (anterior):
  • The thyroid cartilage is the largest piece of cartilage that makes up the larynx. The thyroid cartilage consists of the laryngeal prominence, or “Adam’s apple,” which tends to be more prominent in males.
• Epiglottis (superior):
  • Three smaller, paired cartilages—the arytenoids, corniculates, and cuneiforms—attach to the epiglottis and the vocal cords and muscle that help move the vocal cords to produce speech.
• Cricoid cartilage (inferior):
  • The thick cricoid cartilage forms a ring, with a wide posterior region and a thinner anterior region.

Figure 7.5 Larynx. The larynx extends from the laryngopharynx and the hyoid bone to the trachea. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Did You Know?

Folds of the true vocal cords differ between individuals resulting in voices with different pitches.

 

When the epiglottis is in the “closed” position, the unattached end of the epiglottis rests on the glottis.  A vestibular fold, or false vocal cord, is one of a pair of folded sections of mucous membrane. A true vocal cord is one of the white, membranous folds attached by muscle to the thyroid and arytenoid cartilages of the larynx on their outer edges. The inner edges of the true vocal cords are free, allowing oscillation to produce sound.

The act of swallowing causes the pharynx and larynx to lift upward, allowing the pharynx to expand and the epiglottis of the larynx to swing downward, closing the opening to the trachea. These movements produce a larger area for food to pass through, while preventing food and beverages from entering the trachea.

Figure 7.6 Vocal Cords. The true vocal cords and vestibular folds of the larynx are viewed inferiorly from the laryngopharynx. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Similar to the nasal cavity and nasopharynx, this specialized epithelium produces mucus to trap debris and pathogens as they enter the trachea. The cilia beat the mucus upward towards the laryngopharynx, where it can be swallowed down the esophagus.

Trachea

The trachea is formed by 16 to 20 stacked, C-shaped pieces of hyaline cartilage that are connected by dense connective tissue. The trachealis muscle and elastic connective tissue together form the fibroelastic membrane. The fibroelastic membrane allows the trachea to stretch and expand slightly during inhalation and exhalation, whereas the rings of cartilage provide structural support and prevent the trachea from collapsing. The trachealis muscle can be contracted to force air through the trachea during exhalation. The trachea is lined with pseudostratified ciliated columnar epithelium, which is continuous with the larynx. The esophagus borders the trachea posteriorly.

Figure 7.7 Trachea. (a) The tracheal tube is formed by stacked, C-shaped pieces of hyaline cartilage. (b) The layer visible in this cross-section of tracheal wall tissue between the hyaline cartilage and the lumen of the trachea is the mucosa, which is composed of pseudostratified ciliated columnar epithelium that contains goblet cells. LM × 1220. (Micrograph provided by the Regents of University of Michigan Medical School © 2012). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Bronchial Tree

The trachea branches into the right and left primary bronchi at the carina. These bronchi are also lined by pseudostratified ciliated columnar epithelium containing mucus-producing goblet cells (Figure 7.7b). The carina is a raised structure that contains specialized nervous tissue that induces violent coughing if a foreign body, such as food, is present. Rings of cartilage, similar to those of the trachea, support the structure of the bronchi and prevent their collapse. The primary bronchi enter the lungs at the hilum. The bronchi continue to branch into bronchial a tree. A bronchial tree (or respiratory tree) is the collective term used for these multiple-branched bronchi. The main function of the bronchi, like other conducting zone structures, is to provide a passageway for air to move into and out of each lung. The mucous membrane traps debris and pathogens.

A bronchiole branches from the tertiary bronchi. Bronchioles, which are about 1 mm in diameter, further branch until they become the tiny terminal bronchioles, which lead to the structures of gas exchange. There are more than 1000 terminal bronchioles in each lung. The muscular walls of the bronchioles do not contain cartilage like those of the bronchi. This muscular wall can change the size of the tubing to increase or decrease airflow through the tube.

Respiratory Zone

In contrast to the conducting zone, the respiratory zone includes structures that are directly involved in gas exchange. The respiratory zone begins where the terminal bronchioles join a respiratory bronchiole, the smallest type of bronchiole (see Figure 7.8), which then leads to an alveolar duct, opening into a cluster of alveoli.

Figure 7.8 Respiratory Zone. Bronchioles lead to alveolar sacs in the respiratory zone, where gas exchange occurs. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Alveoli

An alveolar duc opens into a cluster of alveoli. An alveolus is one of the many small, grape-like sacs that are attached to the alveolar ducts. An alveolar sac is a cluster of many individual alveoli that are responsible for gas exchange. An alveolus is approximately 200 μm in diameter with elastic walls that allow the alveolus to stretch during air intake, which greatly increases the surface area available for gas exchange. Alveoli are connected to their neighbors by alveolar pores, which help maintain equal air pressure throughout the alveoli and lung (see Figure 7.9).

Figure 7.9 Structures of the Respiratory Zone. (a) The alveolus is responsible for gas exchange. (b) A micrograph shows the alveolar structures within lung tissue. LM × 178. (Micrograph provided by the Regents of University of Michigan Medical School © 2012). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Concept Check

• What are the components of the bronchial tree?
• What is the purpose of cilia?
• Where does gas exchange take place?

 

Gross Anatomy of the Lungs

The lungs are pyramid-shaped, paired organs that are connected to the trachea by the right and left bronchi; on the inferior surface, the lungs are bordered by the diaphragm. The lungs are enclosed by the pleurae, which are attached to the mediastinum. The right lung is shorter and wider than the left lung, and the left lung occupies a smaller volume than the right. The cardiac notch  allows space for the heart (see Figure 7.10). The apex of the lung is the superior region, whereas the base is the opposite region near the diaphragm. The costal surface of the lung borders the ribs. The mediastinal surface faces the mid line.

Figure 7.10 Gross Anatomy of the Lungs. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Each lung is composed of smaller units called lobes. Fissures separate these lobes from each other. The right lung consists of three lobes: the superior, middle, and inferior lobes. The left lung consists of two lobes: the superior and inferior lobes.  A pulmonary lobule is a subdivision formed as the bronchi branch into bronchioles. Each lobule receives its own large bronchiole that has multiple branches. An interlobular septum is a wall, composed of connective tissue, which separates lobules from one another.

Can you correctly label the respiratory system structures?

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Physiology (Function) of the Respiratory System

Blood Supply

The major function of the lungs is to perform gas exchange, which requires blood from the pulmonary circulation.

• This blood supply contains deoxygenated blood and travels to the lungs where erythrocytes pick up oxygen to be transported to tissues throughout the body.
• The pulmonary artery carries deoxygenated, arterial blood to the alveoli.
• The pulmonary artery branches multiple times as it follows the bronchi, and each branch becomes progressively smaller in diameter.
• One arteriole and an accompanying venule supply and drain one pulmonary lobule. As they near the alveoli, the pulmonary arteries become the pulmonary capillary network.
• The pulmonary capillary network consists of tiny vessels with very thin walls that lack smooth muscle fibers.
• The capillaries branch and follow the bronchioles and structure of the alveoli. It is at this point that the capillary wall meets the alveolar wall, creating the respiratory membrane.
• Once the blood is oxygenated, it drains from the alveoli by way of multiple pulmonary veins, which exit the lungs through the hilum.

Nervous Innervation

The blood supply of the lungs plays an important role in gas exchange and serves as a transport system for gases throughout the body. Innervation by the both the parasympathetic and sympathetic nervous systems provides an important level of control through dilation and constriction of the airway.

• The parasympathetic system causes bronchoconstriction.
• The sympathetic nervous system stimulates bronchodilation.

Reflexes such as coughing, and the ability of the lungs to regulate oxygen and carbon dioxide levels, also result from autonomic nervous system control. Sensory nerve fibers arise from the vagus nerve, and from the second to fifth thoracic ganglia. The pulmonary plexus is a region on the lung root formed by the entrance of the nerves at the hilum. The nerves then follow the bronchi in the lungs and branch to innervate muscle fibers, glands, and blood vessels.

Pleura of the Lungs

Each lung is enclosed within a cavity that is surrounded by the pleura. The pleura (plural = pleurae) is a serous membrane that surrounds the lung. The right and left pleurae, which enclose the right and left lungs, respectively, are separated by the mediastinum.

The pleurae consist of two layers:

1. The visceral pleura is the layer that is superficial to the lungs, and extends into and lines the lung fissures (see Figure 7.11).
2. The parietal pleura is the outer layer that connects to the thoracic wall, the mediastinum, and the diaphragm.

The visceral and parietal pleurae connect to each other at the hilum. The pleural cavity is the space between the visceral and parietal layers.

Figure 7.11 Parietal and Visceral Pleurae of the Lungs. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

The pleurae perform two major functions:

1. Produce pleural fluid that that lubricates surfaces, reduces friction to prevent trauma during breathing, and creates surface tension that helps maintain the position of the lungs against the thoracic wall. This adhesive characteristic of the pleural fluid causes the lungs to enlarge when the thoracic wall expands during ventilation, allowing the lungs to fill with air.
2. The pleurae also create a division between major organs that prevents interference due to the movement of the organs, while preventing the spread of infection.

Pulmonary Ventilation

The difference in pressures drives pulmonary ventilation because air flows down a pressure gradient, that is, air flows from an area of higher pressure to an area of lower pressure.

• Air flows into the lungs largely due to a difference in pressure; atmospheric pressure is greater than intra-alveolar pressure, and intra-alveolar pressure is greater than intrapleural pressure.
• Air flows out of the lungs during expiration based on the same principle; pressure within the lungs becomes greater than the atmospheric pressure.

Pulmonary ventilation comprises two major steps: inspiration and expiration. Inspiration is the and expiration (Figure 7.12). A respiratory cycle is one sequence of inspiration and expiration.

Two muscle groups are used during normal inspiration the diaphragm and the external intercostal muscles. Additional muscles can be used if a bigger breath is required.

• The diaphragm contracts, it moves inferiorly toward the abdominal cavity, creating a larger thoracic cavity and more space for the lungs.
• The external intercostal muscles contract and moves the ribs upward and outward, causing the rib cage to expand, which increases the volume of the thoracic cavity.

Due to the adhesive force of the pleural fluid, the expansion of the thoracic cavity forces the lungs to stretch and expand as well. This increase in volume leads to a decrease in intra-alveolar pressure, creating a pressure lower than atmospheric pressure. As a result, a pressure gradient is created that drives air into the lungs.

Figure 7.12 Inspiration and Expiration. Inspiration and expiration occur due to the expansion and contraction of the thoracic cavity, respectively. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

The process of normal expiration is passive, meaning that energy is not required to push air out of the lungs.

• The elasticity of the lung tissue causes the lung to recoil, as the diaphragm and intercostal muscles relax following inspiration.
• The thoracic cavity and lungs decrease in volume, causing an increase in interpulmonary pressure. The interpulmonary pressure rises above atmospheric pressure, creating a pressure gradient that causes air to leave the lungs.

There are different types, or modes, of breathing that require a slightly different process to allow inspiration and expiration:

• Quiet breathing, also known as eupnea, is a mode of breathing that occurs at rest and does not require the cognitive thought of the individual. During quiet breathing, the diaphragm and external intercostals must contract.
• Diaphragmatic breathing, also known as deep breathing, requires the diaphragm to contract. As the diaphragm relaxes, air passively leaves the lungs.
• Costal breathing, also known as a shallow breath, requires contraction of the intercostal muscles. As the intercostal muscles relax, air passively leaves the lungs.
• Forced breathing, also known as hyperpnea, is a mode of breathing that can occur during exercise or actions that require the active manipulation of breathing, such as singing.
  • During forced breathing, inspiration and expiration both occur due to muscle contractions. In addition to the contraction of the diaphragm and intercostal muscles, other accessory muscles must also contract.
    • During forced inspiration, muscles of the neck contract and lift the thoracic wall, increasing lung volume.
    • During forced expiration, accessory muscles of the abdomen contract, forcing abdominal organs upward against the diaphragm. This helps to push the diaphragm further into the thorax, pushing more air out. In addition, accessory muscles help to compress the rib cage, which also reduces the volume of the thoracic cavity.

Concept Check

• Breathing normally, place your hand on your stomach take in one full respiratory cycle.
  • What type of breathing are you doing?
• Keeping your hand on your stomach, take in one large breath and exhale.
  • What type of breathing are you doing?
• Complete 10 jumping jacks, once completed, place your hand on your stomach and take in one full respiratory cycle.
  • What type of  breathing are you doing?

 

Respiratory Rate and Control of Ventilation

Did You Know?

Respiratory rate is the total number of breaths that occur each minute.

Breathing usually occurs without thought, although at times you can consciously control it, such as when you swim under water, sing a song, or blow bubbles. The respiratory rate is the total number of breaths that occur each minute. Respiratory rate can be an important indicator of disease, as the rate may increase or decrease during an illness or in a disease condition. The respiratory rate is controlled by the respiratory center located within the medulla oblongata in the brain, which responds primarily to changes in carbon dioxide, oxygen, and pH levels in the blood.

The normal respiratory rate of a child decreases from birth to adolescence:

• A child under 1 year of age has a normal respiratory rate between 30 and 60 breaths per minute.
• By the time a child is about 10 years old, the normal rate is closer to 18 to 30.
• By adolescence, the normal respiratory rate is similar to that of adults, 12 to 18 breaths per minute.

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Medical Terms not Easily Broken into Word Parts

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Common Respiratory Abbreviations

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Diseases and Disorders

A variety of diseases can affect the respiratory system, such as asthma, emphysema, chronic obstruction pulmonary disorder (COPD), and lung cancer. All of these conditions affect the gas exchange process and result in labored breathing and other difficulties.  (Betts, et al., 2013).

The Effects of Second-Hand Tobacco Smoke

The burning of a tobacco cigarette creates multiple chemical compounds that are released through mainstream smoke, which is inhaled by the smoker, and through sidestream smoke, which is the smoke that is given off by the burning cigarette. Second-hand smoke, which is a combination of sidestream smoke and the mainstream smoke that is exhaled by the smoker, has been demonstrated by numerous scientific studies to cause disease. At least 40 chemicals in sidestream smoke have been identified that negatively impact human health, leading to the development of cancer or other conditions, such as immune system dysfunction, liver toxicity, cardiac arrhythmias, pulmonary edema, and neurological dysfunction. 

Tobacco and second-hand smoke are considered to be carcinogenic. Exposure to second-hand smoke can cause lung cancer in individuals who are not tobacco users themselves.

• It is estimated that the risk of developing lung cancer is increased by up to 30 percent in nonsmokers who live with an individual who smokes in the house, as compared to nonsmokers who are not regularly exposed to second-hand smoke.
• Children who live with an individual who smokes inside the home have a larger number of lower respiratory infections, which are associated with hospitalizations, and higher risk of sudden infant death syndrome (SIDS). Second-hand smoke in the home has also been linked to a greater number of ear infections in children, as well as worsening symptoms of asthma (Betts, et al., 2013).

Lung cancer is a leading cause of cancer death among both males and females in Canada with 98% occurring in adults over 50. Symptoms often appear in the late stages with 50% being diagnosed at STAGE IV (Government of Canada, 2019a). Symptoms may include shortness of breath, wheezing, blood in the mucus, chronic chest infections, dysphagia, pleural effusion, and enlarged lymph nodes. There are two types of lung cancer, small cell lung cancer (SCLC) linked to cigarette smoking, grows quickly and metastasizes. Non-small cell lung cancer (NSCLC) is more common and grows slowly. Changes in lung cells may lead to benign tumours or malignant tumours. Cancers that start in other parts of the body may metastasize to the lungs. Risk factors include smoking, air pollution, family history exposure to second-hand smoke, exposure to radon gas, and exposure to carcinogens (Government of Canada, 2019). Treatment will depend on the type of lung cancer and the stage at diagnosis. Treatments may include surgery, chemotherapy, targeted therapy, immunotherapy, and radiation therapy (Government of Canada, 2019a).

Spirometry testing is used to find out how well lungs are working by measuring air volume.

• Respiratory volume, describes the amount of air in a given space within the lungs, or which can be moved by the lung, and is dependent on a variety of factors.
• Tidal volume, refers to the amount of air that enters the lungs during quiet breathing, whereas inspiratory reserve volume is the amount of air that enters the lungs when a person inhales past the tidal volume.
• Expiratory reserve volume, is the extra amount of air that can leave with forceful expiration, following tidal expiration.
• Residual volume, is the amount of air that is left in the lungs after expelling the expiratory reserve volume.
• Respiratory capacity, is the combination of two or more volumes.
• Anatomical dead space, refers to the air within the respiratory structures that never participates in gas exchange, because it does not reach functional alveoli.
• Respiratory rate, is the number of breaths taken per minute, which may change during certain diseases or conditions.

Both respiratory rate and depth are controlled by the respiratory centers of the brain, which are stimulated by factors such as chemical and pH changes in the blood. These changes are sensed by central chemoreceptors, which are located in the brain, and peripheral chemoreceptors, which are located in the aortic arch and carotid arteries. A rise in carbon dioxide or a decline in oxygen levels in the blood stimulates an increase in respiratory rate and depth (Betts, et al., 2013).

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Respiratory System Vocabulary

Test Yourself

References

Canadian Cancer Society. (2020). Treatments for non–small cell lung cancer. Cancer Information. https://www.cancer.ca/en/cancer-information/cancer-type/lung/treatment/?region=on

Canadian Medical Association. (2018, August). Respirology profile. Canadian Specialty Profiels. https://www.cma.ca/sites/default/files/2019-01/respirology-e.pdf

College of Respiratory Therapists of Ontario. (n.d.). What is a respiratory therapist?. https://www.crto.on.ca/public/what-is-respiratory-therapy/

CrashCourse. (2015, August 24). Respiratory system, part 1: crash course A&P #31 [Video]. YouTube. https://youtu.be/bHZsvBdUC2I

CrashCourse. (2015, August 31). Respiratory system, part 2: crash course A&P #32 [Video]. YouTube. https://youtu.be/Cqt4LjHnMEA

[freshwaterl]. (2009, September 11). Spirometry [Video]. YouTube. https://youtu.be/y9eiVqddVVo

Government of Canada. (2018, May 1). Asthma in Canada. Data Blog, Government of Canada. https://health-infobase.canada.ca/datalab/asthma-blog.html

Government of Canada. (2019, October 21). Lung cancer. Public Health Agency of Canada. https://www.canada.ca/en/public-health/services/chronic-diseases/cancer/lung-cancer.html

Government of Canada. (2019a, October 21). Lung cancer in Canada. Public Health Agency of Canada. https://www.canada.ca/en/public-health/services/publications/diseases-conditions/lung-cancer.html

London Health Sciences Centre. (2020). Welcome to thoracic surgery. https://www.lhsc.on.ca/thoracic-surgery/welcome-to-thoracic-surgery

Image Descriptions

Figure 7.1 image description: This figure shows the upper half of the human body. The major organs in the respiratory system are labeled. [Return to Figure 7.1].

Figure 7.2 image description: This figure shows a cross section view of the nose and throat. The major parts are labeled. [Return to Figure 7.2].

Figure 7.3 image description: This figure shows a micrograph of pseudostratified epithelium. [Return to Figure 7.3].

Figure 7.4 image description: This figure shows the side view of the face. The different parts of the pharynx are color-coded and labeled (from the top): nasal cavity, hard palate, soft palate, tongue, epiglotis, larynx, esophagus, trachea. [Return to Figure 7.4].

Figure 7.5 image description: The top panel of this figure shows the anterior view of the larynx, and the bottom panel shows the right lateral view of the larynx. [Return to Figure 7.5].

Figure 7.6 image description: This diagram shows the cross section of the larynx. The different types of cartilages are labeled (clockwise from top): pyriform fossa, true vocal cord, epiglottis, tongue, glottis, vestibular fold, trachea, esophagus. [Return to Figure 7.6].

Figure 7.7 image description: The top panel of this figure shows the trachea and its organs. The major parts including the larynx, trachea, bronchi, and lungs are labeled. [Return to Figure 7.7].

Figure 7.8 image description: This image shows the bronchioles and alveolar sacs in the lungs and depicts the exchange of oxygenated and deoxygenated blood in the pulmonary blood vessels. [Return to Figure 7.8].

Figure 7.9 image description: This figure shows the detailed structure of the alveolus. The top panel shows the alveolar sacs and the bronchioles. The middle panel shows a magnified view of the alveolus, and the bottom panel shows a micrograph of the cross section of a bronchiole. [Return to Figure 7.9].

Figure 7.10 image description: Diagram of the lungs with the major parts labelled (from top, clockwise): trachea, superior lobe, main bronchus, lobar bronchus, segmental bronchus, inferior lobe, inferior lobe, middle lobe, superior lobe of the left lung. [Return to Figure 7.10].

Figure 7.11 image description: This figure shows the lungs and the chest wall, which protects the lungs, in the left panel. In the right panel, a magnified image shows the pleural cavity and a pleural sac. [Return to Figure 7.11].

Figure 7.12 image description: The left panel of this image shows a person inhaling air and the location of the chest muscles. The right panel shows the person exhaling air and the contraction of the thoracic cavity. [Return to Figure 7.12].

Urinary System Word Parts

Click on prefixes, combining forms, and suffixes to reveal a list of word parts to memorize for the urinary system.

Introduction to the Urinary System

The urinary system has roles you may be well aware of. Cleansing the blood and ridding the body of wastes probably come to mind. However, there are additional, equally important functions, played by the system. Take, for example, regulation of pH, a function shared with the lungs and the buffers in the blood. Additionally, the regulation of blood pressure is a role shared with the heart and blood vessels. What about regulating the concentration of solutes in the blood? Did you know that the kidney is important in determining the concentration of red blood cells? Eighty-five percent of the erythropoietin (EPO) produced to stimulate red blood cell production is produced in the kidneys. The kidneys also perform the final synthesis step of vitamin D production, converting calcidiol to calcitriol, the active form of vitamin D. If the kidneys fail, these functions are compromised or lost altogether, with devastating effects on homeostasis.

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Urinary System Medical Terms

Anatomy (Structures) of the Urinary System

Kidney(s)

The kidneys lie on either side of the spine in the retroperitoneal space between the parietal peritoneum and the posterior abdominal wall, well protected by muscle, fat, and ribs. They are roughly the size of your fist. The male kidney is typically a bit larger than the female kidney. The kidneys are well vascularized, receiving about twenty-five percent of the cardiac output at rest. Figure 8.1 displays the location of the kidneys.

Figure 8.1 Kidneys. The kidneys are slightly protected by the ribs and are surrounded by fat for protection (not shown). From Betts, et al., 2013. Licensed under CC BY 4.0.

Kidneys’ Internal Structure

A frontal section through the kidney reveals an outer region called the renal cortex and an inner region called the medulla (see Figure 8.2). The renal columns are connective tissue extensions that radiate downward from the cortex through the medulla to separate the most characteristic features of the medulla, the renal pyramids and renal papillae. The papillae are bundles of collecting ducts that transport urine made by nephrons to the calyces of the kidney for excretion. The renal columns also serve to divide the kidney into 6–8 lobes and provide a supportive framework for vessels that enter and exit the cortex. The pyramids and renal columns taken together constitute the kidney lobes.

Figure 8.2 Left Kidney. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Renal Hilum

The renal hilum is the entry and exit site for structures servicing the kidneys: vessels, nerves, lymphatics, and ureters. The medial-facing hila are tucked into the sweeping convex outline of the cortex. Emerging from the hilum is the renal pelvis, which is formed from the major and minor calyxes in the kidney. The smooth muscle in the renal pelvis funnels urine via peristalsis into the ureter. The renal arteries form directly from the descending aorta, whereas the renal veins return cleansed blood directly to the inferior vena cava. The artery, vein, and renal pelvis are arranged in an anterior-to-posterior order.

Nephrons and Vessels

The renal artery first divides into segmental arteries, followed by further branching to form interlobar arteries that pass through the renal columns to reach the cortex (see Figure 8.3). The interlobar arteries, in turn, branch into arcuate arteries, cortical radiate arteries, and then into afferent arterioles. The afferent arterioles service about 1.3 million nephrons in each kidney.

Figure 8.3 Blood Flow in the Kidney. From Betts, et al., 2013. Licensed under CC BY 4.0.

Nephrons are the “functional units” of the kidney; they cleanse the blood and balance the constituents of the circulation. The afferent arterioles form a tuft of high-pressure capillaries about 200 µm in diameter, the glomerulus. The rest of the nephron consists of a continuous sophisticated tubule whose proximal end surrounds the glomerulus in an intimate embrace—this is Bowman’s capsule. The glomerulus and Bowman’s capsule together form the renal corpuscle. As mentioned earlier, these glomerular capillaries filter the blood based on particle size. After passing through the renal corpuscle, the capillaries form a second arteriole, the efferent arteriole (see Figure 8.4). These will next form a capillary network around the more distal portions of the nephron tubule, the peritubular capillaries and vasa recta, before returning to the venous system. As the glomerular filtrate progresses through the nephron, these capillary networks recover most of the solutes and water, and return them to the circulation. Since a capillary bed (the glomerulus) drains into a vessel that in turn forms a second capillary bed, the definition of a portal system is met. This is the only portal system in which an arteriole is found between the first and second capillary beds. (Portal systems also link the hypothalamus to the anterior pituitary, and the blood vessels of the digestive viscera to the liver.

Figure 8.4. Blood Flow in the Nephron. The two capillary beds are clearly shown in this figure. The efferent arteriole is the connecting vessel between the glomerulus and the peritubular capillaries and vasa recta. From Betts, et al., 2013. Licensed under CC BY 4.0.

Ureter(s)

The kidneys and ureters are completely retroperitoneal, and the bladder has a peritoneal covering only over the dome. As urine is formed, it drains into the calyces of the kidney, which merge to form the funnel-shaped renal pelvis in the hilum of each kidney. The hilum narrows to become the ureter of each kidney. As urine passes through the ureter, it does not passively drain into the bladder but rather is propelled by waves of peristalsis. The ureters are approximately 30 cm long. The inner mucosa is lined with transitional epithelium and scattered goblet cells that secrete protective mucus. The muscular layer of the ureter consists of longitudinal and circular smooth muscles that create the peristaltic contractions to move the urine into the bladder without the aid of gravity. Finally, a loose adventitial layer composed of collagen and fat anchors the ureters between the parietal peritoneum and the posterior abdominal wall.

Bladder

The urinary bladder collects urine from both ureters ( see Figure 8.5). The bladder lies anterior to the uterus in females, posterior to the pubic bone and anterior to the rectum. During late pregnancy, its capacity is reduced due to compression by the enlarging uterus, resulting in increased frequency of urination. In males, the anatomy is similar, minus the uterus, and with the addition of the prostate inferior to the bladder. The bladder is partially retroperitoneal (outside the peritoneal cavity) with its peritoneal-covered “dome” projecting into the abdomen when the bladder is distended with urine.

Figure 8.5 Bladder. (a) Anterior cross section of the bladder. (b) The detrusor muscle of the bladder (source: monkey tissue) LM × 448. (Micrograph provided by the Regents of the University of Michigan Medical School © 2012). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Urethra

The urethra transports urine from the bladder to the outside of the body for disposal. The urethra is the only urologic organ that shows any significant anatomic difference between males and females; all other urine transport structures are identical (see Figure 8.6).

Figure 8.6. Female and Male Urethras. The urethra transports urine from the bladder to the outside of the body. This image shows (a) a female urethra and (b) a male urethra. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

The urethra in both males and females begins inferior and central to the two ureteral openings forming the three points of a triangular-shaped area at the base of the bladder called the trigone (Greek tri- = “triangle” and the root of the word “trigonometry”). The urethra tracks posterior and inferior to the pubic symphysis (see Figure 8.6). In both males and females, the proximal urethra is lined by transitional epithelium, whereas the terminal portion is a nonkeratinized, stratified squamous epithelium. In the male, pseudostratified columnar epithelium lines the urethra between these two cell types. Voiding is regulated by an involuntary autonomic nervous system-controlled internal urinary sphincter, consisting of smooth muscle and voluntary skeletal muscle that forms the external urinary sphincter below it.

Micturition Reflex

Micturition is a less-often used, but proper term for urination or voiding. It results from an interplay of involuntary and voluntary actions by the internal and external urethral sphincters. When bladder volume reaches about 150 mL, an urge to void is sensed but is easily overridden. Voluntary control of urination relies on consciously preventing relaxation of the external urethral sphincter to maintain urinary continence. As the bladder fills, subsequent urges become harder to ignore. Ultimately, voluntary constraint fails with resulting incontinence, which will occur as bladder volume approaches 300 to 400 ml.

• Normal micturition is a result of stretch receptors in the bladder wall that transmit nerve impulses to the sacral region of the spinal cord to generate a spinal reflex. The resulting parasympathetic neural outflow causes contraction of the detrusor muscle and relaxation of the involuntary internal urethral sphincter.
• At the same time, the spinal cord inhibits somatic motor neurons, resulting in the relaxation of the skeletal muscle of the external urethral sphincter.
• The micturition reflex is active in infants but with maturity, children learn to override the reflex by asserting external sphincter control, thereby delaying voiding (potty training). This reflex may be preserved even in the face of spinal cord injury that results in paraplegia or quadriplegia. However, relaxation of the external sphincter may not be possible in all cases, and therefore, periodic catheterization may be necessary for bladder emptying.

Nerves involved in the control of urination include the hypogastric, pelvic, and pudendal. Voluntary micturition requires an intact spinal cord and functional pudendal nerve arising from the sacral micturition center. Since the external urinary sphincter is voluntary skeletal muscle, actions by cholinergic neurons maintain contraction (and thereby continence) during filling of the bladder. At the same time, sympathetic nervous activity via the hypogastric nerves suppresses contraction of the detrusor muscle. With further bladder stretch, afferent signals traveling over sacral pelvic nerves activate parasympathetic neurons. This activates efferent neurons to release acetylcholine at the neuromuscular junctions, producing detrusor contraction and bladder emptying.

Anatomy Labeling Activity

Physiology (Function) of the Urinary System

• Remove waste products and medicines from the body
• Balance the body’s fluids
• Balance a variety of electrolytes
• Release hormones to control blood pressure
• Release a hormone to control red blood cell production
• Help with bone health by controlling calcium and phosphorus

Having reviewed the anatomy of the urinary system now is the time to focus on physiology. You will discover that different parts of the nephron utilize specific processes to produce urine: filtration, reabsorption, and secretion. You will learn how each of these processes works and where they occur along the nephron and collecting ducts. The physiologic goal is to modify the composition of the plasma and, in doing so, produce the waste product urine.

Nephrons: The Functional Unit

Nephrons take a simple filtrate of the blood and modify it into urine. Many changes take place in the different parts of the nephron before urine is created for disposal. The term “forming urine” will be used hereafter to describe the filtrate as it is modified into true urine. The principal task of the nephron population is to balance the plasma to homeostatic set points and excrete potential toxins in the urine. They do this by accomplishing three principle functions—filtration, reabsorption, and secretion. They also have additional secondary functions that exert control in three areas: blood pressure (via the production of renin), red blood cell production (via the hormone EPO), and calcium absorption (via the conversion of calcidiol into calcitriol, the active form of vitamin D).

Loop of Henle

The descending and ascending portions of the loop of Henle (sometimes referred to as the nephron loop) are, of course, just continuations of the same tubule. They run adjacent and parallel to each other after having made a hairpin turn at the deepest point of their descent. The descending loop of Henle consists of an initial short, thick portion and long, thin portion, whereas the ascending loop consists of an initial short, thin portion followed by a long, thick portion. The descending and ascending thin portions consist of simple squamous epithelium. Different portions of the loop have different permeabilities for solutes and water.

Collecting Ducts

The collecting ducts are continuous with the nephron but are not technically part of it. In fact, each duct collects filtrate from several nephrons for final modification. Collecting ducts merge as they descend deeper in the medulla to form about 30 terminal ducts, which empty at a papilla.

Glomerular Filtration Rate (GFR)

The volume of filtrate formed by both kidneys per minute is termed the glomerular filtration rate (GFR). The heart pumps about 5 L blood per min under resting conditions. Approximately 20 percent or one liter enters the kidneys to be filtered. On average, this liter results in the production of about 125 mL/min filtrate produced in men (range of 90 to 140 mL/min) and 105 mL/min filtrate produced in women (range of 80 to 125 mL/min). This amount equates to a volume of about 180 L/day in men and 150 L/day in women. Ninety-nine percent of this filtrate is returned to the circulation by reabsorption so that only about 1–2 liters of urine are produced per day.

GFR is influenced by the hydrostatic pressure and colloid osmotic pressure on either side of the capillary membrane of the glomerulus. Recall that filtration occurs as pressure forces fluid and solutes through a semipermeable barrier with the solute movement constrained by particle size. Hydrostatic pressure is the pressure produced by a fluid against a surface. If you have fluid on both sides of a barrier, both fluids exert pressure in opposing directions. The net fluid movement will be in the direction of the lower pressure. Osmosis is the movement of solvent (water) across a membrane that is impermeable to a solute in the solution. This creates osmotic pressure which will exist until the solute concentration is the same on both sides of a semipermeable membrane. As long as the concentration differs, water will move. Glomerular filtration occurs when glomerular hydrostatic pressure exceeds the luminal hydrostatic pressure of Bowman’s capsule. There is also an opposing force, the osmotic pressure, which is typically higher in the glomerular capillary. To understand why this is so, look more closely at the microenvironment on either side of the filtration membrane.

You will find osmotic pressure exerted by the solutes inside the lumen of the capillary as well as inside of Bowman’s capsule. Since the filtration membrane limits the size of particles crossing the membrane, the osmotic pressure inside the glomerular capillary is higher than the osmotic pressure in Bowman’s capsule. Recall that cells and the medium-to-large proteins cannot pass between the podocyte processes or through the fenestrations of the capillary endothelial cells. This means that red and white blood cells, platelets, albumins, and other proteins too large to pass through the filter remain in the capillary, creating an average colloid osmotic pressure of 30 mm Hg within the capillary. The absence of proteins in Bowman’s space (the lumen within Bowman’s capsule) results in an osmotic pressure near zero. Thus, the only pressure moving fluid across the capillary wall into the lumen of Bowman’s space is hydrostatic pressure. Hydrostatic (fluid) pressure is sufficient to push water through the membrane despite the osmotic pressure working against it. The sum of all of the influences, both osmotic and hydrostatic, results in a net filtration pressure (NFP) of about 10 mm Hg (see Figure 8.7).

Figure 8.7 Net Filtration Pressure. The NFP is the sum of osmotic and hydrostatic pressures. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

A proper concentration of solutes in the blood is important in maintaining osmotic pressure both in the glomerulus and systemically. There are disorders in which too much protein passes through the filtration slits into the kidney filtrate. This excess protein in the filtrate leads to a deficiency of circulating plasma proteins. In turn, the presence of protein in the urine increases its osmolarity; this holds more water in the filtrate and results in an increase in urine volume. Because there is less circulating protein, principally albumin, the osmotic pressure of the blood falls. Less osmotic pressure pulling water into the capillaries tips the balance towards hydrostatic pressure, which tends to push it out of the capillaries. The net effect is that water is lost from the circulation to interstitial tissues and cells. This “plumps up” the tissues and cells, a condition termed systemic edema.

Reabsorption and Secretion

The renal corpuscle filters the blood to create a filtrate that differs from blood mainly in the absence of cells and large proteins. From this point to the ends of the collecting ducts, the filtrate or forming urine is undergoing modification through secretion and reabsorption before true urine is produced. Here, some substances are reabsorbed, whereas others are secreted. Note the use of the term “reabsorbed.” All of these substances were “absorbed” in the digestive tract—99 percent of the water and most of the solutes filtered by the nephron must be reabsorbed. Water and substances that are reabsorbed are returned to the circulation by the peritubular and vasa recta capillaries.

It is vital that the flow of blood through the kidney is at a suitable rate to allow for filtration. This rate determines how much solute is retained or discarded, how much water is retained or discarded, and ultimately, the osmolarity of blood and the blood pressure of the body.

Urinalysis

Urinalysis (urine analysis) often provides clues to renal disease. Normally, only traces of protein are found in urine, and when higher amounts are found, damage to the glomeruli is the likely basis. Unusually large quantities of urine may point to diseases like diabetes mellitus or hypothalamic tumors that cause diabetes insipidus. The color of urine is determined mostly by the breakdown products of red blood cell destruction (see Figure 8.8). The “heme” of hemoglobin is converted by the liver into water-soluble forms that can be excreted into the bile and indirectly into the urine. This yellow pigment is urochrome. Urine color may also be affected by certain foods like beets, berries, and fava beans. A kidney stone or a cancer of the urinary system may produce sufficient bleeding to manifest as pink or even bright red urine. Diseases of the liver or obstructions of bile drainage from the liver impart a dark “tea” or “cola” hue to the urine. Dehydration produces darker, concentrated urine that may also possess the slight odor of ammonia. Most of the ammonia produced from protein breakdown is converted into urea by the liver, so ammonia is rarely detected in fresh urine. The strong ammonia odor you may detect in bathrooms or alleys is due to the breakdown of urea into ammonia by bacteria in the environment. About one in five people detect a distinctive odor in their urine after consuming asparagus; other foods such as onions, garlic, and fish can impart their own aromas! These food-caused odors are harmless.

Figure 8.8 Urine Color. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Urine volume varies considerably. The normal range is one to two liters per day.  The kidneys must produce a minimum urine volume of about 500 mL/day to rid the body of wastes. Output below this level may be caused by severe dehydration or renal disease and is termed oliguria. The virtual absence of urine production is termed anuria. Excessive urine production is polyuria, which may be due to diabetes mellitus or diabetes insipidus. In diabetes mellitus, blood glucose levels exceed the number of available sodium-glucose transporters in the kidney, and glucose appears in the urine. The osmotic nature of glucose attracts water, leading to its loss in the urine. In the case of diabetes insipidus, insufficient pituitary antidiuretic hormone (ADH) release or insufficient numbers of ADH receptors in the collecting ducts means that too few water channels are inserted into the cell membranes that line the collecting ducts of the kidney. Insufficient numbers of water channels (aquaporins) reduce water absorption, resulting in high volumes of very dilute urine.

Endocrine Urinary Function

Several hormones have specific, important roles in regulating kidney function. They act to stimulate or inhibit blood flow. Some of these are endocrine, acting from a distance, whereas others are paracrine, acting locally.

Renin–Angiotensin–Aldosterone

Renin is an enzyme that is produced by the granular cells of the afferent arteriole. It enzymatically converts angiotensinogen (made by the liver, freely circulating) into angiotensin I. Its release is stimulated by prostaglandins to decreased extracellular fluid volume.

Angiotensin II is a potent vasoconstrictor that plays an immediate role in the regulation of blood pressure. It acts systemically to cause vasoconstriction as well as constriction of both the afferent and efferent arterioles of the glomerulus. In instances of blood loss or dehydration, it reduces both GFR and renal blood flow, thereby limiting fluid loss and preserving blood volume. Its release is usually stimulated by decreases in blood pressure, and so the preservation of adequate blood pressure is its primary role.

Aldosterone is often called the “salt-retaining hormone,” is released from the adrenal cortex in response to angiotensin II or directly in response to increased plasma potassium. It promotes sodium reabsorption by the nephron, promoting the retention of water.

Antidiuretic Hormone (ADH)

Diuretics are drugs that can increase water loss by interfering with the recapture of solutes and water from the forming urine. They are often prescribed to lower blood pressure. Coffee, tea, and alcoholic beverages are familiar diuretics. ADH, released by the posterior pituitary, works to do the exact opposite. It promotes the recovery of water, decreases urine volume, and maintains plasma osmolarity and blood pressure. It does so by stimulating the movement of aquaporin proteins into the apical cell membrane of principal cells of the collecting ducts to form water channels, allowing the transcellular movement of water from the lumen of the collecting duct into the interstitial space in the medulla of the kidney by osmosis. From there, it enters the vasa recta capillaries to return to the circulation. Water is attracted by the high osmotic environment of the deep kidney medulla.

Parathyroid Hormone

Parathyroid hormone (PTH) is produced by the parathyroid glands in response to decreased circulating calcium levels.

Maintaining Homeostasis

Homeostasis requires that volume and osmolarity be preserved. Blood volume is important in maintaining sufficient blood pressure, and there are nonrenal mechanisms involved in its preservation, including vasoconstriction, which can act within seconds of a drop in pressure. Thirst mechanisms are also activated to promote the consumption of water lost through respiration, evaporation, or urination. Hormonal mechanisms are activated to recover volume while maintaining a normal osmotic environment. These mechanisms act principally on the kidney.

Diuretics and Fluid Volume

A diuretic is a compound that increases urine volume. Three familiar drinks contain diuretic compounds: coffee, tea, and alcohol. The caffeine in coffee and tea works by promoting vasodilation in the nephron, which increases GFR. Alcohol increases GFR by inhibiting ADH release from the posterior pituitary, resulting in less water recovery by the collecting duct. In cases of high blood pressure, diuretics may be prescribed to reduce blood volume and, thereby, reduce blood pressure. The most frequently prescribed anti-hypertensive diuretic is hydrochlorothiazide.

Regulation of Nitrogen Wastes

Nitrogen wastes are produced by the breakdown of proteins during normal metabolism. Proteins are broken down into amino acids, which in turn are deaminated by having their nitrogen groups removed. Deamination converts the amino (NH2) groups into ammonia (NH3), ammonium ion (NH4+), urea, or uric acid (Figure 8.9). Ammonia is extremely toxic, so most of it is very rapidly converted into urea in the liver. Human urinary wastes typically contain primarily urea with small amounts of ammonium and very little uric acid.

Figure 8.9 Nitrogen Wastes. From Betts, et al., 2013. Licensed under CC BY 4.0.

Elimination of Drugs and Hormones

Water-soluble drugs may be excreted in the urine and are influenced by one or all of the following processes: glomerular filtration, tubular secretion, or tubular reabsorption. Drugs that are structurally small can be filtered by the glomerulus with the filtrate. Large drug molecules such as heparin or those that are bound to plasma proteins cannot be filtered and are not readily eliminated. Some drugs can be eliminated by carrier proteins that enable secretion of the drug into the tubule lumen. There are specific carriers that eliminate basic (such as dopamine or histamine) or acidic drugs (such as penicillin or indomethacin). As is the case with other substances, drugs may be both filtered and reabsorbed passively along a concentration gradient.

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Urinary System Medical Terms not Easily Broken into Word Parts

Urinary System Abbreviations

Many terms and phrases related to the urinary system are abbreviated.
Learn these common abbreviations by expanding the list below.

Diseases and Disorders

Diabetic Nephropathy

Diabetic nephropathy impacts the kidneys as a result of having diabetes mellitus type 1 or 2.  Higher levels of blood sugar can lead to high blood pressure and this additional pressure exerted on the kidneys causes destruction of the small filtering structures within the kidney. (Mayo Clinic Staff, 2019). To learn more about diabetic nephropathy visit the Mayo Clinic’s Diabetic Nephropathy web page.

Glomerulonephritis

Glomerulonephritis refers to acute or chronic nephritis that involves inflammation of the capillaries of the renal glomeruli. It has various causes, and is noted especially by blood or protein in the urine and by edema. If untreated, it could lead to kidney failure.

Hydronephrosis

Hydronephrosis is a condition whereby the kidneys begin to swell because of the retention of urine. Several conditions can cause hydronephrosis, such as a kidney stone or blood clot. Treatment will vary, depending on the cause (Cleveland Clinic, 2019). To learn more about hydronephrosis the Cleveland Clinic’s web page on hydronephrosis.

Polycystic Kidney Disease

Polycystic kidney disease (PKD) is a genetic disease where cysts grow inside the kidneys. The kidneys enlarge from the cystic collections and damage to the filtering structures of the kidneys can occur. As the disease progresses it may lead to chronic kidney disease (American Kidney Fund, 2020).  To learn more, visit the Kidney Fund’s PKD web page.

Renal Cell Carcinoma

Renal cell carcinoma is a cancer occurring in the kidney tubes where urine is produced or collected. This one of the most common cancers found within the kidneys. Removal of the cancerous lesions is the typical approach from a treatment perspective (Innovation for Patient Care, 2018). To learn more, visit Innovation for Patient Care’s web page on renal cell carcinoma.

Renal Failure

Renal failure occurs when kidneys suddenly or gradually become unable to filter waste products from blood. When kidneys stop filtering, high level of wastes may build. Two types exist acute kidney failure and chronic kidney failure (Mayo Clinic Staff, 2019a). To learn more about kidney failure visit the Mayo Clinic’s page on Chronic Kidney Failure.

Cystitis

Cystitis is inflammation of the urinary bladder, often caused by an infection. A chronic form of this condition is known as interstitial cystitis. Symptoms of cystitis include bladder pressure, voiding frequently, and pain (Mayo Clinic Staff, 2019b). To learn more about cystitis visit the Mayo Clinic’s page on Interstitial Cystitis.

Urinary Tract Infection

A urinary tract infection (UTI) is an infection caused by bacteria, or sometimes, fungi. The exact type of bacterial growth is determined by conducting urine for culture and sensitivity (C&S) testing. In rare cases a UTI may be caused by a virus (Lights & Boskey, 2019). For more information, visit Healthline’s web page on Urinary Tract Infections.

Urinary Incontinence

Urinary incontinence is a loss of bladder control. Those afflicted with the condition will experience urine leakage from the bladder. Weak bladder muscles are a risk factor for developing this condition (Kim & O’Connell, 2017). To learn more about this condition visit Healthline’s webpage Urologic Diseases.

Medical Terms in Context

Medical Specialties and Procedures Related to the Urinary System

Urology is specialty that “addresses the medical and surgical treatment of disorders and diseases of the female urinary tract and the male urogenital system” (Canadian Medical Association, 2018). This specialty focuses on diagnosis, treatment, and surgical repair. Common clinical visits involve kidney stones, kidney failure and bladder dysfunction. To learn more about urology as a specialty visit the Urology Profile (PDF file) authored by the Canadian Medical Association.

Urologist

A urologist is a medical specialist involved in the diagnosis and treatment of urinary and male genitourinary system conditions, disorders, and diseases such as prostate disease, renal and bladder dysfunctions, and others (Canadian Medical Association, 2018).

Procedures and Testing

Urinalysis

A urinalysis is microscopic group of urine testing. This test detects and measures several substances in the urine such as  products of normal and abnormal metabolism and bacteria (Lab Tests Online, 2020). To learn more about urinalysis visit Lab Tests Online’s Urinalysis web page.

Urine for C&S

Urine for culture and sensitivity. Urine produced by the kidneys is analyzed by way of a urine culture test which can detect and identify bacteria in the urine, which may be causing a urinary tract infection (UTI). If harmful bacteria is found a sensitivity report is generated.  This report lists antibiotics sensitive in the treatment of the bacteria present (Lab Tests Online, 2020a). To learn more about Urine for C&S, visit Lab Tests Online’s Urine Culture web page.

24 Hour Urine Collection

This is a test whereby all urinary output is collected over a 24-hour period of time. The analysis of urinary output over this extended period of time provides a greater indication of normal or abnormal kidney function (Lab Tests Online, 2017). To learn more a, visit Lab Tests Online’s 24-hour Urine Sample article.

CT Scan of Kidney

Computed tomography is a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce a variety of images. It provides detailed images of the kidney looking for disease, cancer, obstructions and other kidney conditions (Johns Hopkins Medicine, n.d.) . To learn more about a CT scan of the kidney visit  Johns Hopkins Medicine’s page on Computed Tomography (CT or CAT) Scan of the Kidney.

Cystoscopy

A cystoscopy is a  procedure allowing a physician to check for bladder or ureteral problems, such as bladder cancer.  An endoscope, also known as a cystoscope, containing a camera at the end of it is used (Canadian Cancer Society, 2020). To learn more about cystoscopy visit the Canadian Cancer Society’s Cystoscopy and Ureteroscopy web page .

Dialysis

Dialysis is a treatment that removes waste products from the blood when the kidneys are not fully functioning. This type of therapy is available at home or in a hospital or clinic and there are two main types: peritoneal dialysis and hemodialysis (Kidney Foundation, 2020). To learn more about dialysis visit the Kidney Foundation’s Dialysis web page.

Intravenous Pyelogram

An intravenous pyelogram (IVP) is a specialized x-ray designed to produce views of the entire urinary tract. A dye is used to secure the enhanced imaging. The x-rays can also show how well the urinary tract is functioning and any identify any blockages (Canadian Cancer Society, 2020a). To learn more about IVP visit the Canadian Cancer Society’s IVP web page.

Kidney Scan

A kidney scan is an imaging test which views the kidneys. It is considered a nuclear imaging test as it uses radioactive tracers to pick up hot or cold spots within the kidney. These variation are are considered abnormal.

Kidney Transplant

When kidneys fail or when a person is in end stage chronic kidney disease, a surgical procedure is performed in the form of a kidney transplant. This procedure involves harvesting a donor kidney which is transplanted into the recipient in need of a functioning kidney to support vital function of the urinary system.

Urinary System Vocabulary

Adventitial

The outermost layer of the wall of a blood vessel.

Apical

Relating to or denoting an apex.

Autonomic

Involuntary or unconscious.

Calyces

A cuplike cavity or structure.

Deamination

The removal of an amino group from a molecule.

Detrusor

A muscle which forms a layer of the wall of the bladder.

Excretion

Waste is eliminated from an organism. In vertebrates this is primarily carried out by the lungs, kidneys, and skin.

Homeostasis

A biological process that results in stable equilibrium.

Hydrostatic

Relating to the equilibrium of liquids and the pressure exerted by liquid at rest.

Hypothalamic

A region of the forebrain below the thalamus.

Lethargy

Periods of weakness.

Mitochondria

An organelle found in large numbers in most cells.

Osmosis

A process by which molecules of a solvent tend to pass through a membrane from a less concentrated solution into a more concentrated one.

pH

pH is a measure of how acidic or alkaline a substance is, as determined by the number of free hydrogen ions in the substance.

Prostaglandins

Any of a group of compounds with varying hormone-like effects.

Pseudostratified

Consisting of closely packed cells which appear to be arranged in layers.

Solutes

The minor component in a solution.

Voiding

Excrete (waste matter).

Test Yourself

References

American Kidney Fund. (2020, June 17). Polycystic kidney disease. https://www.kidneyfund.org/kidney-disease/other-kidney-conditions/polycystic-kidney-disease.html

Canadian Medical Association. (2018, August). Urology profile. Canadian Medical Association Speciatly Profiles. https://www.cma.ca/sites/default/files/2019-01/urology-e.pdf

Canadian Cancer Society. (2020). Cystoscopy and ureteroscopy. Canadian Cancer Society: Cancer Information. https://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/tests-and-procedures/cystoscopy/?region=on

Canadian Cancer Society. (2020a). Intravenous pyelogram. Canadian Cancer Society: Cancer Information. https://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/tests-and-procedures/intravenous-pyelogram/?region=on

Cleveland Clinic. (2019, May 22). Hydronephrosis. https://my.clevelandclinic.org/health/diseases/15417-hydronephrosis

[CrashCourse]. (2015, October 12). Urinary system, part 1: Crash course A&P #38 [Video]. YouTube. https://www.youtube.com/watch?v=l128tW1H5a8

[CrashCourse]. (2015, June 22). Urinary system, part 2: Crash course A&P #39 [Video]. YouTube. https://youtu.be/DlqyyyvTI3k

Innovation for Patient Care. (2020, October 16). Renal cell carcinoma: The most common form of kidney cancer in adults. https://www.ipsen.ca/therapeutic-areas/oncology/renal-cell-carcinoma/

Johns Hopkins Medicine. (n.d.). Computed tomography (CT or CAT) scan of the kidney. John Hopkins Medicine: Health. https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/ct-scan-of-the-kidney

Kidney Foundation of Canada. (2020). Dialysis. Kidney Foundation. https://kidney.ca/Kidney-Health/Living-With-Kidney-Failure/Dialysis

Lab Tests Online. (2017, July 10). 24-hour urine sample. https://labtestsonline.org/glossary/urine-24

Lab Tests Online. (2020, June 16). Urinalysis. https://labtestsonline.org/tests/urinalysis

Lab Tests Online. (2020a, January 30). Urine culture. https://labtestsonline.org/tests/urinalysis

Lights, V., & Boskey, E. (2019, March 21). Everything you need to know about urinary tract infection. Healthline. https://www.healthline.com/health/urinary-tract-infection-adults

Mayo Clinic Staff. (2019a, August 15). Chronic kidney disease. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/chronic-kidney-disease/symptoms-causes/syc-20354521

Mayo Clinic Staff. (2019, September 19). Diabetic nephropathy. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/diabetic-nephropathy/symptoms-causes/syc-20354556

Mayo Clinic Staff. (2019b, September 14). Interstitial cystitis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/interstitial-cystitis/symptoms-causes/syc-20354357

Image Descriptions

Figure 8.2 image description: LeftThe left panel of this figure shows the location of the kidneys in the abdomen. The right panel shows the cross section of the kidney. [Return to Figure 8.2].

Figure 8.5 image description: The left panel of this figure shows the cross section of the bladder and the major parts are labeled. The right panel shows a micrograph of the bladder. [Return to Figure 8.5].

Figure 8.6 image description: Diagrams of the (a) female and (b) male genitalia highlighting the respective urethras. [Return to Figure 8.6].

Figure 8.7 image description: This figure shows the different pressures acting across the glomerulus including blood hydrostatic pressure, blood colloid osmotic pressure, capsular hydrostatic pressure. [Return to Figure 8.7].

Figure 8.8 image description: This color chart shows 8 different shades of yellow and associates each shade with stages of hydration (lightest 3 shades) or dehydration (remaining 5 darker shades). [Return to Figure 8.8].

Unless otherwise indicated, this chapter contains material adapted from Anatomy and Physiology (on OpenStax), by Betts, et al. and is used under a a CC BY 4.0 international license. Download and access this book for free at https://openstax.org/books/anatomy-and-physiology/pages/1-introduction.

Male Reproductive System Word Parts

Click on prefixes, combining forms, and suffixes to reveal a list of word parts to memorize for the Male Reproductive System.

Introduction to the Male Reproductive System

Gametes are the reproductive cells that combine to form a fetus. Organs called gonads produce the gametes, along with the hormones that regulate human reproduction. The male gametes are called sperm. Spermatogenesis occurs within the seminiferous tubules that make up most of the testis. The scrotum is a sac that holds the testes outside of the body cavity.

Watch this video:

A YouTube element has been excluded from this version of the text. You can view it online here: https://ecampusontario.pressbooks.pub/medicalterminology/?p=251

Media 9.1. Reproductive System, Part 2 – Male Reproductive System: Crash Course A&P 41 [Online video]. Copyright 2015 by CrashCourse.

Male Reproductive Medical Terms

Anatomy (Structures) of the Male Reproductive System

The structures of the male reproductive system include the testes, the epididymis, the penis, and the ducts and glands that produce and carry semen. Sperm exit the scrotum through the vas deferens. The spermatic cord is an enclosed sheath which includes the vas deferens, arteries, veins and nerves. The seminal vesicles and prostate gland add fluids to the sperm to create semen .

Figure 9.1. Male Reproductive System. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Physiology (Function) of the Male Reproductive System

Spermatogenesis

Spermatogenesis occurs in the seminiferous tubules that form the bulk of each testis. The process begins at puberty, after which time sperm are produced constantly throughout a man’s life. One production cycle takes approximately 64 days. One production cycle is considered  from spermatogonia through to formed sperm. A new cycle starts approximately every 16 days, although this timing is not synchronous across the seminiferous tubules.

Sperm

Sperm are smaller than most cells in the body; in fact, the volume of a sperm cell is 85,000 times less than that of the female gamete. Approximately 100 to 300 million sperm are produced each day, whereas women typically ovulate only one oocyte   per month as is true for most cells in the body, the structure of sperm cells speaks to their function. Sperm have a distinctive head, mid-piece, and tail region (see Figure 9.2).

Figure 9.2. Structure of Sperm. Sperm cells are divided into a head, containing DNA; a mid-piece, containing mitochondria; and a tail, providing motility. The acrosome is oval and somewhat flattened. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Sperm Transport

To fertilize an egg, sperm must be moved from the seminiferous tubules in the testes, through the epididymis, and—later during ejaculation—along the length of the penis and out into the female reproductive tract. It takes an average of 12 days for sperm to move through the coils of the epididymis, with the shortest recorded transit time in humans being one day.

Epididymis

Sperm enter the head of the epididymis and are moved by the contraction of smooth muscles lining the epididymal tubes. As the sperm mature they acquire the ability to move under their own power. Once inside the female reproductive tract, they will use this ability to move independently toward the unfertilized egg. The more mature sperm are then stored in the tail of the epididymis until ejaculation occurs.

Ducts

During ejaculation, sperm exit the tail of the epididymis and are pushed by smooth muscle contraction to the vas deferens (also called the ductus deferens). The vas deferens is a thick, muscular tube that is bundled together inside the scrotum with connective tissue, blood vessels, and nerves into a structure called the spermatic cord. From each epididymis, each vas deferens extends through the inguinal canal in the abdominal wall and continues to a region called the ampulla. The sperm is mixed with fluid from the paired seminal vesicles and moves into its associated ejaculatory duct. The ejaculatory ducts transport the seminal fluid to the prostate gland.

Prostate Gland

The prostate gland secretes an alkaline, milky fluid to the passing seminal fluid (referred to as semen) to first coagulate and then decoagulate the semen following ejaculation. The temporary thickening of semen helps retain it within the female reproductive tract and once decoagulated the sperm can pass farther into the female reproductive tract.

Bulbourethral Glands

Bulbourethral glands release a thick, salty fluid that lubricates the end of the urethra and vagina, and helps to clean urine residues from the penile urethra.

Anatomy Labeling Activity

Common Male Reproductive System Abbreviations

Diseases and Disorders

Erectile Dysfunction Disorder (EDD) 

Erectile dysfunction (ED) is a condition in which a male has difficulty either initiating or maintaining an erection. The combined prevalence of minimal, moderate, and complete ED is approximately 40% in men at age 40 and reaches nearly 70% by 70 years of age. In addition to aging, ED is associated with diabetes, vascular disease, psychiatric disorders, prostate disorders, the use of some drugs such as certain antidepressants, and problems with the testes resulting in low testosterone concentrations. These physical and emotional conditions can lead to disruptions in the vasodilation pathway and result in an inability to achieve an erection  (Betts, et al., 2013).

Cancer

Prostate Cancer

According to the Centers for Disease Control and Prevention (CDC), prostate cancer is the second most common cancer occurring in men. However, some forms of prostate cancer grow very slowly and may not require treatment. Aggressive forms of prostate cancer, in contrast, involve metastasis to organs like the lungs and brain. There is no link between Benign Prostatic Hyperplasia and prostate cancer, but the symptoms are similar. Prostate cancer is detected by medical history, a blood test, and a digital rectal exam that allows physicians to palpate the prostate and check for unusual masses. If a mass is detected, the cancer diagnosis is confirmed by biopsy of the cells (Betts, et al., 2013).

Testicular Cancer

Testicular cancer begins in the testicle or testis. It is most often found in men age 15 to 44 years, although it can be diagnosed at any age (Canadian Cancer Society, 2020). Testicular cancer is rare and treatable when diagnosed early. Common symptoms are a painless lump in the testicle, swelling, a heavy feeling in the scrotum or abdomen, amongst others. Sometimes, testicular cancer is found during infertility testing. An orchiectomy  is the most common procedure for diagnosing and treating testicular cancer (Canadian Cancer Society, 2020). To learn more about testicular cancer, diagnosis and treatments please go to the Canadian Cancer Society’s web page on testicular cancer.

Sexually Transmitted Infections (STIs)

The terms for sexually transmitted infections (STI) and sexuality transmitted diseases (STD) are often used interchangeably. Sexuality transmitted disease (STD) implies the disease was acquired through sexual transmission. A disease is a disorder of structure or function in a human, which produces specific signs or symptoms. A disease must be managed, as with the case of human immunodeficiency virus (which can also be acquired through the transmission of other bodily fluids; thus not solely sexual transmission). The treatment may include antiretrovirals or anti-virals (Urology Care Foundation, 2019).

Chlamydia (CT)

Chlamydia is one of the most common sexually transmitted infections (STIs) caused by bacteria that infect the cervix, urethra and other reproductive organs. Chlamydia is easy to treat and can be cured. Many people with chlamydia do not have any symptoms and unknowingly pass the infection to their sexual partner(s). If symptoms develop, they usually appear two to six weeks after sexual contact with an infected person. Males may have penial discharge and itching around the urethra. The urethra is the opening in the penis. Males may also experience dysuria , polyuria , urethral pain and urethritis (Ontario Agency for Health Protection and Promotion , 2019; Region of Peel, 2007).

Chlamydia spreads through unprotected oral, anal or vaginal sex with an infected person. Chlamydia can be spread to the eyes via the hands with direct contact of infected fluids. Until a patient finishes their treatment, they continue to have the infection and can continue to pass it to others. Chlamydia is treated with antibiotic pills. If the patient has epididymitis, they may need to be hospitalized and be treated with intravenous (IV) antibiotics. All sexual partners within the past 60 days should be examined, treated, and informed that having no symptoms does not mean there is no infection (Ontario Agency for Health Protection and Promotion, 2019; Region of Peel, 2007).

Gonorrhea (Gonococcus) – (GC)

Gonorrhea is a sexually transmitted infection (STI) caused by bacteria that infects the cervix, urethra and other reproductive organs. Infections can also infect the throat and anus. Gonorrhea can be treated and cured. Many people infected with gonorrhea have no symptoms and can unknowingly pass the infection on to their sexual partner(s). If symptoms develop, they may appear two to seven days after sexual contact with an infected person. Symptoms vary depending on which part of the body is infected. Males may have yellowish-white discharge from the penis. They may also have dysuria , polyuria , testicular pain and testitis . Gonorrhea infection from oral sex may lead to sore throat and swollen glands. Gonorrhea infection from anal sex may cause itchiness and discharge from the anus. Gonorrhea is spread through unprotected oral, vaginal or anal sex with an infected person.  Until the patient finishes their treatment, they continue to have the infection and can pass it to others (Ontario Agency for Health Protection and Promotion, 2019a; Region of Peel, 2007).

Gonorrhea is treated with oral antibiotics in combination with an intramuscular (IM) injection. It is important that one completes the treatment and abstain from unprotected sexual activity for at least seven days following treatment. If the patient develops epididymitis, the patient may need to go to a hospital and be treated with intravenous antibiotics.
All sexual partners within the past 60 days should be examined, treated and informed that having no symptoms does not mean there is no infection (Ontario Agency for Health Protection and Promotion, 2019a; Region of Peel, 2007).

Reportable Diseases

Both chlamydia and gonorrhea are reportable diseases to the Ministry of Health and Long Term Care. Therefore, the local health department will be calling the doctor’s office or patient to ensure correct treatment was received and sexual partners have been followed up with testing and treatment (Ontario Agency for Health Protection and Promotion, 2019a; Region of Peel, 2007). To learn more about STIs and STDs such as chlamydia and gonorrhea please go to the Public Health Ontario website.

Human Papillomavirus- HPV

HPV is another common sexually transmitted infection (STI). Both males and females can be infected with HPV. Around three quarters of sexually active individuals have been exposed to HPV during their lifetime. There are over 100 strains of HPV and some strains of HPV can cause visible genital warts. The warts are usually painless but may be itchy, uncomfortable and hard to treat. Some strains of HPV cause genital, anal, throat and cervical cancers. HPV spreads through sexual activity and skin-to-skin contact in the genital area with an infected person. Since some people are asymptomatic they don’t know they have the virus and consequently pass the virus to their sexual partners. Treatments are available for genital warts but there is no cure for HPV (York Region Health Connect, n.d.). To learn more about HPV symptoms, treatments, and prognosis visit the York Region Fact Sheet (PDF file) on HPV. 

HPV Vaccine

A vaccine called Gardasil® 9 is available for 9 HPV strains. This vaccine assists the immune system in protecting the body against infections and diseases caused by HPV (York Region Health Connection, n.d.). To learn more about Gardasil® 9 treatments, please visit the Gardasil® 9 website.

Herpes Simplex Virus (HSV)

Genital herpes is a sexually transmitted infection (STI) that is caused by a virus called herpes simplex virus (HSV). There are two types of herpes simplex viruses:

• Type 1- oral herpes or cold sores (HSV-1)
• Type 2- genital herpes (HSV-2).

These viruses are very similar and either type can cause genital herpes or cold sores. Symptoms might include dysuria, enlarged glands, myalgia, arthralgia and fever. Once a patient is infected with HSV, the virus remains in their body even after the symptoms are gone and can cause recurring outbreaks. When the virus becomes active again, the symptoms return but are usually less painful and heal faster. Recurring outbreaks vary from person-to-person, however they can be triggered by emotional or physical stress, exposure to sunlight, hormonal changes, poor nutrition, sexual intercourse, lack of sleep or a low immune system.

Herpes is spread through direct contact with the sores or blisters of an infected person. Contact (and transfer of the virus) can occur from genitals-to-genitals, mouth-to-genitals or mouth-to-mouth. Herpes can also be passed to the anal area. Herpes spreads easily during sexual contact while symptoms are present, or just before an outbreak of symptoms. An infected person may spread herpes even when they have no symptoms; this is called asymptomatic shedding. One can spread the herpes virus to other parts of their body after touching the sores; autoinoculation. The fingers, eyes and other body areas can accidentally become infected in this way. Hand washing after touching sores and blisters is recommended to prevent spreading the virus.

There is no cure for herpes. Antiviral pills help to reduce symptoms and speed the healing of blisters or sores and are prescribed by a doctor. Treatment of symptoms may be managed with medication for pain, bath salts, cold compresses and urinating in water may help to relieve discomfort. Keep the infected area clean and dry, wear cotton underwear and loose clothing to reduce discomfort. All sexual partner(s) should be informed. The only way to reduce the risk of transmission of herpes is to avoid direct contact with the sores and to use condoms. Condoms will reduce but not eliminate risk as the virus can be present and shed from the skin in the genital area (Ontario Ministry of Health and Long-Term Care, 2015).

To learn more about the symptoms, complications, treatments and prognosis of HSV please visit the Ontario Ministry of Health and Long-Term Care’s Sexually Transmitted Diseases : Genital Herpes website or Public Health Ontario’s Testing Index.

STI Medical Abbreviations

Medical Terms in Context

Medical Specialties and Procedures related to the Male Reproductive System

Vasectomy

Watch the Animated Dissection of Anatomy for Medicine’s (A.D.A.M.) video to learn about a vasectomy. As described in this video, a vasectomy is a procedure in which a small section of the ductus (vas) deferens is removed from the scrotum. This cuts off the path taken by sperm through the ductus deferens. (as cited in Betts, et al., 2013).

No-Scalpel Vasectomy (NSV)

An alternative to a traditional vasectomy is the no-scalpel vasectomy (NSV). This is a minimally invasive procedure and an added benefit is that the recovery time is shorter. All vasectomies are completed by a urologist (Gentle Procedures Clinic, n.d.). To learn more about the NSV procedure, visit No-Scalpel Vasectomy Procedure Info by the Gentle Procedures Clinic in Toronto, Ontario.

Urology

Urology is a surgical sub specialty in which the surgeon has additional training in the treatments of diseases and disorders of the male and female urogenital systems (Canadian Medical Association, 2018). To learn more about urology and the training involved to become a urologist visit the Canadian Medical Association’s Urology Profile.

Male Reproductive Vocabulary

Arthralgia

Joint pain.

Bulbourethral glands

(Also, Cowper’s glands) glands that secrete a lubricating mucus that cleans and lubricates the urethra prior to and during ejaculation.

Corpus cavernosum

Either of two columns of erectile tissue in the penis that fill with blood during an erection.

Corpus spongiosum

(Plural = corpora cavernosa) column of erectile tissue in the penis that fills with blood during an erection and surrounds the penile urethra on the ventral portion of the penis.

Ductus deferens

(also, vas deferens) duct that transports sperm from the epididymis through the spermatic cord and into the ejaculatory duct; also referred as the vas deferens.

Dysuria

Painful urination.

Ejaculatory duct

Duct that connects the ampulla of the ductus deferens with the duct of the seminal vesicle at the prostatic urethra.

Epididymis

(plural = epididymides) coiled tubular structure in which sperm start to mature and are stored until ejaculation.

Epididymitis

Inflammation/swelling of the epididymis.

Gamete

Haploid reproductive cell that contributes genetic material to form an offspring.

Glans penis

Bulbous end of the penis that contains a large number of nerve endings.

Gonadotropin-releasing hormone (GnRH)

Hormone released by the hypothalamus that regulates the production of follicle-stimulating hormone and luteinizing hormone from the pituitary gland.

Gonads

Reproductive organs (testes in men and ovaries in women) that produce gametes and reproductive hormones.

Inguinal canal

Opening in abdominal wall that connects the testes to the abdominal cavity.

Leydig cells

Cells between the seminiferous tubules of the testes that produce testosterone, a type of interstitial cell.

Myalgia

Muscle pain.

Penis

Male organ of copulation.

Polyuria

Frequent urination.

Prepuce

(Also, foreskin) flap of skin that forms a collar around, and thus protects and lubricates, the glans penis; also referred as the foreskin.

Prostate gland

Doughnut-shaped gland at the base of the bladder surrounding the urethra and contributing fluid to semen during ejaculation.

Scrotum

External pouch of skin and muscle that houses the testes.

Semen

Ejaculatory fluid composed of sperm and secretions from the seminal vesicles, prostate, and bulbourethral glands.

Seminal vesicle

Gland that produces seminal fluid, which contributes to semen.

Seminiferous tubules

Tube structures within the testes where spermatogenesis occurs.

Sertoli cells

Cells that support germ cells through the process of spermatogenesis; a type of sustentacular cell.

Sperm

(Also, spermatozoon) male gamete.

Spermatic cord

Bundle of nerves and blood vessels that supplies the testes; contains ductus deferens.

Spermatid

Immature sperm cells produced by meiosis II of secondary spermatocytes.

Spermatocyte

Cell that results from the division of spermatogonium and undergoes meiosis I and meiosis II to form spermatids.

Spermatogenesis

Formation of new sperm, occurs in the seminiferous tubules of the testes.

Spermatogonia

Diploid precursor cells that become sperm (singular = spermatogonium).

Spermiogenesis

Transformation of spermatids to spermatozoa during spermatogenesis.

Testes

Male gonads (singular = testis).

Testitis

Inflammation of the testicles.

Urethritis

Inflammation of the urethra.

Test Yourself

References

Canadian Cancer Society. (2020). Symptoms of testicular cancer. https://www.cancer.ca/en/cancer-information/cancer-type/testicular/signs-and-symptoms/?region=on

Canadian Medical Association. (2018). Urology Profile. https://www.cma.ca/sites/default/files/2019-01/urology-e.pdf

CrashCourse. (2015, November 9). Reproductive system, part 2 – Male reproductive system: Crash course A&P 41. YouTube. https://youtu.be/-XQcnO4iX_U

Gentle Procedures Clinic. (n.d). No-Scalpel vasectomy procedure info. https://gentleprocedurestoronto.ca/vasectomy/no-scalpel-no-needle/

Ontario Agency for Health Protection and Promotion. (2019). Chlamydia. Public Health Ontario. https://www.publichealthontario.ca/en/diseases-and-conditions/infectious-diseases/sexually-transmitted-infections/chlamydia

Ontario Agency for Health Protection and Promotion. (2019a). Gonorrhea. Public Health Ontario. https://www.publichealthontario.ca/en/diseases-and-conditions/infectious-diseases/sexually-transmitted-infections/gonorrhea

Ontario Ministry of Health and Long-Term Care. (2015). Sexually transmitted diseases: Genital herpes (hur-peez). Publications. http://www.health.gov.on.ca/en/public/publications/std/herpes.aspx

Region of Peel. (2007). Chlamydia and Gonorrhea. https://www.peelregion.ca/health/talk-to-me/download/lesson-plans/lesson6-pdf/lesson6i.pdf

Urology Care Foundation. (2019). What are sexually transmitted infections (STIs) or diseases (STDs)?. https://www.urologyhealth.org/urologic-conditions/sexually-transmitted-infections#Acquired_Immune_Deficiency_Syndrome_(AIDS)

York Region Health Connection. (n.d.). Human Papillomavirus: https://www.york.ca/wps/wcm/connect/yorkpublic/b5158069-a667-4f43-bb25-e0449ba22caa/6052+Human+Papilloma+Virus+Fact+Sheet.pdf?MOD=AJPERES&CACHEID=b5158069-a667-4f43-bb25-e0449ba22caa

Image Descriptions

Figure 9.1 image description: This figure shows the different organs in the male reproductive system. The top panel shows the side view of a man and an uncircumcised and a circumcised penis. The bottom panel shows the lateral view of the male reproductive system and the major parts are labeled. [Return to Figure 9.1].

Figure 9.2 image description: This diagram shows the structure of sperm; the major parts are labeled (from left to right): head section (acrosome, plasma membrane, nucleaus), mid-piece (centriole, mitochondria, flagellum), tail (flagellum, axial filament), end piece (end piece). [Return to Figure 9.2].

Unless otherwise indicated, this chapter contains material adapted from Anatomy and Physiology (on OpenStax), by Betts, et al. and is used under a a CC BY 4.0 international license. Download and access this book for free at https://openstax.org/books/anatomy-and-physiology/pages/1-introduction.

Female Reproductive System Word Parts

Click on prefixes, combining forms, and suffixes to reveal a list of word parts to memorize for the female reproductive system.

Introduction to the Female Reproductive System

The female reproductive system produces gametes and reproductive hormones. In addition, the female reproductive system supports the developing fetus and delivers it to the outside world. The female reproductive system is located primarily inside the pelvic cavity. The female gonads are called ovaries and the gamete they produce is called an oocyte.

Figure 10.1 Female Reproductive System. The major organs of the female reproductive system are located inside the pelvic cavity. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Watch this video:

A YouTube element has been excluded from this version of the text. You can view it online here: https://ecampusontario.pressbooks.pub/medicalterminology/?p=253

Media 10.1. Reproductive System, Part 1 – Female Reproductive System: Crash Course A&P #40 [Online video]. Copyright 2015 by CrashCourse.

Female Reproductive System Medical Terms

Anatomy (Structures) of the Female Reproductive System

External Female Genitals

The external female reproductive structures are referred to collectively as the vulva and they include:

• The mons pubis is a pad of fat that is located at the anterior, over the pubic bone. After puberty, it becomes covered in pubic hair.
• The labia majora (labia = “lips”; majora = “larger”) are folds of hair-covered skin that begin just posterior to the mons pubis.
• The  labia minora (labia = “lips”; minora = “smaller”) is thinner and more pigmented and extends medially to the labia majora.
  • Although they naturally vary in shape and size from woman to woman, the labia minora serve to protect the female urethra and the entrance to the female reproductive tract.
  • The superior, anterior portions of the labia minora come together to encircle the clitoris (or glans clitoris), an organ that originates from the same cells as the glans penis and has abundant nerves that make it important in sexual sensation and orgasm. The hymen is a thin membrane that sometimes partially covers the entrance to the vagina.  
• The vaginal opening is located between the opening of the urethra and the anus. It is flanked by outlets to the Bartholin’s glands.

Figure 10.2. The Vulva. The external female genitalia are referred to collectively as the vulva. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Internal Female Reproductive Organs

Vagina

The vagina is a muscular canal (approximately 10 cm long) that is the entrance to the reproductive tract. It also serves as the exit from the uterus during menses and childbirth. The outer walls of the anterior and posterior vagina are columns with ridges. The superior fornix meets the uterine cervix. The cervix is the opening to the uterus.

The walls of the vagina are lined with:

• An outer, fibrous adventitia
• A middle layer of smooth muscle
• An inner mucous membrane with transverse folds called rugae.

Together, the middle and inner layers allow the expansion of the vagina to accommodate intercourse and childbirth. The thin, perforated hymen can partially surround the opening to the vaginal orifice. The Bartholin’s glands  and the lesser vestibular glands (located near the clitoris) secrete mucus, which keeps the vestibular area moist.

The vagina has a normal population of microorganisms that help to protect against infection. There is both pathogenic bacteria, and yeast in the vagina. In a healthy woman, the most predominant type of vaginal bacteria is from the genus Lactobacillus, which secretes lactic acid. the lactic acid protects the vagina by maintaining an acidic pH (below 4.5).

Lactic acid, in combination with other vaginal secretions, makes the vagina a self-cleansing organ. However, douching can disrupt the normal balance of healthy microorganisms, and increase a woman’s risk for infections and irritation. It is recommend that women do not douche and that they allow the vagina to maintain its normal healthy population of protective microbial flora.  

The Menstrual Cycle

The three phases of the menstrual cycle are:

1. The menses phase of the menstrual cycle is the phase during which reproductive hormone levels are low, the woman menstruates, and the lining is shed. The menses phase lasts between 2 – 7 days with an average of 5 days.
2. The proliferative phase is when menstrual flow ceases and the endometrium begins to proliferate . During this phase reproductive hormones are working in homeostasis to trigger ovulation on approximately day 14 of a typical 28-day menstrual cycle. Ovulation marks the end of the proliferative phase.
3. The secretory phase the endometrial lining prepares for implantation of a fertilized egg. If no pregnancy occurs within approximately 10- 12 days the endometrium will grow thinner and shed starting the first day of the next cycle.

Anatomy Labeling Activity

Female Reproductive System Terms not Easily Broken into Word Parts

Female Reproductive System Medical Abbreviations

Diseases and Disorders of the Female Reproductive System

Cancer

Breast Cancer

Breast cancer starts in the cells that line the ducts or the lobule of the breast. Some warning signs include a new lump in the breast or axilla, thickening or swelling, irritation or dimpling of the breast skin, redness or flaky skin, pain, discharge, all in the breast or nipple area, and change in breast size. Risk factors include family history, obesity, hormonal treatment and changes in breast cancer-related genes (BRCA1 or BRCA2) (Centers for Disease Control and Prevention, n.d.; Cancer Care Ontario, n.d.). 

Treatment options include chemotherapy, radiation and surgical interventions such as mastectomy, biopsy, incision and drainage and mammoplasty (Centers for Disease Control and Prevention, n.d.; Cancer Care Ontario, n.d.). To learn more about breast cancer, view the Cancer Care Ontario: Breast Cancer web page.

Cervical Cancer

Cervical cancer is typically slow-growing cancer and is highly curable when found and treated early. Advanced cervical cancer may cause abnormal bleeding or discharge from the vagina such as bleeding after sex. It is diagnosed during a Papanicolaou test (or Pap smear) which looks for precancers, cell changes, on the cervix. The Pap test can find cervical cancer early, when treatment is most effective. The Pap test only screens for cervical cancer (Centers for Disease Control and Prevention, 2019).

The HPV (Human papillomavirus) test looks for HPV strains which is the virus that can cause precancerous cell changes. Almost all cervical cancers are caused by HPV. HPV is a common virus that is passed from one person to another during sexual contact. In Canada, there is the HPV vaccine. The age of administration varies between the provinces and territories. See below under HPV for more information about the HPV vaccine (York Region Health Connect, n.d.). To learn more about cervical cancer please visit the Centers for Disease Control and Prevention’s cervical cancer factsheet (PDF file).

Endometriosis

Endometriosis is an abnormal condition of the endometrium. Endometriosis occurs when this tissue grows and implants outside the uterus. The female hormone estrogen causes these implants to grow, bleed, and break down. They are implanted outside the uterus have no way to leave the body. They become painful, inflamed, and swollen. The inflammation causes scar tissue around nearby organs which can interfere with their normal functioning and cause pain (Canadian Women’s Health Network, 2012).

Endometriosis generally appears between the ages of 15 and 50.  Signs and symptoms may include dysmenorrhea, lumbago, dyspareunia, menstrual irregularity and infertility. One-third of women diagnosed with endometriosis have no symptoms at all.Diagnosis may include laparoscopy and endometrial biopsy. Treatment may include medication, surgical interventions such as hysterectomy and oophorectomy.  The cause of endometriosis is unknown (Canadian Women’s Health Network, 2012). To learn more about endometriosis visit the Endometriosis FAQ article on Canadian Women’s Health Network.

PCOS

Polycystic Ovary Syndrome (PCOS) has no known etiology but researchers have linked it to excessive insulin production. Excessive insulin in the body can release extra male hormones in women. Since the ovaries produce high levels of androgens this causes the eggs to develop into cysts and instead of releasing during ovulation, the cysts build up and enlarge. The most common symptoms of PCOS include oligomenorrhea, amenorrhea, polymenorrhea, enlarged ovaries with multiple small painless cysts or follicles that form in the ovary, acrochordons, acanthosis nigricans, hirsuitism, thinning hair, acne, weight gain, anxiety, depression, hyperglycemia, and infertility (Canadian Women’s Health Network, 2012a).

Treatments like medications such as birth control pills or antiandrogens can help balance the hormones in your body and relieve some of the symptoms (Canadian Women’s Health Network, 2012a).. To learn more about PCOS visit the PCOS article on the Canadian Women’s Health Network.

Sexually Transmitted Infections (STIs)

The terms for Sexually Transmitted Infections (STI) and Sexuality Transmitted Diseases (STD) are often used interchangeably. Sexuality Transmitted Diseases (STD) implies the disease was acquired through sexual transmission. A disease is a disorder of structure or function in a human, which produces specific signs or symptoms. A disease must be managed, as with the case of Human Immunodeficiency Virus (which can also be acquired to through the transmission of other bodily fluids; thus not solely sexual transmission). The treatment may include antiretrovirals or anti-virals (Urology Care Foundation, 2019).

Chlamydia (CT)

Chlamydia is one of the most common sexually transmitted infections (STIs) caused by bacteria that infect the cervix, urethra and other reproductive organs. Chlamydia is easy to treat and can be cured. Many people with chlamydia do not have any symptoms and unknowingly pass the infection to their sexual partner(s). If symptoms develop, they usually appear two to six weeks after sexual contact with an infected person. While females are most often asymptomatic they may experience cervicitis. Left untreated, chlamydia in females can lead to Pelvic Inflammatory Disease (PID) which can cause permanent damage to the reproductive organs and subsequent infertility (Sexually Transmitted Infections (STIs) Chlamydia, 2018) (Chlamydia and Gonorrhea, n.d.).

Chlamydia spreads through unprotected oral, anal or vaginal sex with an infected person. Chlamydia can be spread to the eyes via the hands with direct contact of infected fluids. Until a patient finishes their treatment, they continue to have the infection and can continue to pass it to others. Chlamydia is treated with antibiotic pills. If the patient has epididymitis, they may need to be hospitalized and be treated with intravenous (IV) antibiotics. All sexual partners within the past 60 days should be examined, treated, and informed that having no symptoms does not mean there is no infection (Ontario Agency for Health Protection and Promotion , 2019; Region of Peel, 2007).

Gonorrhea (Gonococcus) – (GC)

Gonorrhea is a sexually transmitted infection (STI) caused by bacteria that infects the cervix, urethra and other reproductive organs. Infections can also infect the throat and anus. Gonorrhea can be treated and cured. Many people infected with Gonorrhea have no symptoms and can unknowingly pass the infection on to their sexual partner(s). If symptoms develop, they may appear two to seven days after sexual contact with an infected person. Symptoms vary depending on which part of the body is infected. Females may experience abnormal vaginal bleeding, discharge, or dysuria. Left untreated, Gonorrhea in females may lead to pelvic inflammatory disease and fertility complications such as ectopic pregnancy. Gonorrhea infection from oral sex may lead to sore throat and swollen glands. Gonorrhea infection from anal sex may cause itchiness and discharge from the anus. Gonorrhea is spread through unprotected oral, vaginal or anal sex with an infected person.  Until the patient finishes their treatment, they continue to have the infection and can pass it to others (Ontario Agency for Health Protection and Promotion, 2019a; Region of Peel, 2007).

Gonorrhea is treated with oral antibiotics in combination with an intramuscular (IM) injection. It is important that one completes the treatment and abstain from unprotected sexual activity for at least seven days following treatment. All sexual partners within the past 60 days should be examined, treated and informed that having no symptoms does not mean there is no infection (Ontario Agency for Health Protection and Promotion, 2019a; Region of Peel, 2007).

Reportable Diseases

Both chlamydia and gonorrhea are reportable diseases to the Ministry of Health and Long Term Care. Therefore, the local health department will be calling the doctors office or patient to ensure correct treatment was received and sexual partners have been followed up with testing and treatment (Ontario Agency for Health Protection and Promotion, 2019a; Region of Peel, 2007). To learn more about STIs and STDs such as chlamydia and gonorrhea please go to the Public Health Ontario web page on sexually transmitted infections.

Human Papillomavirus- HPV

HPV is a common sexually transmitted infection (STI). Both males and females can be infected with HPV. Almost three quarters of sexually active individuals have been exposed to HPV during their lifetime. There are over 100 strains of HPV and some strains of HPV can cause visible genital warts. The warts are usually painless but may be itchy, uncomfortable and hard to treat. Some strains of HPV cause genital, anal, throat and cervical cancers. HPV spreads through sexual activity and skin-to-skin contact in the genital area with an infected person. Since some people are asymptomatic they don’t know they have the virus and consequently pass the virus to their sexual partners. Treatments are available for genital warts but there is no cure for HPV (York Region Health Connect, n.d.).. To learn more about HPV symptoms, treatments, and prognosis visit the York Region Fact Sheet on HPV (PDF file).

HPV Vaccine

A vaccine called Gardasil® 9 is available for 9 HPV strains. This vaccine assists the immune system in protecting the body against infections and diseases caused by HPV (York Region Health Connect, n.d.). To learn more about Gardasil® 9 treatments, please visit the Gardasil® 9 website.

Herpes Simplex Virus (HSV)

Genital herpes is a sexually transmitted infection (STI) that is caused by a virus called herpes simplex virus (HSV). There are two types of herpes simplex viruses:

• Type 1- oral herpes or cold sores (HSV-1)
• Type 2- genital herpes (HSV-2).

These viruses are very similar and either type can cause genital herpes or cold sores. Symptoms might include dysuria, enlarged glands, myalgia, arthralgia and fever. Once a patient is infected with HSV, the virus remains in their body even after the symptoms are gone and can cause recurring outbreaks. Between the outbreaks, the virus stays in their body. When the virus becomes active again, the symptoms return but are usually less painful and heal faster. Recurring outbreaks vary from person-to-person, however they can be triggered by emotional or physical stress, exposure to sunlight, hormonal changes, poor nutrition, sexual intercourse, lack of sleep or a low immune system (Ontario Ministry of Health and Long-Term Care, 2015).

Herpes is spread through direct contact with the sores or blisters of an infected person. Contact (and transfer of the virus) can occur from genitals-to-genitals, mouth-to-genitals or mouth-to-mouth. Herpes can also be passed to the anal area. Herpes spreads easily during sexual contact while symptoms are present, or just before an outbreak of symptoms. An infected person may spread herpes even when they have no symptoms; this is called asymptomatic shedding. One can spread the herpes virus to other parts of their body after touching the sores; autoinoculation. The fingers, eyes and other body areas can accidentally become infected in this way. Hand washing after touching sores and blisters is recommended to prevent spreading the virus (Ontario Ministry of Health and Long-Term Care, 2015).

There is no cure for herpes. Antiviral pills help to reduce symptoms and speed the healing of blisters or sores and are prescribed by a doctor. Treatment of symptoms may be managed with medication for pain, bath salts, cold compresses and urinating in water may help to relieve discomfort. Keep the infected area clean and dry, wear cotton underwear and loose clothing to reduce discomfort. All sexual partner(s) should be informed. The only way to reduce the risk of transmission of herpes is to avoid direct contact with the sores and to use condoms. Condoms will reduce but not eliminate risk as the virus can be present and shed from the skin in the genital area (Ontario Ministry of Health and Long-Term Care, 2015).

To learn more about the symptoms, complications, treatments and prognosis of HSV please visit the Ontario Ministry of Health and Long-Term Care’s Sexually Transmitted Diseases : Genital Herpes website or Public Health Ontario’s Testing Index.

Female Reproductive System Medical Abbreviations

Medical Terms in Context

Medical Specialties and Procedures related to the Female Reproductive System

Gynecology

A gynecologist is a specialist in the area of gynecology focusing on the diagnosis, treatment, management and prevention of diseases and disorders of the female reproductive system. Obstetrics is a specialty that provides care through pregnancy, labour, and puerperium. Further subspecialties in women’s health include contraception, reproductive endocrinology, infertility, adolescent gynecology, endoscopy and gynecological oncology (Canadian Medical Association, 2018). To learn more about obstetrics or gynecology please follow visit the Canadian Medical Association’s Obstetrics/Gynecology Profile page (PDF file).

Hysterectomy

A hysterectomy is done to stage or treat female reproductive cancers, treat precancerous conditions of the cervix and some non-cancerous conditions that have not responded to other forms of treatment. There are three types of hysterectomy:

• A total hysterectomy removes both the uterus and the cervix.
• A subtotal hysterectomy removes the uterus only.
• A radical hysterectomy removes uterus, cervix, part of the vagina, and ligaments.

Sometimes the ovaries and fallopian tubes are removed at the same time that a hysterectomy is done. A bilateral salpino-oophorectomy (BSO)  removes both ovaries and fallopian tubes. A unilateral salpingo-oophorectomy removes one ovary and one Fallopian tube (Canadian Cancer Society, 2020). To learn more about hysterectomy please follow visit the Canadian Cancer Society’s page on hysterectomies.

Female Reproductive System Vocabulary

Acanthosis Nigricans

A disorder that causes darkening and thickening of the skin on the neck, groin, underarms or skin folds.

Acrochordons

Skin tags, teardrop-sized pieces of skin that can be as large as raisins and are typically found in the armpits or neck area.

Amenorrhea

Absence of periods.

Androgens

Male hormones.

Antiandrogens

A group of medications that counteract the effects of male hormones.

Antibiotics

Medications that stop bacterial infections.

Antiretrovirals

Treatment that works against the virus replication.

Anti-virals

Treatments that work effectively against a virus.

Asymptomatic

Pertaining to without symptoms.

Autoinoculation

Self inoculation.

Axilla

The armpit.

Bartholin’s glands

Also known as greater vestibular glands they are responsible to secrete mucus to keep the vestibular area moist.

Bilateral

Pertaining to both sides.

Douching

Washing the vagina with fluid.

Dysmenorrhea

Painful periods.

Dyspareunia

Painful intercourse.

Dysuria

Painful urination.

Endocrinology

The study of the endocrine glands and hormones.

Endometrium

The innermost layer containing a connective tissue lining covered by epithelial tissue that lines the lumen. Provides the site of implantation for a fertilized egg. Sheds during menstruation if no egg is fertilized.

Endoscopy

Process of viewing internally.

Fornix

Superior portion of the vagina.

Gametes

Haploid reproductive cells that contribute genetic material to form an offspring.

Gynecologist

Specialist in the study and treatment of the female reproductive system.

Gynecology

The study of the female reproductive system

Hirsuitism

Excess hair all over the body.

Homeostasis

Biological process that results in stable equilibrium.

Hysterectomy

Surgical removal of the uterus.

Inferior

Pertaining to below.

Intramuscular

Pertaining to within the muscle.

Laparoscopy

Process of viewing internal organs.

Lumbago

Lower back pain.

Mammoplasty

Surgical repair of the breast particularly after a mastectomy.

Mastectomy

Excision of breast(s) and or breast tissue.

Oligomenorrhea

Infrequent or irregular periods.

Oocyte

Female gamete.

Oophorectomy

Surgical removal of the fallopian/uterine tubes.

Polymenorrhea

Excessive bleeding during one’s period.

Polyuria

Frequent urination.

Proliferate

Reproduce rapidly.

Puerperium

Time directly after childbirth.

Superior

Pertaining to above.

Unilateral

Pertaining to one side.

Urethritis

Inflammation of the urethra.

Test Yourself

References

Canadian Medical Association. (2018, August). Obstetrics/gynecology profile. Canadian Medical Association Specialty Proflies. https://www.cma.ca/sites/default/files/2019-01/obgyn-e.pdf

Canadian Women’s Health Network. (2012). Endometriosis. http://www.cwhn.ca/en/node/40779

Canadian Women’s Health Network. (2012a). Polycystic ovary syndrome (PCOS). http://www.cwhn.ca/en/node/44804

Cancer Care Ontario. (n.d.). Breast cancer. Ontario Health. https://www.cancercareontario.ca/en/types-of-cancer/breast-cancer

Centers for Disease Control and Prevention. (n.d.). Breast cancer: What you need to know. CDC: Cancer. https://www.cdc.gov/cancer/breast/pdf/breastcancerfactsheet.pdf

Centers for Disease Control and Prevention. (2019, January). Cervical cancer: Inside knowledge about gynecolocic cancer. CDC: Cancer. https://www.cdc.gov/cancer/cervical/pdf/cervical_facts.pdf?src=SocialMediaToolkits

[CrashCourse]. (2015, October 2015). Reproductive system, part 1 – female reproductive system: Crash course A&P #40 [Video]. YouTube. https://www.youtube.com/watch?v=RFDatCchpus

Ontario Agency for Health Protection and Promotion. (2019). Chlamydia. Public Health Ontario. https://www.publichealthontario.ca/en/diseases-and-conditions/infectious-diseases/sexually-transmitted-infections/chlamydia

Ontario Ministry of Health and Long-Term Care. (2015). Sexually transmitted diseases: Genital herpes (hur-peez). Publications. http://www.health.gov.on.ca/en/public/publications/std/herpes.aspx

Ontario Agency for Health Protection and Promotion. (2019a). Gonorrhea. Public Health Ontario. https://www.publichealthontario.ca/en/diseases-and-conditions/infectious-diseases/sexually-transmitted-infections/gonorrhea

Region of Peel. (2007). Chlamydia and Gonorrhea. https://www.peelregion.ca/health/talk-to-me/download/lesson-plans/lesson6-pdf/lesson6i.pdf

Urology Care Foundation. (2019). What are sexually transmitted infections (STIs) or diseases (STDs). Urology Care Foundation: Urologic Conditions. https://www.urologyhealth.org/urologic-conditions/sexually-transmitted-infections#Acquired_Immune_Deficiency_Syndrome_(AIDS)

York Region Health Connection. (n.d.). Human papillomavirus. https://www.york.ca/wps/wcm/connect/yorkpublic/b5158069-a667-4f43-bb25-e0449ba22caa/6052+Human+Papilloma+Virus+Fact+Sheet.pdf?MOD=AJPERES&CACHEID=b5158069-a667-4f43-bb25-e0449ba22caa

Image Descriptions

Figure 10.1 image description: This figure shows the structure and the different organs in the female reproductive system. The top panel shows the lateral view with labels (clockwise from top): utuerus, ovary, formix of uterus, cervix, rectum, vagina, anus, labium majora, labium minora, clitoris, urethra, mons pubis, pybic symphysis, bladder; and the bottom panel shows the anterior view with labels (clockwise from top): ovary, ovarian ligament, broad ligament, labia minora, labia majora, vagina, cervix, uterine tube, usterus, fimbriae. [Return to Figure 10.1].

Figure 10.2 image description: This figure shows the parts of the vulva. The right panel shows the external anterior view and the left panel shows the internal anteriolateral view. The major parts are labeled (from top): prepuce, glans clitoris, labia minora, corpus cavernosum, bulb of vestibule, urethral opening, labia majora, vaginal opening, opening of right Bartholin’s gland, Bartholin’s glands, anus. [Return to Figure 10.2].

Obstetric Word Parts

Introduction to Obstetrics

Obstetrics is a specialty that is concerned with the mother and fetus during pregnancy, childbirth and the immediate postpartum period. Obstetricians study obstetrics and gynecology and are referred to as OB/GYN Obstetrics and Gynecology.

Watch this video:

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Media 11.1. Reproductive System, Part 4 – Pregnancy & Development: Crash Course A&P #43 [Online video]. Copyright 2015 by CrashCourse.

Obstetrics Medical Terms

Fertilization

Fertilization occurs when a sperm and an oocyte (egg) combine. Because each of these reproductive cells is a haploid cell containing half of the genetic material needed to form a human being, their combination forms a diploid cell. This new single cell is called a zygote.

Most of the time, a woman releases a single egg during an ovulation cycle.

• In approximately 1 percent of ovulation cycles, two eggs are released and both are fertilized.
  • Two zygotes form, implant, and develop, resulting in the birth of dizygotic (or fraternal) twins. Because dizygotic twins develop from two eggs fertilized by two sperm, they are no more identical than siblings born at different times.
• Less common, one zygote can divide into two separate offspring during early development. This results in the birth of monozygotic (or identical) twins.

Stages of Childbirth

The process of childbirth can be divided into three stages (see Figure 11.1):

• cervical dilation
• expulsion of the newborn
• after birth

For vaginal birth to occur, the cervix must dilate fully to 10 cm in diameter, wide enough to deliver the newborn’s head. The dilation stage is the longest stage of labour and typically takes 6-12 hours. However, it varies widely and may take minutes, hours, or days, depending in part on whether the mother has given birth before. In each subsequent labour, this stage tends to be shorter.

Figure 11.1 Stages of Childbirth. The stages of childbirth include Stage 1, early cervical dilation; Stage 2, full dilation and expulsion of the newborn; and Stage 3, delivery of the placenta and associated fetal membranes. (The position of the newborn’s shoulder is described relative to the mother). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Concept Check

• How is a due date determined?
• Explain the difference between a monozygotic pregnancy and a dizygotic pregnancy.

Homeostasis in the Newborn: Apgar Score

Did You Know?

The Apgar score was introduced in 1952 by Dr. Virginia Apgar to assess the effect of anesthesia on newborns and mothers in labour.

In the minutes following birth, a newborn must undergo dramatic systemic changes to be able to survive outside the womb. An obstetrician, midwife, or nurse can estimate how well a newborn is doing by obtaining an Apgar score. The Apgar score was introduced in 1952 by the anesthesiologist Dr. Virginia Apgar as a method to assess the effects on the newborn of anesthesia given to the labouring mother. Healthcare providers now use it to assess the general well-being of the newborn, whether or not analgesics or anesthetics were used.

The five criteria, skin colour, heart rate, reflex, muscle tone, and respiration, are assessed and each criterion is assigned a score of 0, 1, or 2. Scores are taken at 1 minute after birth and again at 5 minutes after birth. Each time scores are taken, the five scores are added together. High scores (out of a possible 10) indicate the baby has made the transition from the womb well, whereas lower scores indicate that the baby may be in distress.

The technique for determining an Apgar score is quick and easy, painless for the newborn, and does not require any instruments except for a stethoscope. A convenient way to remember the five scoring criteria is to apply the mnemonic APGAR:

• Appearance (skin colour)
• Pulse (heart rate)
• Grimace (reflex)
• Activity (muscle tone)
• Respiration 

Of the five Apgar criteria, heart rate and respiration are the most critical. Poor scores for either of these measurements may indicate the need for immediate medical attention to resuscitate or stabilize the newborn. In general, any score lower than 7 at the 5-minute mark indicates that medical assistance may be needed. A total score below 5 indicates an emergency situation. Normally, a newborn will get an intermediate score of 1 for some of the Apgar criteria and will progress to a 2 by the 5-minute assessment. Scores of 8 or above are normal.

Obstetrics Medical Terms not Easily Broken into Word Parts

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Obstetrics Abbreviations

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Medical Terms in Context

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Procedures Related to Obstetrics

In Vitro Fertilization (IVF)

Did You Know?

According to Health Canada, one in six Canadian couples have struggled with conceiving (Fertility, 2019).

IVF, which stands for in vitro fertilization, is an assisted reproductive technology. In vitro, which in Latin translates to in glass, refers to a procedure that takes place outside of the body. There are many different indications for IVF. For example, a woman may produce normal eggs, but the eggs cannot reach the uterus because the uterine tubes are blocked or otherwise compromised. A man may have a low sperm count, low sperm motility, sperm with an unusually high percentage of morphological abnormalities, or sperm that are incapable of penetrating the zona pellucida of an egg. Figure 11.2 illustrates the steps involved in IVF.

Figure 11.2 IVF. In vitro fertilization involves egg collection from the ovaries, fertilization in a petri dish, and the transfer of embryos into the uterus. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Prenatal Screening and Diagnostic Testing

Cardiovascular System – Heart Word Parts

Click on prefixes, combining forms, and suffixes to reveal a list of word parts to memorize for the cardiovascular system – Heart.

Introduction to the Heart

The heart is a fist-sized vital organ that has one job: to pump blood. If one assumes an average heart rate of 75 beats per minute, a human heart would beat approximately 108,000 times in one day, more than 39 million times in one year, and nearly 3 billion times during a 75-year lifespan. At rest, each of the major pumping chambers of the heart ejects approximately 70 mL blood per contraction in an adult. This would be equal to 5.25 liters of blood per minute and approximately 14,000 liters per day. Over one year, that would equal 10,000,000 liters of blood sent through roughly 100,000 km of blood vessels. In order to understand how that happens, it is necessary to understand the anatomy and physiology of the heart.

Watch this video:

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Media 12.1. The Heart, Part 1 – Under Pressure: Crash Course A&P #25 [Online video]. Copyright 2015 by CrashCourse.

Cardiovascular System – Heart Medical Terms

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Anatomy of the Heart

Location

The human heart is located within the thoracic cavity, between the lungs in the space known as the mediastinum. Figure 12.1 shows the position of the heart within the thoracic cavity. Within the mediastinum, the heart is separated from the other mediastinal structures by a tough membrane known as the pericardium, or pericardial sac, and sits in its own space called the pericardial cavity. The great vessels, which carry blood to and from the heart, are attached to the superior surface of the heart, which is called the base. The base of the heart is located at the level of the third costal cartilage. The inferior tip of the heart, the apex, lies just to the left of the sternum between the junction of the fourth and fifth ribs.

Concept Check

• On the diagram below (Figure 1), locate the mediastinum, the pericardial cavity, the base of the heart and the apex of the heart.
• Locate the largest vein in the body superior vena cava.

Figure 12.1. Position of the Heart in the Thorax. The heart is located within the thoracic cavity, medially between the lungs in the mediastinum. It is about the size of a fist, is broad at the top, and tapers toward the base. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Membranes and Layers of the Heart Walls

The heart and the roots of the great vessels are surrounded by a membrane known as the pericardium or pericardial sac. The pericardium consists of two distinct sub layers:

• The sturdy outer fibrous pericardium is made of tough, dense connective tissue that protects the heart and holds it in position.
• Separated by the pericardial cavity and containing pericardial fluid the inner serous pericardium consists of two layers:
  • the outer parietal pericardium, which is fused to the fibrous pericardium.
  • the inner visceral pericardium, or epicardium, which is fused to the heart and forms the outer layer of the heart wall.

The walls of the heart consist of three layers:

• The outer epicardium, which is another name for the visceral pericardium mentioned above.
• The thick, middle myocardium, which is made of muscle tissue and gives the heart its ability to contract.
• The inner endocardium, which lines the heart chambers and is the main component of the heart valves.

Concept Check

• Look at Figure 12.2 below, and name the layers of the heart wall and surrounding membranes, starting with the innermost layer.
• As shown on the diagram, suggest why is the myocardium layer is thicker than the endocardium layer?

 

Figure 12.2. Pericardial Membranes and Layers of the Heart Wall. The pericardial membrane that surrounds the heart consists of three layers and the pericardial cavity. The heart wall also consists of three layers. The pericardial membrane and the heart wall share the epicardium From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Internal Structures of the Heart

The heart consists of four chambers:

• The upper chambers are the right and left atria (singular: atrium).
• The lower chambers are the right and left ventricles.

The interventricular septum is a muscular wall that separates the right and left ventricles. The interatrial septum separates the right and left atria.

The atrium and ventricle on each side of the heart are separated by an atrioventricular (AV) valve:

• The right AV valve, or tricuspid valve, separates the right atrium and right ventricle.
• The left AV valve, or bicuspid valve, separates the left ventricle and the left atrium. This valve is also called the mitral valve.

There are also two semilunar valves:

• The pulmonary valve separates the right ventricle from the pulmonary trunk.
• The aortic valve separates the left ventricle from the aorta (De Saix, et al., 2013).

Anatomy Labeling Activity

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Physiology of the Heart

Figure 12.3. Pulmonary Circuit Blood exiting from the right ventricle flows into the pulmonary trunk, which bifurcates into the two pulmonary arteries. These vessels branch to supply blood to the pulmonary capillaries, where gas exchange occurs within the lung alveoli. Blood returns via the pulmonary veins to the left atrium. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Pulmonary Circuit

Blood exiting from the right ventricle flows into the pulmonary trunk, which bifurcates into the two pulmonary arteries. These vessels branch to supply blood to the pulmonary capillaries, where gas exchange occurs within the lung alveoli. Blood returns via the pulmonary veins to the left atrium.

Concept Check

• On Figure 12.4 below, use your finger to trace the pathway of blood flowing through the left side of the heart, naming each of the following structures as you encounter them: right and left pulmonary veins, left atrium, mitral valve, left ventricle, aortic valve, aorta.

Figure 12.4. Dual System of the Human Blood Circulation. Blood flows from the right atrium to the right ventricle, where it is pumped into the pulmonary circuit. The blood in the pulmonary artery branches is low in oxygen but relatively high in carbon dioxide. Gas exchange occurs in the pulmonary capillaries (oxygen into the blood, carbon dioxide out), and blood high in oxygen and low in carbon dioxide is returned to the left atrium. From here, blood enters the left ventricle, which pumps it into the systemic circuit. Following exchange in the systemic capillaries (oxygen and nutrients out of the capillaries and carbon dioxide and wastes in), blood returns to the right atrium and the cycle is repeated. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Cardiac Cycle

The process of pumping and circulating blood is active, coordinated and rhythmic. Each heartbeat represents one cycle of the heart receiving blood and ejecting blood.

• Diastole is the portion of the cycle in which the heart is relaxed and the atria and ventricles are filling with blood. The AV valves are open, so that blood can move from the atria to the ventricles.
• Systole is the portion of the cycle in which the heart contracts, AV valves slam shut, and the ventricles eject blood to the lungs and to the body through the open semilunar valves. Once this phase ends, the semilunar valves close, in preparation for another filling phase.

2. The Heart as an Organ: The Coronary Blood Supply

Myocardial cells require their own blood supply to carry out their function of contracting and relaxing the heart in order to pump blood. Their own blood supply provides nutrients and oxygen and carry away carbon dioxide and waste. These functions are provided by the coronary arteries and coronary veins.

Concept Check

On the image below, locate the three main coronary arteries:

• Anterior interventricular artery (more commonly known as the left anterior descending artery, or LAD)
• Circumflex artery (Cx)
• Right coronary artery (RCA)

Follow the path of each of these three arteries to try to determine which parts of the myocardium each artery (along with its many smaller branches) supplies with blood.

Figure 12.5 Coronary Circulation. The anterior view of the heart shows the prominent coronary surface vessels. The posterior view of the heart shows the prominent coronary surface vessels. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

3. The Heart’s Electrical Conduction System

In order for all parts of the heart to work together to beat regularly and effectively, the heart has its own electrical system, which initiates and conducts each heartbeat through the entire myocardium. Specialized groups of heart cells perform this function all on their own, without requiring messages from the central nervous system.

Watch this video:

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Media 12.2. The Heart, Part 2 – Heart Throbs: Crash Course A&P #26 [Online video]. Copyright 2015 by CrashCourse.

Figure 12.6. Conduction System of the Heart. Specialized conducting components of the heart include the sinoatrial node, the internodal pathways, the atrioventricular node, the atrioventricular bundle, the right and left bundle branches, and the Purkinje fibers. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

We can detect and record the electrical activity of the heart’s conduction system using an electrocardiogram (ECG or EKG). Figure 12.7 shows the electrical impulse originating in the SA node (step 2) and travelling through the heart’s conduction system, allowing the heart to complete one cardiac cycle. Each waveform on the ECG tracing represents electricity moving through and affecting a different part of the heart. Did you notice that the AV valves close when the electrical impulse reaches the ventricles, just before systole occurs?

Figure 12.7. ECG Tracing Correlated to the Cardiac Cycle. This diagram correlates an ECG tracing with the electrical and mechanical events of a heart contraction. Each segment of an ECG tracing corresponds to one event in the cardiac cycle. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Heart Terms not Easily Broken into Word Parts An interactive or media element has been excluded from this version of the text. You can view it online here:
https://ecampusontario.pressbooks.pub/medicalterminology/?p=259

Heart Abbreviations

Many terms and phrases related to the cardiovascular system- heart are abbreviated.
Learn these common abbreviations by expanding the list below.

Diseases and Disorders

Cardiomyopathy

The heart of a well-trained athlete can be considerably larger than the average person’s heart. This is because exercise results in an increase in muscle cells called hypertrophy . Hearts of athletes can pump blood more effectively at lower rates than those of non-athletes. However, when an enlarged heart is not the result of exercise, it may be due to hypertrophic cardiomyopathy. The cause of an abnormally enlarged heart muscle is unknown, but the condition is often undiagnosed and can cause sudden death in apparently otherwise healthy young people (Betts, et al., 2013).

Other types of cardiomyopathy include:

• Dilated cardiomyopathy, which also has an unknown cause and is seen in people of any age. In this disorder, one of the ventricles of the heart is larger than normal.
• Arrhythmogenic cardiomyopathy, an inherited condition which results in irregular heart rhythms.
• Restrictive cardiomyopathy, which is a complication of other conditions which cause the myocardium to scar or stiffen (Centers for Disease Control and Prevention, 2019).

Cardiomyopathy may also be caused by myocardial infarctions, myocardial infections, pregnancy, alcohol or cocaine abuse, autoimmune and endocrine diseases. Because the myocardium is responsible for contracting and pumping blood, patients with cardiomyopathy experience impaired heart function which may lead to heart failure. (Centers for Disease Control and Prevention, 2019). To learn more about cardiomyopathy visit the CDC’s cardiomyopathy web page.

Heart Failure

Heart failure is defined as the inability of the heart to pump enough blood to meet the needs of the body. It is also called congestive heart failure (CHF). This condition causes swelling in the lower extremities and shortness of breath, due to a buildup of fluid in the lungs. It may be caused by cardiomyopathy and it may lead to hypertension and heart valve disorders (Heart & Stroke, n.d.). To learn more, visit the Heart & Stroke’s congestive heart failure web page.

Valvular Heart Disease

The four heart valves open and close at specific times during the cardiac cycle, in order to ensure that blood flows in only one direction through the heart. This requires that these valves open and close completely. Infections such as rheumatic disease or bacterial endocarditis can affect the heart valves and result in scar tissue formation which interferes with valve function. Other causes of heart valve disease include: congenitally malformed valves, autoimmune diseases, and other cardiovascular diseases such as aortic aneurysms and atherosclerosis (Centers for Disease Control and Prevention, 2019a).

Heart valve disease may be asymptomatic, or cause dyspnea, arrhythmias, fatigue and other symptoms. It is often detected when a heart murmur is heard through a stethoscope (Centers for Disease Control and Prevention, 2019a).

• Mitral Valve Prolaspse
  • The mitral (bicuspid) valve is diseased or malformed and is not able to close completely, allowing the regurgitation of blood back into the left atrium during systole. Because some of the blood goes back into the atrium, insufficient blood is pumped out of the ventricle into the systemic circulation. This inability to close properly and the resulting regurgitation may also be found in other heart valves (Centers for Disease Control and Prevention, 2019a).
• Aortic Stenosis
  • The aortic valve is narrowed and hardened, preventing it from opening fully and allowing sufficient blood to travel to the systemic circulation. Any heart valve can be stenosed, but this disorder most often affects the aortic valve (Centers for Disease Control and Prevention, 2019a).

Visit the CDC’s page on valvular heart disease to learn more.

Aneurysms

An aneurysm is a defect in the wall of an artery in which the wall becomes thin and weak and starts to balloon out as blood pulses against the vessel wall. This can happen to any artery and even to the myocardial walls. Aneurysms sometimes occur in the portion of the aorta that is in the thorax (see Figure 12.8). If these aneurysms start to leak between layers of the vessel wall, the condition is known as aortic dissection. If an aortic or cardiac aneurysm bursts, there is sudden, massive internal bleeding (Centers for Disease Control and Prevention, 2019b).

Figure 12.8. Arteries of the Thoracic and Abdominal Regions The thoracic aorta gives rise to the arteries of the visceral and parietal branches. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

People who smoke, have hypertension, hypercholesterolemia, and/or atherosclerosis have an increased risk of developing aneurysms. Having a family history of aneurysms or certain genetic diseases may also increase a person’s risk of developing an aneurysm.

Aneurysms are often asymptomatic and may be detected incidentally during diagnostic tests that are being done for other reasons. They are sometimes repaired surgically and sometimes treated with medications such as antihypertensives (Centers for Disease Control and Prevention, 2019b; Tittley, n.d.). Visit the Canadian Society for Vascular Surgery’s page on thoracic aortic aneurysms to learn more.

Heart Defects

Fetal circulation is different from postnatal circulation. There are 2 extra openings in the fetal heart, the foramen ovale and the ductus arteriosus, which allow blood circulation that bypasses the immature fetal lungs. The fetal blood is reoxygenated by the mother’s lungs and transported between mother and fetus via the placenta. These two openings usually close around the time of birth (Betts, et al., 2013).

Septal defects are commonly first detected through auscultation. Unusual heart sounds may be detected because blood is not flowing and valves are not closing correctly. Medical imaging is ordered to confirm or rule out a diagnosis. In many cases, treatment may not be needed.

• Patent ductus arteriosus is a congenital condition in which the ductus arteriosus fails to close.  If untreated, the condition can result in congestive heart failure.
• Patent foramen ovale is one type of atrial septal defect (ASD), due to a failure of the hole in the interatrial septum to close at birth.
  • As much as 20 – 25 percent of the general population may have a patent foramen ovale, most have the benign, asymptomatic version but in extreme cases a surgical repair is required to close the opening permanently.
• Tetralogy of Fallot is a congenital condition that may also occur from exposure to unknown environmental factors; it occurs when there is an opening in the interventricular septum caused by blockage of the pulmonary trunk, normally at the pulmonary semilunar valve. This allows blood that is relatively low in oxygen from the right ventricle to flow into the left ventricle and mix with the blood that is relatively high in oxygen.
  • Symptoms include a distinct heart murmur, low blood oxygen percent saturation, dyspnea, polycythemia,  clubbing of the fingers and toes, and in children, difficulty in feeding or failure to grow and develop.
  • It is the most common cause of cyanosis following birth. Other heart defects may also accompany this condition, which is typically confirmed by echocardiography imaging.
• In the case of severe septal defects, including both tetralogy of fallot and patent foramen ovale, failure of the heart to develop properly can lead to a condition commonly known as a blue baby Regardless of normal skin pigmentation, individuals with this condition have an insufficient supply of oxygenated blood, which leads to cyanosis, especially when active (Betts, et al., 2013).

Figure 12.9. Congenital Heart Defects. (a) A patent foramen ovale defect is an abnormal opening in the interatrial septum, or more commonly, a failure of the foramen ovale to close. (b) Coarctation of the aorta is an abnormal narrowing of the aorta. (c) A patent ductus arteriosus is the failure of the ductus arteriosus to close. (d) Tetralogy of Fallot includes an abnormal opening in the interventricular septum. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Diseases of the Coronary Circulation

Coronary Artery Disease (CAD)

Coronary artery disease occurs when the buildup of plaque in the coronary arteries obstructs the flow of blood and decreases compliance of the vessels. This condition is called atherosclerosis. As the disease progresses and coronary blood vessels become more and more narrow, cells of the myocardium become ischemic, which causes symptoms of angina pectoris, in some patients. If untreated, coronary artery disease can lead to MI.

The image below shows the blockage of coronary arteries on an angiogram (Betts, et al., 2013).

Figure 12.10. Angiogram of Atherosclerotic Coronary Arteries. In this coronary angiogram (X-ray), the dye makes visible two occluded coronary arteries. Such blockages can lead to decreased blood flow (ischemia) and insufficient oxygen (hypoxia) delivered to the cardiac tissues. If uncorrected, this can lead to cardiac muscle death (myocardial infarction). From Betts, et al., 2013. Licensed under CC BY 4.0.

 

CAD is progressive and chronic. Risk factors include smoking, family history, hypertension, obesity, diabetes, high alcohol consumption, lack of exercise, stress, and hyperlipidemia. Treatments may include medication, changes to diet and exercise, angioplasty with a balloon catheter, insertion of a stent, or coronary artery bypass graft (CABG) (Betts, et al., 2013).

• Angioplasty is a procedure in which the occlusion is mechanically widened with a balloon. A specialized catheter with an expandable tip is inserted into a blood vessel in the arm or leg, and then directed to the site of the occlusion. At this point, the balloon is inflated to compress the plaque material and to open the vessel to increase blood flow. Once the balloon is deflated and retracted, a stent consisting of a specialized mesh is typically inserted at the site of occlusion to reinforce the weakened and damaged walls and prevent re-occlusion.
• Coronary bypass surgery (Coronary artery bypass graft CABG) is a surgical procedure which grafts a replacement vessel obtained from another part of the body to bypass the occluded area. (Betts, et al., 2013).

Myocardial Infarction

Myocardial infarction (MI) is the medical term for a heart attack.

An MI normally results from a lack of blood flow to a region of the heart, resulting in death of the cardiac muscle cells. An MI often occurs when a coronary artery is blocked by the buildup of atherosclerotic plaque. It can also occur when a piece of an atherosclerotic plaque breaks off and travels through the coronary arterial system until it lodges in one of the smaller vessels. MIs may be triggered by excessive exercise, in which the partially occluded artery is no longer able to pump sufficient quantities of blood, or severe stress, which may induce spasm of the smooth muscle in the walls of the vessel (Betts, et al., 2013).

In the case of acute MI (AMI), there is often sudden pain beneath the sternum (retrosternal pain) called angina pectoris, often radiating down the left arm in males but not in female patients. Other common symptoms include dyspnea, palpitations, nausea and vomiting, diaphoresis, anxiety, and syncope. Many of the symptoms are shared with other medical conditions, including anxiety attacks and simple indigestion, so differential diagnosis is critical (Betts, et al., 2013).

An MI can be confirmed by examining the patient’s ECG.

Other diagnostic tests include:

• echocardiography.
• CT.
• MRI.
• Common blood tests indicating an MI include elevated levels of creatine kinase MB and cardiac troponin, both of which are released by damaged cardiac muscle cells (Betts, et al., 2013).

MIs may induce dangerous heart rhythms and even cardiac arrest. Important risk factors for MI include coronary artery disease, age, smoking, high blood levels of LDL, low levels of HDL, hypertension, diabetes mellitus, obesity, lack of physical exercise, chronic kidney disease, excessive alcohol consumption, and use of illegal drugs (Betts, et al., 2013).

Diseases of the (Electrical) Conduction System

Arrhythmia

The heart’s natural pacemaker, the sinoatrial (SA) node initiates an electrical impulse 60-90 times per minute in a resting adult. This impulse travels through the heart’s conduction system in order to ensure a smooth, coordinated pumping action. This electrical activity can be detected and recorded through the skin using an electrocardiograph. Arrhyhmias may occur when the SA node fails to initiate an impulse, or when the conduction system fails to transmit that impulse through the heart.

In the event that the electrical activity of the heart is severely disrupted, cessation of electrical activity or fibrillation may occur. In fibrillation, the heart beats in a wild, uncontrolled manner, which prevents it from being able to pump effectively.

• Atrial fibrillation is a serious condition, but as long as the ventricles continue to pump blood, the patient’s life may not be in immediate danger.
• Ventrical fibrillation is a medical emergency that requires life support, because the ventricles are not effectively pumping blood, left untreated ventricular fibrillation may lead to brain death.

The most common treatment is defibrillation which uses special paddles to apply a charge to the heart from an external electrical source in an attempt to establish a normal sinus rhythm. A defibrillator effectively stops the heart so that the SA node can trigger a normal conduction cycle. External automated defibrillators (EADs) are being placed in areas frequented by large numbers of people, such as schools, restaurants, and airports. These devices contain simple and direct verbal instructions that can be followed by non-medical personnel in an attempt to save a life (Betts, et al., 2013).

Abnormal Heart Rates

Bradycardia is the condition in which resting adult heart rate drops below 60 bpm. a client exhibiting symptoms such as weakness, fatigue, dizziness, syncope, chest discomfort, palpitations or respiratory distress may indicate that the heart is not providing sufficient oxygenated blood to the tissues. If the patient is not exhibiting symptoms then bradycardia is not considered clinically significant. The term relative bradycardia may be used with a patient who has a HR in the normal range but is still suffering from these symptoms.  Most patients remain asymptomatic as long as the HR remains above 50 bpm.

Tachycardia is the condition in which the resting rate is above 100 bpm. Tachycardia is not normal in a resting patient and may be detected in pregnant women or individuals experiencing extreme stress. Some individuals may remain asymptomatic, but when present, symptoms may include dizziness, shortness of breath, rapid pulse, heart palpitations, chest pain, or syncope. Treatment depends upon the underlying cause but may include medications, implantable cardioverter defibrillators, ablation, or surgery (Betts, et al., 2013).

Heart Block

A heart block refers to an interruption in the normal conduction pathway. Heart blocks are generally named after the part of the conduction system that is causing the problem. For example, bundle branch blocks occur within either the left or right atrioventricular bundle branches.

AV blocks are often described by degrees. A first-degree or partial block indicates a delay in conduction between the SA and AV nodes. A second-degree or incomplete block occurs when some impulses from the SA node reach the AV node and continue, while others do not. In the third-degree or complete block, there is no correlation between atrial activity and ventricular activity. This means that none of the impulses generated by the SA node get transmitted to the rest of the heart and the AV node must take over as the primary pacemaker, initiating contractions at 40–60 beats per minute, which is adequate to maintain consciousness.

In order to speed up the heart rate and restore full sinus rhythm, a cardiologist can implant an artificial pacemaker, which delivers electrical impulses to the heart muscle to ensure that the heart continues to contract and pump blood effectively. These artificial pacemakers are programmable by the cardiologists and can either provide stimulation temporarily upon demand or on a continuous basis. Some devices also contain built-in defibrillators (Betts, et al., 2013).

Figure 12.11. Common ECG Abnormalities. (a) In a second-degree or partial block, one-half of the P waves are not followed by the QRS complex and T waves while the other half are. (b) In atrial fibrillation, the electrical pattern is abnormal prior to the QRS complex, and the frequency between the QRS complexes has increased. (c) In ventricular tachycardia, the shape of the QRS complex is abnormal. (d) In ventricular fibrillation, there is no normal electrical activity. (e) In a third-degree block, there is no correlation between atrial activity (the P wave) and ventricular activity (the QRS complex). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Medical Terms in Context

Medical Specialties and Procedures Related to the Heart

Cardiologists and Cardiovascular Surgeons

Cardiologists are medical doctors that specialize in diagnosing and treating heart disease non-invasively. Cardiovascular/thoracic surgeons provide surgical treatments for the heart and other thoracic organs (Canadian Medical Association, 2018). To learn more about these specialists please visit the CMA’s Canadian Specialy Profiles web page.

Cardiology Technologists

Cardiology Technologists complete a college training program and perform diagnostic tests such as electrocardiography, stress testing, Holter monitor testing, ambulatory blood pressure testing, as well as pacemaker monitoring and programming (Canadian Society of Cardiology Technologists, n.d.). Please visit the Canadian Society of Cardiology Technologists web page for more information.

Cardiovascular Perfusionists

Cardiovascular perfusionists complete a college training program and are responsible for operation of the heart-lung bypass machine during open heart surgery. They also monitor the patient’s vitals, adminstering IV fluids, and other drugs (Michener Institute of Education, n.d.). Please visit the Michener Institute’s Cardiovasular Perfusion program page for more information.

Cardiovascular System – Heart Vocabulary

5.25 liters of blood

The volume of blood ejected by the ventricle in one minute is called the cardiac output.

70 mL blood per contraction

The amount of blood ejected from the ventricle in one contraction is called the stroke volume.

Ablation

Using extreme heat or extreme cold to destroy cells in part of the heart which were causing abnormal rhythms.

Angina Pectoris

Chest pain.

Angiogram

An x-ray of the coronary blood vessels using a special catheter and an injection of dye.

Antihypertensives

Class of medications used to treat high blood pressure.

Arrhythmias

Absence of a regular heart rhythm.

Asymptomatic

Pertaining to without symptoms.

Atherosclerosis

A hardening of the arteries that involves the accumulation of plaque.

Auscultation

Listening to the heart using a stethoscope.

AV

Atrioventricular: the area of the heart where the atria and ventricles meet.

AV Valves

Atrioventricular valves: mitral (bicuspid) valve allows blood to flow from left atrium to left ventricle, tricuspid valve allows blood to flow from right atrium to right ventricle.

Bradycardia

Pertaining to a slow heart (rate).

Cardiac Troponin

The regulatory protein for muscle contraction.

Clubbing of the fingers and toes

Broadening of the nails and exaggerated curvature of the nails.

Compliance

The ability of the blood vessels to dilate and constrict as needed.

Congenital

Present at birth.

Creatine Kinase MB

An enzyme that catalyzes the conversion of creatine to phosphocreatine, consuming ATP.

CT

Computerized tomography: a special 3-dimensional x-ray, also called CAT=Computerized Axial Tomography.

Cyanosis

Abnormal condition of blue (bluish colour, lips and nail beds). Typically caused by low oxygenation.

Diabetes Mellitus

An endocrine system disorder in which the pancreas does not produce insulin or the cells of the body do not respond to insulin. This results in high levels of glucose in the blood.

Diaphoresis

Sweating.

Ductus Arteriosus

Connection between pulmonary trunk and aorta in the fetal heart.

Dyspnea

Difficult breathing.

ECG

ECG/EKG both these abbreviations mean electrocardiogram or a recording of the electrical impulses in the heart.

Echocardiography

Process of using sound to record the heart.

Electrocardiograph

Instrument used to record electrical activity within the heart.

Foramen Ovale

Opening between right and left atria, which is normal in the fetal heart.

Great Vessels

The great vessels include the superior vena cava, inferior vena cava, aorta and pulmonary trunk.

HDL

High-density lipoprotein, often referred to as ‘good’ cholesterol.

Heart Murmur

An abnormal heart sound.

Heart Rate

The number of times the heart contracts in one minute.

Hypercholesterolemia

Higher than normal levels of cholesterol in the blood.

Hyperlipidemia

Excessive fat in the blood.

Hypertension

High blood pressure.

Implantable Cardioverter Defibrillators (ICD)

An electronic implant that provides an automatic shock to convert a dangerous heart rhythm to a normal heart rhythm.

Inferior Vena Cava

One of the two largest veins in the body. It carries deoxygenated blood from the torso and legs back to the heart.

Interatrial Septum

The wall separating the right and left atria.

Interventricular Septum

The wall of myocardium that separates the right and left ventricles.

Ischemic

Ischemia is a condition in which cells receive insufficient amounts of blood and oxygen.

LDL

Low-density lipoprotein, often referred to as ‘bad’ cholesterol.

Mitral Valve

Also known as the bicuspid valve.

MRI

Magnetic Resonance Imaging: Highly detailed images produced using a strong magnet and radio waves.

Pacemaker

An electronic implant that initiates a heart beat.

Palpitations

A feeling in the chest that may be caused by an irregular heart rhythm.

Pericardial fluid

Pericardial fluid is a serous fluid which allow the 2 layers of serous pericardium to slide smoothly against each other as the heart beats.

Plaque

A fatty material including cholesterol, connective tissue, white blood cells, and some smooth muscle cells.

Polycythemia

A disorder in which too many red blood cells are produced.

Pulmonary Trunk

Very large artery referred to as a trunk, a term indicating that the vessel gives rise to several smaller arteries.

Roots of the Great Vessels

The part of each great vessel (aorta, pulmonary trunk, inferior vena cava, superior vena cava) that connects to the base of the heart.

Serous

You may recall that serous membranes throughout the body are folded back on themselves, which results in a double-layered membrane separated by serous fluid. The serous membrane surrounding the lungs is called pleura. The serous membrane surrounding the abdominopelvic organs is called peritoneum.

Silent Mis

A myocardial infarction without symptoms. The patient may not know that they are having an MI.

Sinus Rhythm

This is the rhythm set by the heart’s pacemaker, the sinoatrial node and is usually approximately 60-90 beats per minute in a resting adult.

Superior Vena Cava

One of the two largest veins in the body. It carries deoxygenated blood from the head and upper extremities back to the heart.

Syncope

Fainting.

Tachycardia

Condition of a fast heart (rate).

Test Yourself

References

Canadian Medical Association. (2018). Canadian Specialty Profiles. https://www.cma.ca/canadian-specialty-profiles

Canadian Society of Cardiology Technologists. (n.d.). Becoming a registered cardiology technologist. https://www.csct.ca/education/about-being-rct

Centers for Disease Control and Prevention. (2019). Cardiomyopathy. CDC. https://www.cdc.gov/heartdisease/cardiomyopathy.htm

Centers for Disease Control and Prevention. (2019a). Valvular heart disease. CDC. https://www.cdc.gov/heartdisease/valvular_disease.htm

Centers for Disease Control and Prevention. (2019b). Aortic aneurysm. CDC. https://www.cdc.gov/heartdisease/aortic_aneurysm.htm

[CrashCourse]. (2015, July 6). The heart, part 1 – under pressure: Crash course A&P #25 [Video]. YouTube. https://youtu.be/X9ZZ6tcxArI

[CrashCourse]. (2015, July 13). The heart, part 2 – heart throbs: Crash course A&P #26 [Video]. YouTube. https://youtu.be/FLBMwcvOaEo

Heart & Stroke. (n.d.). Heart failure. Heart and Stroke Foundation. https://www.heartandstroke.ca/heart/conditions/heart-failure

Mitchener Institute for Education. (n.d.). Cardiovascular perfusion. Michener Institute of Education at UHN. https://michener.ca/program/cardiovascular-perfusion/

Tittley, J. G. (n.d.). Thoracic aortic aneurysms (TAA). Retrieved from Canadian Society for Vascular Surgery: https://canadianvascular.ca/Thoracic-Aortic-Aneurysms-(TAA)

Image Descriptions

Figure 12.1 image description: This diagram shows the location of the heart in the thorax (sagittal and anterior views). The sagittal view labels read (from top, clockwise): first rib, aortic arch, thoracic arch, esophagus, inferior vena cava, diaphragm, thymus, trachea. The anterior view lables read (from top, clockwise): mediastinum, arch of aorta, pulmonary trunk, left auricle, left lung, left ventricle, pericardial cavity, apex of heart, edge of parietal pericardium, diaphgragm, edge of parietal pleura, ribs, right ventricle, right atrium, right auricle, right lung, superior vena cava. [Return to Figure 12.1].

Figure 12.2 image description: This image shows a magnified view of the structure of the heart wall. Labels read (from top, clockwise): pericardial cavity, fibrous pericardium, parietal layer of serous pericardium, epicardium (visceral layer of serous pericardium), myocardium, endocardium. [Return to Figure 12.2].

Figure 12.3 image description: This diagram shows the network of blood vessels in the lungs. Labels read (from top, clockwise (left-side of the body): aortic arch, pulmonary trunk, left lung, left pulmonary arteries, left pulmonary vein, pulmonary capillaries, descending aorta, (right side of body) inferior vena cava, right pulmonary veins, right pulmonary arteries, right lung, superior vena cava, ascending aorta. [Return to Figure 12.3].

Figure 12.4 image description: The top panel shows the human heart with the arteries and veins labeled (from top, clockwise): aorta, left pulmonary arteries, pulmonary trunk, left atrium, left pulmonary veins, aortic semilunar valve, mitral valve, left ventricle, inferior vena cava, right ventricle, tricuspid valve, right atrium, pulmonary semilunar valve, right pulmonary veins, right pulmonary arteries, superior vena cava. The bottom panel shows a rough map of the the human circulatory system. Labels read (from top, clockwise): systemic capillaries of upper body, systemic arteries to upper body, pulmonary trunk, left atrium, left ventricle, systemic arteries to lower body, systemic capillaries of lower body, systemic veins from lower body, right ventricle, right atrium, pulmonary capillaries in lungs, systemic veins from upper body. [Return to Figure 12.4].

Figure 12.5 image description: The top panel of this figure shows the anterior view of the heart while the bottom panel shows the posterior view of the heart. The different blood vessels are labeled. Anterior view labels (from top of diagram, clockwise): left coronary artery, pulmonary trunk, circumflex artery, anterior interventricular artery, great cardiac vein, small cardiac vein, anterior cardiac veins, atrial arteries, right atrium, right coronary artery, ascending aorta, aortic arch. Posterior view labels (from top of diagram, clockwise): coronary sinus, small cardiac vein, right coronary artery, marginal artery, middle cardiac vein, posterior cardiac vein, posterior interventricular artery, marginal artery, great cardiac vein, circumflex artery. [Return to Figure 12.5].

Figure 12.6 image description: This image shows the anterior view of the frontal section of the heart with the major parts labeled. Labels read (from top of diagram, clockwise) arch of aorta, Bachman’s bundle, atrioventricular bundle (bundle of His), left ventricle, right and left bundle branches, Purkinje fibers, right ventricle, right atrium, posterior intermodal, middle intermodal, atrioventricular node, anterior intermodal, Sinoatrial node. [Return to Figure 12.6].

Figure 12.7 image description: This diagram shows the six different stages of heart contraction and relaxation along with the stages in the QT cycle. [Return to Figure 12.7].

Figure 12.8 image description: This diagram shows the arteries in the thoracic and abdominal cavity. Visceral branches of the thoracic aorta labels (from top): bronchial, esophageal, mediastinal, pericardial, thoracic aorta, aortic hiatus, celiac trunk, left gastric, splenic, common hepatic, superior mesenteric, abdominal aorta, inferior mesenteric, external iliac. Parietal (somatic) branches of thoracic aorta labels (from top): intercostal, superior phrenic, inferior phrenic, diaphragm, adrenal, renal, gonadal, lumbar, medial sacral, common iliac, internal iliac. [Return to Figure 12.8].

Figure 12.9 image description: This diagram shows the structure of the heart with different congenital defects. The top left panel shows patent foramen ovale (label reads foramen ovale fails to close), the top right panel shows coarctation of the aorta (label reads narrow segment of aorta), the bottom left panel shows patent ductus ateriosus (label reads Ductus arteriosus remains open) and the bottom right shows tetralogy of fallot (labels read aorta emerges from both ventricles, interventricular septal defect, enlarged right ventricle, stenosed pulmonary semilunar valve). [Return to Figure 12.9].

Figure 12.11 image description: In this image the QT cycle for different heart conditions are shown. From top to bottom, the arrhythmias shown are second-degree partial block (text reads: Note how half of the P waves are not followed by the QRS complex and T waves while the other half are. Question: what would you expect to happen to heart rate?), atrial fibrillation (text reads: Note the abnormal electric pattern prior to the QRS complexes. Also note how the frequency between the QRS complexes has increased. Question: What t would you expect to happen to heart rate?), ventricular tachycardia (text reads: Note the unusual shape of the QRS complex, focusing on the S component. Question: What would you expect to happen to heart rate?), ventricular fibrillation (text reads: Note the total lack of normal electrical activity. Question: What would you expect to happen to heart rate?), and third degree block (text reads: Note that in a third-degree block some of the impulses initiated by the SA node do not reach the AV node while others do. Also note that the P waves are not followed by the QRS complex. Question: What would you expect to happen to heart rate?). [Return to Figure 12.11].

Unless otherwise indicated, this chapter contains material adapted from Anatomy and Physiology (on OpenStax), by Betts, et al. and is used under a a CC BY 4.0 international license. Download and access this book for free at https://openstax.org/books/anatomy-and-physiology/pages/1-introduction.

Blood Vessels and Blood Word Parts

Click on prefixes, combining forms, and suffixes to reveal a list of word parts to memorize for the Cardiovascular System – Blood.

Introduction to the Blood Vessels and Blood

Our large, complex bodies need blood to deliver nutrients to and remove wastes from our trillions of cells. The heart, as discussed in the previous chapter, pumps blood throughout the body in a network of blood vessels. Together, these three components—blood, heart, and vessels—makes up the cardiovascular system.

Virtually every cell, tissue, organ, and system in the body is impacted by the circulatory system. This includes the generalized and more specialized functions of transport of materials, capillary exchange, maintaining health by transporting white blood cells and various immunoglobulins (antibodies), hemostasis, regulation of body temperature, and helping to maintain acid-base balance. Table 13.1 summarizes the important relationships between the circulatory system and the other body systems.

Table 13.1 Interaction of the Circulatory System with Other Body Systems. A table depicting the various body systems and the role of the circulatory system in each. Adapted from Betts, et al., 2013. Licensed under CC BY 4.0.

SYSTEM	ROLE OF CIRCULATORY SYSTEM
Digestive Digestive System	Absorbs nutrients and water; delivers nutrients (except most lipids) to liver for processing by hepatic portal vein; provides nutrients essential for hematopoiesis and building hemoglobin.
Endocrine Endocrine System	Delivers hormones: atrial natriuretic hormone (peptide) secreted by the heart atrial cells to help regulate blood volumes and pressures; epinephrine, ANH, angiotensin II, ADH, and thyroixine to help regulate blood pressure; estrogen to promote vascular health in women and men.
Integumentary Integumentary System	Carries clotting factors, platelets, and white blood cells for hemostasis, fighting infection, and repairing damage; regulates temperature by controlling blood flow to the surface, where heat can be dissipated; provides some coloration of integument; acts as a blood reservoir.
Lymphatic Lymphatic System	Transports various white blood cells, including those produced by lymphatic tissue, and immunoglobulins (antibodies) throughout the body to maintain health; carries excess tissue fluid not able to be reabsorbed by the vascular capillaries back to the lymphatic system for processing.
Muscular Muscular System	Provides nutrients and oxygen for contraction; removes lactic acid and distributes heat generated by contraction; muscular pumps aid in venous return; exercise contributes to cardiovascular health and helps to prevent atherosclerosis.
Nervous Nervous System	Produces cerebrospinal fluid (CSF) within choroid plexuses;contributes to blood-brain barrier; cardiac and vasomotor centers regulate cardiac output and blood flow through vessels via the autonomic system.
Reproductive Reproductive System	Aids in erection of genitalia in both sexes during sexual arousal; transports gonadotropic hormones that regulate reproductive functions.
Respiratory Respiratory System	Provides blood for critical exchange of gases to carry oxygen needed for metabolic reactions and carbon dioxide generated as byproducts of these processes.
Skeletal Skeletal System	Provides calcium,phosphate, and other minerals critical for bone matrix; transports hormones regulating buildup and absorption of matrix including growth hormone (somatotropin), thyroid hormone, calcitronins, and parathryoid hormones; erythropoietin stimulates myeloid cell hematopoiesis; some level of protection for select vessels by bony structures.
Urinary Urinary System	Delivers 20% of resting circulation to kidneys for filtering, reabsorption of useful products, and secretion of excesses; regulates blood volume and pressure by regulating fluid loss in the form of urine and by releasing the enzyme renin that is essential in the renin-angiotensin-aldosterone mechanism.

Watch this video:

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Media 13.1  Blood Vessels, Part 1 – Form and Function: Crash Course A&P #27 [Online video]. Copyright 2015 by CrashCourse.

Cardiovascular System – Blood Vessels and Blood Medical Terms

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Anatomy of the Blood Vessels

Blood pumped by the heart flows through a series of vessels known as arteries, arterioles, capillaries, venules, and veins before returning to the heart.

• Arteries transport blood away from the heart and branch into smaller vessels, forming arterioles.
• Arterioles distribute blood to capillary beds, the sites of exchange with the body tissues.
• A capillary is a microscopic channel that supplies blood to the tissues themselves, a process called perfusion.
  • Exchange of gases and other substances occurs in the capillaries between the blood and the surrounding cells and their tissue fluid (interstitial fluid).
  • For capillaries to function, their walls must be leaky, allowing substances to pass through.
  • Capillaries lead back to small vessels known as venules.
• Venules are small veins that converge into larger veins.
• A vein is a blood vessel that conducts blood toward the heart
  • Compared to arteries, veins are thin-walled vessels with large and irregular lumens
  • Larger veins are commonly equipped with valves that promote the unidirectional flow of blood toward the heart and prevent backflow toward the capillaries caused by the inherent low blood pressure in veins as well as the pull of gravity
  • Other ways in which the body assists the transport of venous blood back to the heart involve contractions of skeletal muscles in the extremities (see figure below), as well as pressure variations caused by breathing motion in the chest.

Figure 13.1 Skeletal Muscle Pump. The contraction of skeletal muscles surrounding a vein compresses the blood and increases the pressure in that area. This action forces blood closer to the heart where venous pressure is lower. Note the importance of the one-way valves to assure that blood flows only in the proper direction. From Betts, et al., 2013. Licensed under CC BY 4.0.  [Image description.]

Both arteries and veins have the same three distinct tissue layers, called tunics, for the garments first worn by ancient Romans. From the most interior layer to the outer, these tunics are the tunica intima, the tunica media, and the tunica externa (see Figure 13.3). The smooth muscle in the middle layer, the tunica media, provides the vessel with the ability to vasoconstrict and vasodilate as needed to ensure sufficient blood flow.

Figure 13.2 Structure of Blood Vessels. (a) Arteries and (b) veins share the same general features, but the walls of arteries are much thicker because of the higher pressure of the blood that flows through them. (c) A micrograph shows the relative differences in thickness. LM × 160. (Micrograph provided by the Regents of the University of Michigan Medical School © 2012). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

The Major Arteries and Veins in the Human Body

 

Figure 13.3 Systemic Arteries. The major systemic arteries shown here deliver oxygenated blood throughout the body. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Figure 13.4 Major Systemic Veins of the Body. The major systemic veins of the body are shown here in an anterior view. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Figure 13.5 Cardiovascular Circulation. The pulmonary circuit moves blood from the right side of the heart to the lungs and back to the heart. The systemic circuit moves blood from the left side of the heart to the head and body and returns it to the right side of the heart to repeat the cycle. The arrows indicate the direction of blood flow, and the colors show the relative levels of oxygen concentration. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Figure 13.6 Pulse Sites. The pulse is most readily measured at the radial artery, but can be measured at any of the pulse points shown. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

The Composition (Anatomy) of Blood and the Functions of the Components

Blood is a connective tissue made up of cellular elements and an extracellular matrix. The cellular elements are referred to as the formed elements and include red blood cells (RBCs), white blood cells (WBCs), and platelets. The extracellular matrix, called plasma, makes blood unique among connective tissues because it is fluid. This fluid, which is mostly water, perpetually suspends the formed elements and enables them to circulate throughout the body within the cardiovascular system.

Did You Know?

Blood constitutes approximately 8% of adult body weight.

In the laboratory, blood samples are often centrifuged in order to separate the components of blood from one another (see the figure below). Erythrocytes are the heaviest elements in blood and settle at the very bottom of the tube. Above the erythrocyte layer we see the buffy coat, a pale, thin layer of leukocytes and thrombocytes, which together make up less than 1% of the sample of whole blood. Above the buffy coat is the blood plasma, normally a pale, straw-colored fluid, which constitutes the remainder of the sample.

In normal blood, about 45 percent of a sample is erythrocytes, which is referred to as the hematocrit. The hematocrit of any one sample can vary significantly, however, about 36–50 percent, according to gender and other factors. Not counting the buffy coat, which makes up less than 1% of the blood, we can estimate the mean plasma percentage to be the percent of blood that is not erythrocytes: approximately 55%.

Figure 13.7 Composition of Blood. The cellular elements of blood include a vast number of erythrocytes and comparatively fewer leukocytes and platelets. Plasma is the fluid in which the formed elements are suspended. A sample of blood spun in a centrifuge reveals that plasma is the lightest component. It floats at the top of the tube separated from the heaviest elements, the erythrocytes, by a buffy coat of leukocytes and platelets. Hematocrit is the percentage of the total sample that is comprised of erythrocytes. Depressed and elevated hematocrit levels are shown for comparison. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

The table below provides a useful summary of the components of blood and their functions.

Table 13.3 Major Blood Components. This table displays the components of blood and their associated functions. Adapted from Betts, et al., 2013. Licensed under CC BY 4.0.

COMPONENT AND % OF BLOOD	SUBCOMPONENT AND % OF COMPONENT	TYPE AND % (WHERE APPROPRIATE)	SITE OF PRODUCTION	MAJOR FUNCTION(S)
Plasma 46 – 63 percent	Water 92 percent	Fluid	Absorbed by intestinal tract or produced by metabolism	Transport medium
	Plasma proteins	Albumin 54 – 60 percent	Liver	Maintain osmotic concentration, transport lipid molecules
		Globulins 35 – 38 percent	Alpha globulins – liver	Transport, maintain osmotic concentration
			Beta globulins – liver	Transport, maintain osmotic concentration
			Gamma globulins (immunoglobulins) – plasma cells	Immune responses
		Fibrinogen 4 – 7 percent	Liver	Blood clotting in hemostasis
	Regulatory proteins < 1 percent	Hormones and enzymes	Various sources	Regulate various body functions
	Other solutes 1 percent	Nutrients, gases, and wastes	Absorbed by intestinal tract, exchanged in respiratory system, or produced by cells	Numerous and varied
Formed elements 37 – 54 percent	Erythrocytes 99 percent	Erythrocytes	Red bone marrow	Transport gases, primarily oxygen and some carbon dioxide
	Leukocytes < 1 percent Platelets < 1 percent	Granular Leukocytes: neutrophils eosinophils basophils	Red bone marrow	Nonspecific immunity
		Agranular leukocytes: lymphocytes monocytes	Lymphocytes: bone marrow and lyphatic tissue	Lymphocytes: specific immunity
			Monocytes: redbone marrow	Monocytes: nonspecific immunity
	Platelets < 1 percent	n/a	Megakaryocytes: Red Bone Marrow	Hemostasis

Concept Check

Use the table above to answer these questions:

• What substance makes up most of the plasma?
• What are some general functions of plasma and its components?
• What is the function of erythrocytes?
• What is the overall function of leukocytes? (Hint: which word appears in all 3 chart cells that list leukocyte functions?)
• What is the function of platelets?

Blood Plasma

Like other fluids in the body, plasma is composed primarily of water. In fact, it is about 92% water. Dissolved or suspended within this water is a mixture of substances, most of which are proteins. The major components of plasma and their functions are summarized in the table above.

Formed Elements (Erythrocytes, Leukocytes, Thrombocytes)

The table below summarizes the main facts about the formed elements in blood.

Table 13.4 Summary of Formed Elements in Blood. Adapted from Betts, et al., 2013. Licensed under CC BY 4.0.

FORMED ELEMENT	MAJOR SUBTYPES	NUMBER PRESENT PER MICROLITER (µL) AND MEAN (RANGE)	APPEARANCE IN A STANDARD BLOOD SMEAR	SUMMARY OF FUNCTIONS	COMMENTS
Erythrocytes (red blood cells) Red Blood Cell	n/a	5.2 million ( 4.4-5.0 million)	Flattened biconcave disk; no nucleus; pale red colour	Transport oxygen and some carbon dioxide between tissues and lungs	Lifespan of approximately 120 days
Leukocytes (white blood cells)	n/a	7000 (5000 – 10,000)	Obvious dark-staining nucleus	All function in body defenses	Exit capillaries and move into tissues; lifespan of usually a few hours or days
Leukocytes (white blood cells) Types	Granulocytes including neutrophils, eosinophils, and basophils	4360 (1800-9950)	Abundant granules in cytoplasm; nucleus normal lobed	Nonspecific (innate) resistance to disease	Classified according to membrane-bound granules in cytoplasm
	Neutrophils Neutrophil Cell	4150 (1800-7300)	Nuclear lobes increase with age; pale lilac granules	Phagocytic; particularly effective against bacteria. Release cytotoxic chemicals from granules	Most common leukocyte; lifespan of minutes to days
	Eosinophils Eosinophils Cell	165 (0-700)	Nucleus generally two-lobed; bright red-orange granules	Phagocytic cells; particularly effective with antigen-antibody complexes. Release antihistamines. Increase in allergies and parasitic infections	Lifespan of minutes to days
	Basophils Basophil Cell	44 (0-150)	Nucleus generally two-lobed but difficult to see due to presence of heavy, dense, dark purple granules	Promotes inflammation	Least common leukocyte; lifespan unknown
	Agranulocytes including lymphocytes and monocytes	2640 (1700-4950)	Lack abundant granules in cytoplasm; have a simple-shaped nucleus that may be indented	Body defenses	Group consists of two major cell types from different lineages
	Lymphocytes Lymphocytes Cell	2185 (1500-4000)	Spherical cells with a single often large nucleus occupying much of the cell’s volume; stains purple; see in large (natural killer cells) and small (B and T cells) variants	Primarily specific (adaptive) immunity; T cells directly attack other cells (cellular immunity). B cells release antibodies (humoral immunity); natural killer cells are similar to T cells but nonspecific	Initial cells originate in bone marrow, but secondary production occurs in lymphatic tissue; several distinct subtypes; memory cells form after exposure to a pathogen and rapidly increase responses to subsequent exposure; lifespan of many years
	Monocytes Monocytes Cell	455 (200-950)	Largest leukocyte with an indented or horseshoe-shaped nucleus	Very effective phagocytic cells engulfing pathogens or worn out cells; also serve as antigen-presenting cells (APCs) for other components of the immune system	Produced in red bone marrow; referred to as macrophages after leaving circulation
Platelets Platelete Cells	n/a	350,000 (150,000 – 500,000)	Cellular fragments surrounded by a plasma membrane and containing granules; purple stain	Hemostasis plus release growth factors for repair and healing of tissue	Formed from megakaryocytes that remain in the red bone marrow and shed platelets into circulation

Hemopoiesis/Hematopoiesis

The lifespan of the formed elements is very brief. Although one type of leukocyte (memory cells) can survive for years, most erythrocytes, leukocytes, and platelets normally live only a few hours to a few weeks. Thus, the body must form new blood cells and platelets quickly and continuously, a process known as hemopoiesis.

In children, hemopoiesis can occur in the medullary cavity of long bones; in adults, the process is largely restricted to the cranial and pelvic bones, the vertebrae, the sternum, and the proximal epiphyses of the femur and humerus. Throughout adulthood, the liver and spleen maintain their ability to generate the formed elements. This process is referred to as extramedullary hemopoiesis. When a disease such as bone cancer destroys the bone marrow, causing hemopoiesis to fail, extramedullary hemopoiesis may be initiated .

All formed elements arise from stem cells of the red bone marrow, called hemopoietic stem cell, or hemocytoblast. Hemopoiesis begins when the hemopoietic stem cell is exposed to appropriate chemical stimuli collectively called hemopoietic growth factors, which prompt it to divide and differentiate. One daughter cell remains a hemopoietic stem cell, allowing hemopoiesis to continue. The other daughter cell becomes either of two types of more specialized stem cells. Follow the chart below from top to bottom to learn how stem cells become mature formed elements of blood.

Figure 13.8 Hematopoietic System of Bone Marrow. Hemopoiesis is the proliferation and differentiation of the formed elements of blood. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Erythrocytes

The most abundant formed elements in blood, erythrocytes are basically sacs packed with an oxygen-carrying compound called hemoglobin. Production of erythrocytes in the red bone marrow occurs at the staggering rate of more than 2 million cells per second. For this production to occur, raw materials including iron, copper, zinc B-vitamins, glucose, lipids, and amino acids must be present in adequate amounts. Erythrocytes live only 120 days on average, and thus must be continually replaced. Worn-out erythrocytes are phagocytized by macrophages and their hemoglobin is broken down. The breakdown products are recycled or removed as wastes.

Figure 13.9 Shape of Red Blood Cells. Erythrocytes are biconcave discs with very shallow centers. This shape optimizes the ratio of surface area to volume, facilitating gas exchange. It also enables them to fold up as they move through narrow blood vessels. From Betts, et al., 2013. Licensed under CC BY 4.0.

Leukocytes

Leukocytes protect the body against invading microorganisms and body cells with mutated DNA, and they clean up debris, thus they are a major component of the body’s defenses against disease. Figure 13.10 shows the different types of leukocytes.

Figure 13.10 Leukocytes. (Micrographs provided by the Regents of University of Michigan Medical School © 2012). From Betts, et al., 2013. Licensed under CC BY 4.0.

Concept Check

• What is hemoglobin?
• Can you name the 5 types of leukocytes?

 

Leukocytes routinely leave the bloodstream to perform their defensive functions in the body’s tissues, where they are often given distinct names, such as macrophage or microglia, depending on their function. As shown in Figure 1 below, they leave the capillaries—the smallest blood vessels—or other small vessels through a process known as emigration or diapedesis in which they squeeze through adjacent cells in a blood vessel wall.

Once they have exited the capillaries, some leukocytes will take up fixed positions in lymphatic tissue, bone marrow, the spleen, the thymus, or other organs. Others will move about through the tissue spaces, sometimes wandering freely, and sometimes moving toward the direction in which they are drawn by chemical signals, a mechanism known as positive chemotaxis.

Figure 13.11 Emigration. Leukocytes exit the blood vessel and then move through the connective tissue of the dermis toward the site of a wound. Some leukocytes, such as the eosinophil and neutrophil, are characterized as granular leukocytes. They release chemicals from their granules that destroy pathogens; they are also capable of phagocytosis. The monocyte differentiates into a [pb_glossary id="969"]macrophage[/pb_glossary] that then [pb_glossary id="1618"]phagocytizes[/pb_glossary] the pathogens. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Lymphocytes

Lymphocytes are one of the types of leukocytes and will be discussed in more detail here, since they tie into the next chapter which discussed the body’s defenses The three major groups of lymphocytes include natural killer cells, B cells, and T cells.

• • Natural killer (NK) cells are capable of recognizing cells that do not express “self” proteins on their plasma membrane or that contain foreign or abnormal markers. These “nonself” cells include cancer cells, cells infected with a virus, and other cells with atypical surface proteins.
  • B lymphocytes (B cells) and T lymphocytes (T cells), play prominent roles in defending the body against specific pathogens (disease-causing microorganisms) and are involved in specific immunity. B cells undergo a maturation process in the bone marrow, whereas T cells undergo maturation in the thymus. This site of the maturation process gives rise to the name B and T cells.
    • Plasma cells, a type of B cell, produce the antibodies or immunoglobulins that bind to specific foreign or abnormal components of plasma membranes.
    • T cells provide immunity by physically attacking foreign or diseased cells.
    • Memory cells are a variety of both B and T cells that form after exposure to a pathogen and mount rapid responses upon subsequent exposures. Unlike other leukocytes, memory cells live for many years.

Platelets

After entering the circulation, approximately one-third of the newly-formed platelets migrate to the spleen for storage for later release in response to any rupture in a blood vessel. They then become activated to perform their primary function, which is to limit blood loss. Platelets remain only about 10 days, then are phagocytized by macrophages.

Platelets are key players in hemostasis, the process by which the body seals a ruptured blood vessel and prevents further loss of blood. Although rupture of larger vessels usually requires medical intervention, hemostasis is quite effective in dealing with small, simple wounds. There are three steps to the process: vascular spasm, the formation of a platelet plug, and coagulation (blood clotting). Failure of any of these steps will result in hemorrhage.  The figure below summarizes the steps of hemostatis.

 

Figure 13.12 Hemostasis. (a) An injury to a blood vessel initiates the process of hemostasis. Blood clotting involves three steps. First, vascular spasm constricts the flow of blood. Next, a platelet plug forms to temporarily seal small openings in the vessel. Coagulation then enables the repair of the vessel wall once the leakage of blood has stopped. (b) The synthesis of fibrin in blood clots involves either an intrinsic pathway or an extrinsic pathway, both of which lead to a common pathway. (credit a: Kevin MacKenzie). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Fibrinolysis is the process in which a clot is degraded in a healing vessel. An anticoagulant is any substance that opposes coagulation. Several circulating plasma anticoagulants play a role in limiting the coagulation process to the region of injury and restoring a normal, clot-free condition of blood.

Concept Check

• Can you explain what happens in each step of hemostasis?
• Describe an anticoagulant.

Physiology of Blood

Although carrying oxygen and nutrients to cells and removing wastes from cells is the main function of blood, it is important to realize that blood also serves in defense, distribution of heat, and maintenance of homeostasis.

Transportation

• Nutrients from the foods you eat are absorbed in the digestive tract. Most of these travel in the bloodstream directly to the liver, where they are processed and released back into the bloodstream for delivery to body cells.
• Oxygen from the air you breathe diffuses into the blood, which moves from the lungs to the heart, which then pumps it out to the rest of the body.
• Endocrine glands scattered throughout the body release their products, called hormones, into the bloodstream, which carries them to distant target cells.
• Blood also picks up cellular wastes and byproducts, and transports them to various organs for removal. For instance, blood moves carbon dioxide to the lungs for exhalation from the body, and various waste products are transported to the kidneys and liver for excretion from the body in the form of urine or bile.

Defense

• Leukocytes protect the organism from disease-causing bacteria, cells with mutated DNA that could multiply to become cancerous, or body cells infected with viruses.
• When damage to the vessels results in bleeding, blood platelets and certain proteins dissolved in the plasma, interact to block the ruptured areas of the blood vessels involved. This protects the body from further blood loss.

Homeostasis

• If you were exercising on a warm day, your rising core body temperature would trigger several homeostatic mechanisms, including increased transport of blood from your core to your body periphery, which is typically cooler. As blood passes through the vessels of the skin, heat would be dissipated to the environment, and the blood returning to your body core would be cooler. In contrast, on a cold day, blood is diverted away from the skin to maintain a warmer body core. In extreme cases, this may result in frostbite.
• Blood helps to regulate the water content of body cells.
• Blood also helps to maintain the chemical balance of the body. Proteins and other compounds in blood act as buffers, which thereby help to regulate the pH of body tissues. The pH of blood ranges from 7.35 to 7.45.

Concept Check

These three terms all sound similar. Can you explain them by breaking down the word parts?

• Hemostasis
• Homeostasis
• Hemopoiesis

 

Blood Types

In order to understand blood types, it is important to understand several terms that relate to the body’s immune functions (discussed in detail in the next chapter)

• Antigens are substances that the body does not recognize as belonging to itself (“self”) and that therefore trigger a defensive response from the leukocytes of the immune system. Many people have antigens on the surfaces of their red blood cells. More than 50 antigens have been identified on erythrocyte membranes, but the most significant in terms of their potential harm to patients are classified in two groups: the ABO blood group and the Rh blood group.
• Antibodies are proteins which are produced by plasma cells in response to a “non-self” antigen being present in the body. Antibodies attach to the antigens on the plasma membranes of the erythrocytes in a blood transfusion and cause them to adhere to one another.
• Agglutination refers to the resulting clumps of red blood cells that are formed in such an antigen-antibody reaction. These clumps can block small blood vessels, thereby cutting of the supply of oxygen and nutrients to the tissues.
• Hemolysis, or the breakdown of the erythrocyte’s cell membrane, takes place as the clumps of red cells start to degrade. The resulting release of the cell’s contents, mainly hemoglobin, into the bloodstream can cause kidney failure.

ABO Blood Group

ABO blood types are genetically determined. Each type is determined by the presence or absence of certain antigens on the individual’s red blood cell membrane, as well as the presence or absence of certain antibodies. Normally the body must be exposed to a foreign antigen before an antibody can be produced. This is not the case for the ABO blood group, in which some blood types come preloaded with their own set of antibodies against another type. The table below shows the ABO blood group as well as the universal donor and recipient in relation to blood transfusions.

Figure 13.13 ABO Blood Groups. From Betts, et al., 2013. Licensed under CC BY 4.0.

• Blood Type A
  • People whose erythrocytes have A antigens on their erythrocyte membrane surface.
  • People who have type A blood, without any prior exposure to incompatible blood, have preformed anti-B antibodies circulating in their blood. These antibodies will cause a serious immune reaction if they encounter blood that has B antigens.
• Blood Type B
  • People whose erythrocytes have B antigens.
  • People with type B blood has preformed anti-A antibodies.
• Blood Type AB
  • People can also have both A and B antigens on their erythrocytes, in which case they are blood type AB.
  • Individuals with type AB blood, do not have preformed antibodies to either A or B antigens.
• Blood Type O
  • People with neither A nor B antigens are designated blood type O.
  • People with type O blood have both anti-A and anti-B antibodies circulating in their blood plasma.

Rh Blood Group

The Rh blood group is classified according to the presence or absence of a second erythrocyte antigen identified as Rh. Those who have the Rh D antigen present on their erythrocytes are described as Rh positive (Rh⁺) and those who lack it are Rh negative (Rh⁻). Note that the Rh group is distinct from the ABO group, so any individual, no matter their ABO blood type, may have or lack this Rh antigen. When identifying a patient’s blood type, the Rh group is designated by adding the word positive or negative to the ABO type. For example, A positive (A⁺) means ABO group A blood with the Rh antigen present, and AB negative (AB⁻) means ABO group AB blood without the Rh antigen.

Hemolytic Disease of the Newborn (HDN)

Antibodies to the Rh antigen are produced only in Rh⁻ individuals after exposure to the antigen. This process, called sensitization, occurs following a transfusion with Rh-incompatible blood or, more commonly, with the birth of an Rh⁺ baby to an Rh⁻ mother.

• In a first pregnancy problems are rare, since the baby’s Rh⁺ cells rarely cross the placenta. However, during or immediately after birth, the Rh⁻ mother can be exposed to the baby’s Rh⁺ cells (Figure below). Research has shown that this occurs in about 13−14 percent of such pregnancies. After exposure, the mother’s immune system begins to generate anti-Rh antibodies.
• In a second pregnancy if a mother should conceive a Rh⁺ baby, the Rh antibodies she has produced can cross the placenta into the fetal bloodstream and destroy the fetal RBCs. This condition, known as hemolytic disease of the newborn (HDN) or erythroblastosis fetalis. This may cause anemia in mild cases, but the agglutination and hemolysis can be so severe that without treatment the fetus may die in the womb or shortly after birth.
  • A drug known as RhoGAM, short for Rh immune globulin, can temporarily prevent the development of Rh antibodies in the Rh⁻ mother, thereby averting this potentially serious disease for the fetus. RhoGAM antibodies destroy any fetal Rh⁺ erythrocytes that may cross the placental barrier. RhoGAM is normally administered to Rh⁻ mothers during weeks 26−28 of pregnancy and within 72 hours following birth.

Figure 13.14 Erythroblastosis Fetalis. The first exposure of an Rh− mother to Rh+ erythrocytes during pregnancy induces sensitization. Anti-Rh antibodies begin to circulate in the mother’s bloodstream. A second exposure occurs with a subsequent pregnancy with an Rh+ fetus in the uterus. Maternal anti-Rh antibodies may cross the placenta and enter the fetal bloodstream, causing agglutination and hemolysis of fetal erythrocytes. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Blood Transfusions

Figure 13.15 is an example of a commercially produced “bedside” card which enables quick typing of both a recipient’s and donor’s blood before transfusion. The card contains three reaction sites or wells. One is coated with an anti-A antibody, one with an anti-B antibody, and one with an anti-D antibody (tests for the presence of Rh factor D). Mixing a drop of blood and saline into each well enables the blood to interact with a preparation of type-specific antibodies, also called anti-seras. Agglutination of RBCs in a given site indicates a positive identification of the blood antigens, in this case A and Rh antigens for blood type A+. To avoid serious and potentially fatal immune reactions, the donor’s and recipient’s blood types must match

Figure 13.15. Cross Matching Blood Types. From Betts, et al., 2013. Licensed under CC BY 4.0.

To avoid transfusion reactions, it is best to transfuse only matching blood types; that is, a type B⁺ recipient should ideally receive blood only from a type B⁺ donor and so on. That said, in emergency situations, when acute hemorrhage threatens the patient’s life, there may not be time for cross matching to identify blood type. In these cases, blood from a universal donor may be transfused.

Blood Vessel Medical Terms Not Easily Broken into Word Parts

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Common Diseases and Disorders of Blood Vessels and/or Blood

Arteriosclerosis

Arteriosclerosis is normally defined as the more generalized loss of compliance, “hardening of the arteries,” whereas atherosclerosis is a more specific term for the build-up of plaque in the walls of the vessel and is a specific type of arteriosclerosis.

When arteriosclerosis causes vessel compliance to be reduced, pressure and resistance within the vessel increase. This is a leading cause of hypertension and coronary heart disease, as it causes the heart to work harder to overcome this resistance. Any artery in the body can be affected by these pathological conditions, and individuals who have pathologies like coronary artery disease, may also be at risk for other vascular injuries, like strokes or peripheral arterial disease.

Atherosclerosis is a type of arteriosclerosis in which plaques form when circulating triglycerides, cholesterol and other substances seep between the damaged endothelial lining cells and become trapped within the artery wall, resulting in narrowed arteries and impaired blood flow (see Figure 13.16) (Betts, et al., 2013).

Figure 13.16 Atherosclerosis. (a) Atherosclerosis can result from plaques formed by the buildup of fatty, calcified deposits in an artery. (b) Plaques can also take other forms, as shown in this micrograph of a coronary artery that has a buildup of connective tissue within the artery wall. LM × 40. (Micrograph provided by the Regents of University of Michigan Medical School © 2012). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Sometimes a plaque can rupture, causing microscopic tears in the artery wall that allow blood to leak into the tissue on the other side. When this happens, platelets rush to the site to clot the blood. This clot can further obstruct the artery and—if it occurs in a coronary or cerebral artery—cause a sudden heart attack or stroke. Alternatively, plaque can break off and travel through the bloodstream as an embolus until it blocks a more distant, smaller artery.

Peripheral arterial disease (PAD, also called peripheral vascular disease, PVD), occurs when atherosclerosis affects arteries in the legs. A major risk factor for both arteriosclerosis and atherosclerosis is advanced age, as the conditions tend to progress over time. There is also a distinct genetic component, and pre-existing hypertension and/or diabetes also greatly increase the risk. However, obesity, poor nutrition, lack of physical activity, and tobacco use all are major risk factors.

Treatment of atherosclerosis includes lifestyle changes, such as weight loss, smoking cessation, regular exercise, and adoption of a diet low in sodium and saturated fats. Medications to reduce cholesterol and blood pressure may be prescribed. For blocked coronary arteries, angioplasty or coronary artery bypass graft (CABG) surgery may be warranted. In an carotid endarterectomy, plaque is surgically removed from the walls of a the carotid artery, which is the main source of oxygenated blood for the brain (Betts, et al., 2013).

Edema and Varicose Veins

Despite the presence of valves and the contributions of other anatomical and physiological adaptations that assist in moving blood through veins, over the course of a day, some blood will inevitably pool, especially in the lower limbs, due to the pull of gravity. Any blood that accumulates in a vein will increase the pressure within it, which can then be reflected back into the smaller veins, venules, and eventually even the capillaries. This increased pressure in the capillaries will push of fluids out of the capillaries and into the interstitial fluid, causing a condition called edema.

Most people experience a daily accumulation of tissue fluid, especially if they spend much of their work life on their feet (like most health professionals). However, clinical edema goes beyond normal swelling and requires medical treatment. Edema has many potential causes, including hypertension and heart failure, severe protein deficiency, renal failure, and many others. In order to treat edema, which is a sign rather than a discrete disorder, the underlying cause must be diagnosed and alleviated.

Figure 13.17 Varicose Veins. Varicose veins are commonly found in the lower limbs. (credit: Thomas Kriese). From Betts, et al., 2013. Licensed under CC BY 4.0.

Edema may be accompanied by varicose veins, especially in the superficial veins of the legs (see Figure 13.17). This disorder arises when defective valves allow blood to accumulate within the veins, causing them to distend, twist, and become visible on the surface of the skin. Varicose veins may occur in both sexes, but are more common in women and are often related to pregnancy. More than simple cosmetic blemishes, varicose veins are often painful and sometimes itchy or throbbing. Without treatment, they tend to grow worse over time. The use of support hose, as well as elevating the feet and legs whenever possible, may be helpful in alleviating this condition (Betts, et al., 2013).

 
 

Hypertension

Hypertension is defined as chronic and persistent blood pressure measurements of 140/90 mm Hg or above. Pressures between 120/80 and 140/90 mm Hg are defined as prehypertension. Hypertension is typically a silent disorder and patients may fail to recognize the seriousness of their condition and fail to follow their treatment plan, putting them at risk for a heart attack or stroke. Hypertension may also lead to an aneurysm, peripheral arterial disease, chronic kidney disease, or heart failure (Betts, et al., 2013).

Hemorrhage

Minor blood loss is managed by hemostasis and repair. Hemorrhage is a loss of blood that cannot be controlled by hemostatic mechanisms. Initially, the body responds to hemorrhage by initiating mechanisms aimed at increasing blood pressure and maintaining blood flow. Ultimately, however, blood volume will need to be restored, either through physiological processes or through medical intervention. If blood loss is less than 20 percent of total blood volume, fast-acting homeostatic mechanisms causing increased cardiac output and vasoconstriction, would usually return blood pressure to normal and redirect the remaining blood to the tissues. Blood volume will then need to be restored via slower-acting homeostatic mechanisms, to increase body fluids and erythrocyte production (Betts, et al., 2013).

Circulatory Shock

The loss of too much blood may lead to circulatory shock, a life-threatening condition in which the circulatory system is unable to maintain blood flow to adequately supply sufficient oxygen and other nutrients to the tissues to maintain cellular metabolism. It should not be confused with emotional or psychological shock. Typically, the patient in circulatory shock will demonstrate an increased heart rate but decreased blood pressure. Urine output will fall dramatically, and the patient may appear confused or lose consciousness. Unfortunately, shock is an example of a positive-feedback loop that, if uncorrected, may lead to the death of the patient (Betts, et al., 2013).

There are several recognized forms of shock:

• Hypovolemic shock in adults is typically caused by hemorrhage, although in children it may be caused by fluid losses related to severe vomiting or diarrhea.
• Cardiogenic shock results from the inability of the heart to maintain cardiac output. Most often, it results from a myocardial infarction (heart attack), but it may also be caused by arrhythmias, valve disorders, cardiomyopathies, cardiac failure, or simply insufficient flow of blood through the cardiac vessels.
• Vascular shock occurs when arterioles lose their normal muscular tone and dilate dramatically. It may arise from a variety of causes, and treatments almost always involve fluid replacement and medications, called inotropic or pressor agents, which restore tone to the muscles of the vessels.
• Anaphylactic shock is a severe allergic response that causes the widespread release of histamines, triggering vasodilation throughout the body.
• Obstructive shock, as the name would suggest, occurs when a significant portion of the vascular system is blocked. It is not always recognized as a distinct condition and may be grouped with cardiogenic shock, including pulmonary embolism and cardiac tamponade. Treatments depend upon the underlying cause and, in addition to administering fluids intravenously, often include the administration of anticoagulants, removal of fluid from the pericardial cavity, or air from the thoracic cavity, and surgery as required. The most common cause is a pulmonary embolism. Other causes include stenosis of the aortic valve; cardiac tamponade; and a pneumothorax (Betts, et al., 2013).

Blood Disorders

Erythrocyte Disorders

Changes in the levels of RBCs can have significant effects on the body’s ability to effectively deliver oxygen to the tissues (Betts, et al., 2013).

Did You Know?

Did you know?
‘O2 sat’ or ‘percent sat’ is the percent saturation; that is, the percentage of hemoglobin sites occupied by oxygen in a patient’s blood.

Anemia

The size, shape, and number of erythrocytes, and the number of hemoglobin molecules can have a major impact on a person’s health. When the number of RBCs or hemoglobin is deficient, the general condition is called anemia. There are more than 400 types of anemia.

Anemia can be broken down into three major groups: those caused by blood loss, those caused by faulty or decreased RBC production, and those caused by excessive destruction of RBCs. In addition to these causes, various disease processes also can lead to anemias. These include chronic kidney diseases often associated with a decreased production of EPO, hypothyroidism, some forms of cancer, lupus, and rheumatoid arthritis(Betts, et al., 2013).

Blood Loss Anemias:

Causes:

• Bleeding from wounds or other lesions, including ulcers, hemorrhoids, inflammation of the stomach (gastritis), and some cancers of the gastrointestinal tract
  • The excessive use of aspirin or other nonsteroidal anti-inflammatory drugs such as ibuprofen can trigger ulceration and gastritis
• Excessive menstruation and loss of blood during childbirth.

Anemias Caused by Faulty or Decreased RBC Production:

• Sickle cell anemia

Figure 13.18 Sickle Cells. (credit: Janice Haney Carr). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

• • A genetic disorder involving the production of an abnormal type of hemoglobin which delivers less oxygen to tissues and causes erythrocytes to assume a sickle (or crescent) shape.
• Iron deficiency anemia
  • The most common type of anemia and results when the amount of available iron is insufficient to allow production of sufficient heme.
• Vitamin deficiency anemia (Generally insufficient vitamin B12 and folate).
• Megaloblastic anemia involves a deficiency of vitamin B12 and/or folate, often due to inadequate dietary intake.
• Pernicious anemia is caused by poor absorption of vitamin B12 and is often seen in patients with Crohn disease, surgical removal of the intestines or stomach (common in some weight loss surgeries), intestinal parasites, and AIDS[/pb_glossary.
• Aplastic anemia is the condition in which myeloid stem cells are defective or replaced by cancer cells, resulting in insufficient quantities of RBCs being produced. This condition by be inherited, or it may be triggered by radiation, medication, chemotherapy, or infection.
• Thalassemia is an inherited condition typically occurring in individuals from the Middle East, the Mediterranean, African, and Southeast Asia, in which maturation of the RBCs does not proceed normally. The most severe form is called Cooley’s anemia (Betts, et al., 2013).

Polycythemia

Polycythemia is an elevated RBC count and is detected in a patient’s elevated [pb_glossary id="1613"]hematocrit. It can occur transiently in a person who is dehydrated; when water intake is inadequate or water losses are excessive, the plasma volume falls. As a result, the hematocrit rises. A mild form of polycythemia is chronic but normal in people living at high altitudes. Some elite athletes train at high elevations specifically to induce this phenomenon. Finally, a type of bone marrow disease called polycythemia vera causes an excessive production of immature erythrocytes. Polycythemia vera can dangerously elevate the viscosity of blood, raising blood pressure and making it more difficult for the heart to pump blood throughout the body. It is a relatively rare disease that occurs more often in men than women, and is more likely to be present in elderly patients those over 60 years of age (Betts, et al., 2013).

Platelet Disorders/Clotting Disorders

Thrombocytosis

Thrombocytosis is a condition in which there are too many platelets. This may trigger thrombosis, a potentially fatal disorder. A thrombus (plural = thrombi) is an aggregation of platelets, erythrocytes, and even WBCs typically trapped within a mass of fibrin strands. While the formation of a clot is a normal step in hemostasis, thrombi can form within an intact or only slightly damaged blood vessel, adhering to the vessel wall and decreasing or obstructing the flow of blood. (Betts, et al., 2013).

Thrombophilia

Thrombophilia, also called hypercoagulation, is a condition in which there is a tendency to form thrombosis. This may be an inherited disorder or may be caused by other conditions including lupus, immune reactions to heparin, polycythemia vera, thrombocytosis, sickle cell disease, pregnancy, and even obesity.

When a portion of a thrombus breaks free from the vessel wall and enters the circulation, it is referred to as an embolus. An embolus that is carried through the bloodstream can be large enough to block a vessel critical to a major organ. When it becomes trapped, an embolus is called an embolism. In the heart, brain, or lungs, an embolism may accordingly cause a heart attack, a stroke, or a pulmonary embolism (Betts, et al., 2013).

Thrombocytopenia

Thrombocytopenia is a condition in which there is an insufficient number of platelets, possibly leading to ineffective blood clotting and excessive bleeding (Betts, et al., 2013).

Hemophilia

Hemophilia is a group of related genetic disorders in which certain plasma clotting factors are lacking or inadequate or nonfunctional. Patients with hemophilia bleed from even minor internal and external wounds, and leak blood into joint spaces after exercise and into urine and stool. Regular infusions of clotting factors isolated from healthy donors can help prevent bleeding in hemophiliac patients. At some point, genetic therapy will become a viable option (Betts, et al., 2013).

Leukocyte Disorders

Leukopenia

Leukopenia is a condition in which too few leukocytes are produced. If this condition is pronounced, the individual may be unable to ward off disease (Betts, et al., 2013).

Leukocytosis

Leukocytosis is excessive leukocyte proliferation. Although leukocyte counts are high, the cells themselves are often nonfunctional, leaving the individual at increased risk for disease (Betts, et al., 2013).

Leukemia

Leukemia is a cancer involving an abundance of leukocytes. It may involve only one specific type of leukocyte from either the myeloid line (myelocytic leukemia) or the lymphoid line (lymphocytic leukemia). In chronic leukemia, mature leukocytes accumulate and fail to die. In acute leukemia, there is an overproduction of young, immature leukocytes. In both conditions the cells do not function properly (Betts, et al., 2013).

Lymphoma

Lymphoma is a form of cancer in which masses of malignant T and/or B lymphocytes collect in lymph nodes, the spleen, the liver, and other tissues. As in leukemia, the malignant leukocytes do not function properly, and the patient is vulnerable to infection. Some forms of lymphoma tend to progress slowly and respond well to treatment. Others tend to progress quickly and require aggressive treatment, without which they are rapidly fatal (Betts, et al., 2013).

Other Conditions Related to Abnormal Leukocyte Counts

Table 13.5. Conditions Related to Abnormal White Blood Cell Counts. From Betts, et al., 2013. Licensed under CC BY 4.0.

CELL TYPE	CONDITIONS RELATED TO HIGH COUNTS	CONDITIONS RELATED TO LOW COUNTS
Neutrophil	Infection, inflammation, burns, unusual stress	Drug toxicity, other disorders
Eosinophil	Allergies, parasitic worm infestations, some autoimmune diseases	Drug toxicity, stress
Basophil	Allergies, parasitic infections, hypothyroidism	Pregnancy, stress, hyperthyroidism
Lymphocyte	Viral infections, some cancers	chronic illness, immunosuppression (due to HIV or steroid therapy)
Monocyte	Viral or fungal infections, tuberculosis, some forms of leukemia, other chronic diseases	Bone marrow suppression

Bone Marrow Biopsy/Bone Marrow Transplant

Sometimes, a healthcare provider will order a bone marrow biopsy, a diagnostic test of a sample of red bone marrow, or a bone marrow transplant, a treatment in which a donor’s healthy bone marrow—and its stem cells—replaces the faulty bone marrow of a patient. These tests and procedures are often used to assist in the diagnosis and treatment of various severe forms of anemia, such as thalassemia major and sickle cell anemia, as well as some types of cancer, specifically leukemia.

In the past, bone marrow sampling or transplant was very painful, as the procedure involved inserting a large-bore needle into the region near the iliac crest of the pelvic bones. Now, direct sampling of bone marrow can often be avoided as stem cells can be isolated in just a few hours from a sample of a patient’s blood. The isolated stem cells are then grown in culture using the appropriate hemopoietic growth factors, and analyzed or sometimes frozen for later use.

For an individual requiring a transplant, a matching donor is essential to prevent the immune system from destroying the donor cells—a phenomenon known as tissue rejection. To treat patients with bone marrow transplants, it is first necessary to destroy the patient’s own diseased marrow through radiation and/or chemotherapy. Donor bone marrow stem cells are then infused into the recipient's bloodstream, so that they can establish themselves in the recipient’s bone marrow (Betts, et al., 2013).

Common Cardiovascular System - Blood, Abbreviations

Many terms and phrases related to the cardiovascular system - blood are abbreviated. Learn these common abbreviations by expanding the list below.

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Medical Terms in Context

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Medical Specialties and Procedures Related to the Blood Vessels and Blood

Vascular Surgeons

Vascular surgery is a specialty in which the physician treats diseases of the blood and lymphatic vessels. This includes repair and replacement of diseased or damaged vessels, removal of plaque from vessels, minimally invasive procedures including the insertion of venous catheters, and traditional surgery (Betts, et al., 2013; Canadian Society for Vascular Surgery, n.d.). For more information, please visit Canadian Society for Vascular Surgery website.

Hematologists

Hematologists are specialist physicians that diagnose and treat blood disorders. These physicians must be well-versed in a wide array of laboratory procedures, basic medical disciplines, and clinical medicine (Canadian Medical Association, 2018). To learn more about hematologists, visit the Canadian Medical Association's specialty profile on hematology (PDF file).

Diagnostic Vascular Technologist

Also known as Canadian Registered Vascular Sonographers (CRVS®), these specialists are technologists that image the vascular system (Sonography Canada, 2020). To learn more, visit the Sonography Canada Credentials web page.

Phlebotomist

Phlebotomists are professionals trained to draw blood (phleb- = “a blood vessel”; -tomy = “to cut”). When more than a few drops of blood are required, phlebotomists perform a venipuncture, typically of a surface vein in the arm. They perform a capillary stick on a finger, an earlobe, or the heel of an infant when only a small quantity of blood is required. An arterial stick is collected from an artery and used to analyze blood gases. After collection, the blood may be analyzed by medical laboratories or perhaps used for transfusions, donations, or research (Betts, et al., 2013).

Medical Laboratory Technologist/Assistant

Medical or clinical laboratories employ a variety of individuals in technical positions. Training is provided through a variety of institutions and certification is through the Canadian Society for Medical Laboratory Science. Two specialized positions are:

• Medical laboratory technologists (MLT) perform complex analyses of tissue, blood and other body fluids.
• Medical laboratory assistants (MLA) spend the majority of their time processing samples, and in some cases, collecting them (Canadian Society for Medical Laboratory Science, n.d.)

Cardiovascular System-Blood Vocabulary

ABG

Arterial blood gas. This test measures blood pH, oxygen and CO2 levels in a sample of arterial blood, usually taken from the wrist.

AIDS

Acquired immunodeficiency syndrome, caused by infection with the HIV virus.

Aneurysm

Weakening of the wall of a blood vessel, causing it to thin and balloon out, and possibly eventually burst, resulting in internal bleeding.

Angioplasty

A balloon-tip catheter is fed through a blood vessel up to the site of the narrowing, the balloon is inflated to re-open the artery. A stent is sometimes placed at the site to reinforce the arterial wall and to prevent re-occlusion.

Anti-B Antibodies

Proteins that will mount an immune response against B antigens.

Antibodies

Also called immunoglobulins, proteins produced by B lymphocytes in response to a non-self antigen.

Antigens

A substance that provokes an immune response. This happens because the immune system sees the antigen as foreign, or 'non-self" (does not belong in that body).

Arteries

Blood vessels that transport blood away from the heart.

Arterioles

A very small artery that leads to a capillary.

Arteriosclerosis

Hardening of arteries.

Atherosclerosis

A hardening of the arteries that involves the accumulation of plaque.

Brachial Artery

Large artery in the upper arm near the biceps muscle.

Capillary

A microscopic channel that supplies blood to the tissues through perfusion.

Cardiac Output

Cardiac output is the measurement of blood flow from the heart through the ventricles, and is usually measured in liters per minute. Any factor that causes cardiac output to increase, by elevating heart rate or stroke volume or both, will elevate blood pressure and promote blood flow.

Cardiac Tamponade

The pericardial sac surrounding the heart has filled with blood or other fluid and the resulting pressure is preventing the heart from beating effectively.

Cardiogenic

Originating from the heart.

Carotid Artery

A large artery in the neck.

Celiac Disease

Inflammation of the intestines caused by exposure to gluten.

Centrifuged

A centrifuge is a common piece of laboratory equipment used to spin test tubes at a high speed in order to separate components in a liquid by weight.

Chemoreceptors

Cells that sense changes in chemical levels.

Chemotaxis

Movement in response to chemicals; a phenomenon in which injured or infected cells and nearby leukocytes emit the equivalent of a chemical “911” call, attracting more leukocytes to the site.

Compliance

The ability of any compartment to expand to accommodate increased content. The greater the compliance of an artery, the more effectively it is able to expand to accommodate surges in blood flow without increased resistance or blood pressure.

Coronary Artery Bypass Graft (CABG)

In a coronary bypass procedure, a non-vital superficial vessel from another part of the body (often the great saphenous vein) or a synthetic vessel is inserted to create a path around the blocked area of a coronary artery.

Coronary Heart Disease

Also called coronary artery disease (CAD); the blood vessels that supply blood to the myocardium become hardened and narrowed, impairing the delivery of oxygen to the heart muscle.

Crohn Disease

A type of inflammatory bowel disease.

Diapedesis

dia- = “through”; -pedan = “to leap”

Diastolic Pressure

The diastolic pressure is the lower value (usually about 80 mm Hg) and represents the arterial pressure of blood during ventricular relaxation, or diastole.

Edema

Swelling.

Embolus

A freely moving piece of a substance (plaque or blood clot) that travels through the circulation until it blocks a smaller blood vessel, cutting of the supply of oxygen to the tissue.

Endothelium

The lining of the lumen of a blood vessel.

Epiphyses

The ends of long bones, singular is epiphysis.

EPO

Erythropoietin is a hormone produced by the kidneys that plays an important role in the homeostasis of red blood cells levels in the body.

Erythrocytes

Red blood cells.

Extramedullary Hemopoiesis

Hemopoiesis outside the medullary cavity of adult bones.

Heart Rate

The number of times the heart contracts in one minute.

Hematocrit

A lab test which measures the percentage red blood cells in a sample of whole blood. It represents how much of the person's blood is made up of red blood cells, by volume.

Hemolysis

Breaking apart of the erythrocyte cell membrane, allowing its contents to leak out.

Hemopoiesis

Also called hematopoiesis; from the Greek root haima- = “blood”; -poiesis = “production”.

Hemopoietic Growth Factors

Chemical messengers which promote the proliferation and differentiation of formed elements and include erythropoietin, thrombopoietin, colony-stimulating factors, and interleukins.

Hemorrhage

Excessive or uncontrolled bleeding from the blood vessels.

Hemostasis

The process by which the body seals a ruptured blood vessel to prevent further blood loss.

Homeostasis

Biological process that results in stable equilibrium.

Hypertension

High blood pressure.

Hypothyroidism

Underactive thyroid gland, insufficient production of thyroid hormones (T3 and T4).

Hypovolemic

hypo=below, lower than normal, volemic=pertaining to volume (in this case, the volume of blood in the body).

Hypoxemia

Low blood oxygen levels.

Hypoxia

Literally: 'lower than normal amount of oxygen to tissues'. Hypoxia means that a tissue is not getting enough oxygen to survive and cell death is likely.

Ischemia

Insufficient blood and oxygen to cells of an organ. These cells are starving for oxygen, but they are still alive.

Leukocytes

White blood cells.

Lupus

An autoimmune disease in which the body mounts an immune response against its own tissues, causing chronic inflammation and tissue damage.

Macrophages

A type of leukocyte (usually a monocyte) that has the ability to ingest and destroy other cells or pathogens.

Medulla Oblongata

A part of the brain stem responsible for control of heart rate and breathing.

Perfusion

The delivery of blood to an area/tissue/organ.

Peripheral Arterial Disease

The obstruction of vessels in peripheral regions of the body.

pH

A measure of how acidic or alkaline a substance is, as determined by the number of free hydrogen ions in the substance.

Phagocytized

Also phagocytosed, this is the process by which certain cells are able to 'eat' other cells or substances by engulfing them

Placenta

The organ of gas and nutrient exchange between the baby and the mother.

Plaque

A fatty material including cholesterol, connective tissue, white blood cells, and some smooth muscle cells.

Plasma Cells

A type of B lymphocyte that produces antibodies which bind to specific foreign or abnormal antigens, in order to destroy them.

Pneumothorax

An excessive amount of air is present in the thoracic cavity, outside of the lungs, putting pressure on the lungs and interfering with venous return, pulmonary function, and delivery of oxygen to the tissues.

Polycythemia Vera

A type of bone marrow disease that causes an excessive production of immature erythrocytes.

Pulmonary Embolism

A piece of a blood clot or other substance has broken free from its original location and traveled through the bloodstream to lodge in a smaller vessel in the lungs. This causes an obstruction in that vessel and hypoxia to the tissues supplied by that vessel.

Rheumatoid Arthritis

An autoimmune disorder in which the body mounts an immune response against its own joint tissues, causing inflammation and damage to the joints.

Sickle Cell Disease

Also called sickle cell anemia: A genetic disorder involving the production of an abnormal type of hemoglobin which delivers less oxygen to tissues and causes erythrocytes to assume a sickle (or crescent) shape.

Silent Disorder

A disease or disorder that often lacks signs or symptoms.

Sphygmomanometer

A blood pressure cuff attached to a measuring device, or gauge.

Systolic Pressure

The systolic pressure is the higher value (typically around 120 mm Hg) and reflects the arterial pressure resulting from the ejection of blood during ventricular contraction, or systole.

Thalassemia

An inherited condition typically occurring in individuals from the Middle East, the Mediterranean, African, and Southeast Asia, in which maturation of the RBCs does not proceed normally. The most severe form is called Cooley’s anemia.

Thrombocytes

Also called platelets, these are cell fragments that aid in blood clotting.

Thrombocytosis

A condition in which there are too many platelets.

Thrombosis

Formation of unwanted blood clots.

Tissue Rejection

Also called organ rejection. The recipient's immune system recognizes the transplanted tissue, the graft, as non-self and mounts an immune response against it, ultimately destroying it.

Vasoconstrict

The smooth muscle layer in the blood vessel wall contracts, causing the vessel diameter to narrow. This increases blood pressure in the vessel.

Vasodilate

The smooth muscle layer in the wall of the blood vessel relaxes, allowing the vessel to widen. This decreases blood pressure in the vessel.

Vein

Blood vessels that carry blood back to the heart.

Venules

Extremely small veins.

Vessel Compliance

The ability of any compartment to expand to accommodate increased content. The greater the compliance of an artery, the more effectively it is able to expand to accommodate surges in blood flow without increased resistance or blood pressure.

Viscosity

The thickness of fluids that affects their ability to flow.

 

Test Yourself

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References

Canadian Medical Association. (2018, August). Hematology profile. CMA Specialty Profiles. https://www.cma.ca/sites/default/files/2019-01/hematology-e.pdf

Canadian Society for Medical Laboratory Science. (n.d.). Who are lab professionals. https://www.csmls.org/Medical-Laboratory-Professionals/About/Who-are-Lab-Professionals.aspx

Canadian Society for Vascular Surgery. (2020). Patients: What is vascular surgery? https://canadianvascular.ca/Patients

[CrashCourse]. (2015, July 20). Blood vessels, part 1 - form and function: Crash course A&P #27 [Video]. YouTube. https://youtu.be/v43ej5lCeBo

Sonography Canada. (2020). Credentials. https://sonographycanada.ca/certification/credentials

 

Image Descriptions

Figure 13.1 image description: The left panel shows the structure of a skeletal muscle vein pump when the muscle is relaxed, and the right panel shows the structure of a skeletal muscle vein pump when the muscle is contracted.[Return to Figure 13.1].

Figure 13.2 image description: The top left panel of this figure shows the ultrastructure of an artery (labels read from top: tunica externa, tunica media, tunica intima, smooth muscle, internal esastic membrane, vasa vasorum, external elastic membrane, nervi vasorum, endothelium, elastic fiber), and the top right panel shows the ultrastructure of a vein (labels read from top: tunica exerna, tunica media, tunica intima, vasa vasorum, smooth muscle, endothelium). The bottom panel shows a micrograph with the cross sections of an artery and a vein. [Return to Figure 13.2].

Figure 13.3 image description: The major arteries in the human body. Labels read (from top, clockwise) right common carotid, left common carotid, axillary, pulmonary trunk, descending aorta, diaphragm, renal, superior mesenteric, gonadal, inferior mesenteric, common iliac, internal iliac, deep femoral, femoral, descending genicular, doraslis pedis, plantar arch, fibular, anterior tibial, posterial tibial, popliteal, palmer arches, exernal iliac, ulnar, radial, brachial, celiac trunk, ascending aorta, aortic arch, brachiocephalic trunk, right subclavian, vertebral. [Return to Figure 13.3].

Figure 13.4 image description: The major veins in the human body. Labels read (from top, clockwise) internal jugular, brachiocephalic, superior vena cava, intercostal, inferior vena cava, gonadal, lumbar, right and left common iliac, external iliac, internal iliac, deep femoral, femoral, posterior tibial, anterior tibial, dorsal venous arch, plantar venous arch, fibular, small saphenous, popliteal, great saphenous, digital, palmar venous arches, ulnar, median antebrachial, medial cubital, hepatic, basilic, brachial, cephalic, axillary, subclavian, externa jugular. [Return to Figure 13.4].

Figure 13.5 image description: This diagram shows how oxygenated and deoxygenated blood flow through the major organs in the body. Pulmonary circulation involves the lungs, pulmonary artery and vein, vena cava, and aorta. Systemic circulation involves the upper body, hepatic vein, renal vein, aorta, liver, hepatic artery, hepatic portal vein, stomach, intestines, renal artery, kidneys, and lower body. [Return to Figure 13.5].

Figure 13.6 image description: The pulse points as shown on a woman's body. Labels read (from top) temporal artery, facial artery, common carotid artery, brachial artery, radial artery, femoral artery, popliteal artery, posterior tibial artery, dorsalis pedis artery. [Return to Figure 13.6].

Figure 13.7 image description: This figure shows three test tubes with a red and yellow liquid in them. The left panel shows normal blood, the center panel shows anemic blood and the right panel shows polycythemic blood. Labels indicate plasma (water, proteins, nutrients, hormones etc.), buffy coat (white blood cells, platelets), and hematocrit (red blood cells). [Return to Figure 13.7].

Figure 13.8 image description: This flowchart shows the pathways in which a multipotent hemotopoietic stem cell differentiates into the different cell types found in blood. From the top (multipotent hematopoietic stem cell can divide and some cells remain stem cells, while the remaining cell goes down one of two paths depending on the chemical signals received: myleoid stem cell or lymphoid stem cell. A myeloid stem cell then can become either a megakaryoblast (which then turns into a magakaryocyte, then becomes platelets), or it can become a proerythroblas (which then becomes a reticulocyte, then becoming an erythrocite), or it can become a myeloblast (which then becomes either a basophil, neutrophil, eosinophil), or it can become a monoblast (which then it becomes a monocyte). If the cell becomes a lymphoid stem cell, it then becomes a lymphoblas, which then becomes either a natural killer cell or a small lymphocyte ( either T or B lymphocyte). [Return to Figure 13.8].

Figure 13.11 image description: This figure shows how leukocytes respond to chemical signals from injured cells. The top panel shows chemical signals sent out by the injured cells (text labels read: 1) Leukocytes in the blood respond to chemical attractants released by pathogens and chemical signals from nearby injured cells). The middle panel shows leukocytes migrating to the injured cells (text labels read: 2)the leukocytes squeeze between the capillary wall as they follow the chemical signlas to where they are most concentrated (positive chemotaxis)). The bottom panel shows macrophages phagocytosing the pathogens (text label reads: 3) Within the damaged tissue, monocytes differentiate into macrophages that pgagocytize the pathogens.The eosinophils and neutrophils release chemicals that break apart pathogens. They are also capable of phagocytosis.). [Return to Figure 13.11].

Figure 13.12 image description: This figure details the steps in the clotting of blood. Each step is shown along with a detailed text box describing the steps on the left. On the right, a signaling pathway shows the different chemical signals involved in the clotting process. The steps described: 1. Injury: a blood vessel is severed. Blood and blood components (e.g. erythrocytes, white blood cells, etc.) are leaking out of the breaks. 2. Vascular spasm: the smooth muscle in the vessel wall contracts near the injury point reducing blood loss. 3. Platelet plug formation: platelets are activated by chemicals released from the injury site and by contact with underlying collagen. The platelets become spiked and stick to each other and the wound site. Initial platelets are activated by chemicals released from the injured cells and by contact with broken collagen. Bound platelets release chemicals that activate and attract other platelets. platelets move toward source of chemical signals and bind. Platelet plug grows in size. 4. Coagulation. In coagulation, fibrinogen is converted to fibrin (see part b), which forms a mesh that traps more platelets and erythrocytes, producing a clot. Part B Fibryn synthesis cascade: Intrinsic pathway (damaged vessel wall), Extrinsic pathway (trauma to extravascular cells), final common pathway (cross-linked fibrin clot). [Return to Figure 13.12].

Figure 13.14 image description: This figure shows an umbilical artery and vein passing through the placenta on the top left. The top right panel shows the first exposure to Rh+ antibodies in the mother. The bottom right panel shows the response when the second exposure in the form of another fetus takes place. Textboxes detail the steps in each process: First exposure birth of first Rh+ infant: 1. During birth, Rh+ fetal erythrocytes leak into maternal blood after breakage of the embryonic chorion, which normally isolates the fetal and maternal blood. 2) Maternal B cells are activated by the Rh antigen and produce large amounts of anti-Rh antibodies. Second exposure: Rh+ fetus: 3) Rh antibody titer in mother's blood is elevated after first exposure. 4) Rh antibodies are small enough to cross the embryonic chorion and attach the fetal erythrocites. [Return to Figure 13.14].

Figure 13.16 image description: The left panel (a) shows the cross-section of a normal and a narrowed artery. A normal artery has no plaque along the artery walls which means there is normal blood flow. In a narrow artery, plague forms on the arterial walls causing abnormal blood flow. The right panel (b) shows a micrograph of an artery with plaque in it. [Return to Figure 13.16].

Figure 13.18 image description: This photograph shows red blood cells of a person suffering from sickle cell anemia. Instead of being discoid shaped like healthy blood cells, sickle red blood cells are shaped like a sickle. [Return to Figure 13.18].

Unless otherwise indicated, this chapter contains material adapted from Anatomy and Physiology (on OpenStax), by Betts, et al. and is used under a a CC BY 4.0 international license. Download and access this book for free at https://openstax.org/books/anatomy-and-physiology/pages/1-introduction.

Word Parts for the Lymphatic and Immune Systems

Click on prefixes, combining forms, and suffixes to reveal a list of word parts to memorize for the Lymphatic and Immune Systems.

Introduction to the Lymphatic and Immune Systems

The lymphatic system is a series of vessels, ducts, and trunks that remove interstitial fluid from the tissues and return it the blood. The lymphatic vessels are also used to transport dietary lipids and cells of the immune system. Cells of the immune system, lymphocytes, all come from the hematopoietic system of the bone marrow. Primary lymphoid organs, the bone marrow and thymus gland, are the locations where lymphocytes proliferate and mature. Secondary lymphoid organs are the site in which mature lymphocytes congregate to mount immune responses. Many immune system cells use the lymphatic and circulatory systems for transport throughout the body to search for and then protect against pathogens.

This chapter begins by describing the anatomy and physiology of the lymphatic system, whose immune functions lead us into a discussion of the body’s multifaceted defenses, which together make up the immune system. Since the lymphatic system shares organs with a number of other body systems, the pathology discussed near the end of this chapter mainly focuses on disorders of the immune system.

Watch this video:

A YouTube element has been excluded from this version of the text. You can view it online here: https://ecampusontario.pressbooks.pub/medicalterminology/?p=1563

Media 14.1 Lymphatic System: Crash Course A&P #44 [Online video]. Copyright 2015 by CrashCourse.

Lymphatic and Immune Systems Medical Terms

Anatomy and Physiology of the Lymphatic System

The lymphatic vessels begin as open-ended capillaries, which feed into larger and larger lymphatic vessels, and eventually empty into the bloodstream. Along the way, the lymph travels through the lymph nodes, which are commonly found near the groin, armpits, neck, chest, and abdomen. Humans have about 500–600 lymph nodes throughout the body (see Figure 14.1). Several organs and tissues that participate in immunity are also part of the lymphatic system.

Figure 14.1 Anatomy of the Lymphatic System. Lymphatic vessels in the arms and legs convey lymph to the larger lymphatic vessels in the torso. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Did you know?

Lymphatic vessels and blood vessels are similar in structure and function. Lymph is not actively pumped by the heart, but is forced through the vessels by the movements of the body muscles. (Betts, et al., 2013).

Lymphatic Capillaries

An important function of the lymphatic system is to return the fluid (lymph) to the blood. Lymph may be thought of as recycled blood plasma. Blood pressure causes leakage of fluid from the blood capillaries, resulting in the accumulation of fluid in the interstitial space. In humans, 20 liters of plasma is released into the interstitial space of the tissues each day due to capillary leakage. The blood vessels reabsorb 17 liters of this interstitial fluid, leaving three litres in the tissues for the lymphatic system to transport back to the circulation. If the lymphatic system is damaged in some way, such as by being blocked by cancer cells or destroyed by injury, interstitial fluid accumulates in the tissue spaces, causing a condition called lymphedema.

Lymphatic capillaries, also called the terminal lymphatics, are vessels where interstitial fluid enters the lymphatic system to become lymph. Located in almost every tissue in the body, these vessels are interlaced among the arterioles and venules of the circulatory system in the soft connective tissues of the body. See Figure 14.2. Exceptions are the central nervous system, bone marrow, bones, teeth, and the cornea of the eye, which do not contain lymph vessels.

Figure 14.2 Lymphatic Capillaries. Lymphatic capillaries are interlaced with the arterioles and venules of the cardiovascular system. Collagen fibers anchor a lymphatic capillary in the tissue (inset). Interstitial fluid slips through spaces between the overlapping endothelial cells that compose the lymphatic capillary.From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

 

Larger Lymphatic Vessels, Trunks, and Ducts

The lymphatic capillaries empty into larger lymphatic vessels, which are similar to veins in terms of their three-tunic structure and the presence of valves. These one-way valves are located fairly close to one another, and each one causes a bulge in the lymphatic vessel, giving the vessels a beaded appearance (see Figure 14.2).

In general, superficial lymphatics, follow the same routes as veins, whereas deep lymphatic vessels of the viscera generally follow the paths of arteries. The superficial and deep lymphatics eventually merge to form larger lymphatic structures known as lymphatic trunks. On the right side of the body, the right sides of the head, thorax, and right upper limb trunks drain lymph fluid into the right subclavian vein via the right lymphatic duct (see Figure 14.3). On the left side of the body, the trunks from the remaining portions of the body drain into the larger thoracic duct, which drains into the left subclavian vein. The thoracic duct itself begins just beneath the diaphragm in the cisterna chyli.

Figure 14.3 Major Trunks and Ducts of the Lymphatic System. The thoracic duct drains a much larger portion of the body than does the right lymphatic duct. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Primary Lymphoid Organs

The primary lymphoid organs are the bone marrow and thymus gland. The lymphoid organs are where lymphocytes mature, proliferate, and are selected, which enables them to attack pathogens without harming the cells of the body.

• Bone Marrow
  • Recall that all blood cells, including lymphocytes, are formed in the red bone marrow.  The B cell undergoes nearly all of its development in the red bone marrow, whereas the immature T cell, called a thymocyte, leaves the bone marrow and matures largely in the thymus gland.

• Thymus
  • The thymus gland, where T cells mature, is a bilobed organ found in the space between the sternum and the aorta of the heart (see Figure 14.4). Connective tissue holds the lobes closely together but also separates them and forms a capsule.
  • The loss of immune function with age is called immunosenescence. One major cause of age-related immune deficiencies is thymic involution.
    • The shrinking of the thymus gland begins at birth at a rate of about three percent tissue loss per year.  This shrinking continues until 35–45 years of age then the rate declines to about one percent loss per year for the rest of one’s life. At that pace, the total loss of thymic epithelial tissue and thymocytes would occur at about 120 years of age. So, in theory, 120 years could be the maximum life span.

Figure 14.4 Location, Structure, and Histology of the Thymus. The thymus lies above the heart. The trabeculae and lobules, including the darkly staining cortex and the lighter staining medulla of each lobule, are clearly visible in the light micrograph of the thymus of a newborn. LM × 100. (Micrograph provided by the Regents of the University of Michigan Medical School © 2012). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Concept Check

• Do you remember what the suffix “-oid” means?
• Can you explain the term lymphoid?

Did You Know?

The thymus gland produces a hormone called thymosin and is therefore also considered to be part of the endocrine system.

 

 Secondary Lymphoid Organs

Lymphocytes develop and mature in the primary lymphoid organs, but they mount immune responses from the secondary lymphoid organs, which include the lymph nodes, spleen, and lymphoid nodules. A naïve lymphocyte is one that has left the primary organ, where it learned to function immunologically, and entered a secondary lymphoid organ where it waits to encounter an antigen against which it will mount a response (see Figure 14.5).

Figure 14.5 Clonal Selection and Expansion of T Lymphocytes. Stem cells differentiate into T cells with specific receptors, called clones. The clones with receptors specific for antigens on the pathogen are selected for and expanded. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Lymph Nodes

Lymph nodes function to remove debris and pathogens from the lymph, and are thus sometimes referred to as the “filters of the lymph” (see Figure 14.6). Any bacteria that infect the interstitial fluid are taken up by the lymphatic capillaries and transported to a regional lymph node. Dendritic cells and macrophages within this organ internalize and kill many of the pathogens that pass through, thereby removing them from the body. The lymph node is also the site of adaptive immune responses mediated by T cells, B cells, and accessory cells of the adaptive immune system.

Figure 14.6 Structure and Histology of a Lymph Node. Lymph nodes are masses of lymphatic tissue located along the larger lymph vessels. The micrograph of the lymph nodes shows a germinal center, which consists of rapidly dividing B cells surrounded by a layer of T cells and other accessory cells. LM × 128. (Micrograph provided by the Regents of the University of Michigan Medical School © 2012). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Did You Know?

You can live without your spleen. Do you remember the term for “surgical removal of the spleen”?

Spleen

The spleen is a vascular organ that is somewhat fragile due to the absence of a capsule. It is about 12 cm long and is attached to the lateral border of the stomach. The spleen is sometimes called the “filter of the blood” because of its extensive vascularization and the presence of macrophages and dendritic cells that remove microbes and other materials from the blood, including dying red blood cells. The spleen also functions as the location of immune responses to blood-borne pathogens.

Figure 14.7 Spleen. (a) The spleen is attached to the stomach. (b) A micrograph of spleen tissue shows the germinal center. The marginal zone is the region between the red pulp and white pulp, which sequesters particulate antigens from the circulation and presents these antigens to lymphocytes in the white pulp. EM × 660. (Micrograph provided by the Regents of the University of Michigan Medical School © 2012). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Lymphoid Nodules

The other lymphoid tissues, the lymphoid nodules, consist of a dense cluster of lymphocytes without a surrounding fibrous capsule. These nodules are located in the respiratory and digestive tracts, areas routinely exposed to environmental pathogens.

Tonsils are lymphoid nodules located along the inner surface of the pharynx and are important in developing immunity to oral pathogens (see Figure 14.8). The tonsil located at the back of the throat, the pharyngeal tonsil, is sometimes referred to as the adenoid when swollen. Such swelling is an indication of an active immune response to infection. Tonsils have deep grooves called crypts, which accumulate all sorts of materials taken into the body through eating and breathing and actually “encourage” pathogens to penetrate deep into the tonsillar tissues where they are eliminated. A major function of tonsils is to help children’s bodies recognize, destroy, and develop immunity to common environmental pathogens so that they will be protected in their later lives. Tonsils are often removed in children who have recurring throat infections since swollen palatine tonsils can interfere with breathing and/or swallowing.

Figure 14.8. Locations and Histology of the Tonsils. (a) The pharyngeal tonsil is located on the roof of the posterior superior wall of the nasopharynx. The palatine tonsils lay on each side of the pharynx. (b) A micrograph shows the palatine tonsil tissue. LM × 40. (Micrograph provided by the Regents of the University of Michigan Medical School © 2012). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Concept Check

Tonsils are named after their locations.

• Look at the figure above and determine which anatomical structure is closely associated with each set of tonsils and was therefore used to name the tonsils, for example, the lingual tonsils are named after the tongue (lingula).
• Can you tell which structures were used to name the palatine tonsils and the pharyngeal tonsils?

Bronchus-associated lymphoid tissue (BALT) consists of lymphoid follicular structures with an overlying epithelial layer found along the bifurcations of the bronchi, and between bronchi and arteries. These tissues, in addition to the tonsils, are effective against inhaled pathogens.

Mucosa-associated lymphoid tissue (MALT) consists of an aggregate of lymphoid follicles directly associated with mucous membrane. MALT makes up dome-shaped structures found underlying the mucosa of the gastrointestinal tract, breast tissue, lungs, and eyes. Peyer’s patches, a type of MALT in the small intestine, are especially important for immune responses against ingested substances (see Figure `14.9). Peyer’s patches contain specialized cells that sample material from the intestinal lumen and transport it to nearby follicles so that adaptive immune responses to potential pathogens can be mounted.

Figure 14.9 Mucosa-associated Lymphoid Tissue (MALT) Nodule. LM × 40. (Micrograph provided by the Regents of the University of Michigan Medical School © 2012). From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

The Organization of the Immune System

The immune system is a collection of barriers, cells, and soluble proteins that interact and communicate with each other in extraordinarily complex ways. The modern model of immune function is organized into a three phases immune response (based on the timing of their effects). Ideally, this response will rid the body of a pathogen entirely (see Figure 14.10).

Think of a primary infection as a race between the pathogen and the immune system:

1. The pathogen bypasses Barrier defenses and starts to multiply in the host’s body.
2. During the first 4 to 5 days, the innate immune response will partially control, but not stop the pathogen growth.
3. The slower but more specific and effective adaptive immune response gears up and becomes progressively stronger, it will begin to clear the pathogen from the body. This clearance is referred to as seroconversion. It should be noted that seroconversion does not necessarily mean a patient is getting well.

Figure 14.10 Cooperation between Innate and Adaptive Immune Responses. The innate immune system enhances adaptive immune responses so they can be more effective. From Betts, et al., 2013. Licensed under CC BY 4.0.

Phase 1: Barrier Defenses

Barrier defenses are part of the body’s most basic innate defense mechanisms. They are not a response to infections, but rather are continuously working to protect against pathogens by preventing them from entering the body, destroying them after they enter, or flushing them out before they can establish themselves.

Barrier defenses examples:

• Skin:
  • Keratinized cells of the surface are too dry for bacteria to grow are continuously sloughed off, along with pathogens that are on their surfaces.
• Skin (sweat glands, sebaceous glands):
  • Lower pH than pathogens prefer, may contain substances that are toxic to pathogens, washing action.
• Oral Cavity (salivary glands):
  • Lysozyme is an enxyme that destroys bacteria.
• Stomach:
  • LowpH which is fatal to many pathogens.
• Mucosal:
  • Traps both microbes and debris, and facilitates their removal.
• Normal flora (nonpathogenic bacteria):
  • Prevents pathogens from growing on mucosal surfaces.

Phase 2: Innate Immune Response

Innate immune responses are critical to the early control of infections. Whereas barrier defenses are the body’s first line of physical defense against pathogens, innate immune responses are the first line of physiological defense. Innate responses occur rapidly, but with less specificity and effectiveness than the adaptive immune response. Within the first few days of an infection, a series of antibacterial proteins are induced, each with activities against certain bacteria. Additionally, interferons are induced that protect cells from viruses in their vicinity. Finally, the innate immune response does not stop when the adaptive immune response is developed. In fact, both can cooperate and one can influence the other in their responses against pathogens.

Innate immune responses (and early induced responses) are in many cases ineffective at completely controlling pathogen growth but they slow pathogen growth and allow time for the adaptive immune response to strengthen and either control or eliminate the pathogen. The innate immune system also sends signals to the cells of the adaptive immune system, guiding them in how to attack the pathogen.

Watch this video:

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Media 14.2 Immune System, Part 1: Crash Course A&P #45 [Online video]. Copyright 2015 by CrashCourse.

Cells of the Innate Immune Response

Phagocytes: Macrophages and Neutrophils

A phagocyte is a cell that is able to surround and engulf a particle or cell, a process called phagocytosis. The phagocytes of the immune system engulf other particles or cells, either to clean an area of debris, old cells, or to kill pathogenic organisms such as bacteria. Macrophages, neutrophils, and dendritic cells are the major phagocytes of the immune system and are the body’s fast acting, front line immunological defense against organisms that have breached barrier defenses and have entered the body.

Macrophages not only participate in innate immune responses but have also evolved to cooperate with lymphocytes as part of the adaptive immune response. Macrophages exist in many tissues of the body, either freely roaming through connective tissues or fixed to reticular fibers within specific tissues such as lymph nodes. When pathogens breach the body’s barrier defenses, macrophages are the first line of defense.

A neutrophil is a phagocytic cell that is attracted via chemotaxis from the bloodstream to infected tissues. contains cytoplasmic granules, which in turn contain a variety of vasoactive mediators such as histamine. Whereas macrophages act like sentries, always on guard against infection, neutrophils can be thought of as military reinforcements that are called into a battle to hasten the destruction of the enemy.

A monocyte is a circulating precursor cell that differentiates into either a macrophage or dendritic cell, which can be rapidly attracted to areas of infection by signal molecules of inflammation.

Natural Killer Cells

NK cells are a type of lymphocyte that have the ability to induce apoptosis in cells infected with pathogens such as intracellular bacteria and viruses. If apoptosis is induced before the virus has the ability to synthesize and assemble all its components, no infectious virus will be released from the cell, thus preventing further infection.

Soluble Mediators of the Innate Immune Response

 The previous discussions have alluded to chemical signals that can induce cells to change various physiological characteristics, such as the expression of a particular receptor. These soluble factors are secreted during innate or early induced responses, and later during adaptive immune responses.

Concept Check

Do you know the difference between these terms?

• Intercellular
• Intracellular
• Interstitial

Cytokines and Chemokines

A cytokine is signaling molecule that allows cells to communicate with each other over short distances. Cytokines are secreted into the intercellular space, and the action of the cytokine induces the receiving cell to change its physiology. A chemokine is a soluble chemical mediator similar to cytokines except that its function is to attract cells (chemotaxis) from longer distances.

Early Induced Proteins

Early induced proteins are those that are not constitutively present in the body, but are made as they are needed early during the innate immune response. Interferons are an example of early induced proteins. Cells infected with viruses secrete interferons that travel to adjacent cells and induce them to make antiviral proteins. Thus, even though the initial cell is sacrificed, the surrounding cells are protected.

Inflammatory Response

The hallmark of the innate immune response is inflammation. Stub a toe, cut a finger, or do any activity that causes tissue damage and inflammation will result, with its four characteristics: heat, redness, pain, and swelling (“loss of function” is sometimes mentioned as a fifth characteristic). It is important to note that inflammation does not have to be initiated by an infection, but can also be caused by tissue injuries. The release of damaged cellular contents into the site of injury is enough to stimulate the response, even in the absence of breaks in physical barriers that would allow pathogens to enter (by hitting your thumb with a hammer, for example). The inflammatory reaction brings in phagocytic cells to the damaged area to clear cellular debris and encourages the entry of clotting factors to set the stage for wound repair. Inflammation also facilitates the transport of antigen to lymph nodes by dendritic cells for the development of the adaptive immune response.

Figure 14.11 Inflammatory Response. From Betts, et al., 2013. Licensed under CC BY 4.0.

The above image summarizes the following events in the inflammatory response:

• • The released contents of injured cells stimulate the release of substances from mast cells including histamine, leukotrienes, and prostaglandins.

• • Histamine increases blood flow to the area by vasodilation, resulting in heat and redness. Histamine also increases the permeability of local capillaries, causing plasma to leak out and form interstitial fluid, resulting in swelling

• • Leukotrienes attract neutrophils from the blood by chemotaxis.
    When local infections are severe, neutrophils are attracted to the sites of infections in large numbers, and as they phagocytose the pathogens and subsequently die, their accumulated cellular remains are visible as pus at the infection site.

• • Prostaglandins cause vasodilation by relaxing vascular smooth muscle and are a major cause of the pain associated with inflammation. Nonsteroidal anti-inflammatory drugs such as aspirin and ibuprofen relieve pain by inhibiting prostaglandin production.

Concept Check

• Do you remember the suffix used to describe ‘inflammation’?
• Describe what causes the pain associated with inflammation.

Acute inflammation is a short-term innate immune response to an insult to the body. If the cause of the inflammation is not resolved, however, it can lead to chronic inflammation, which is associated with major tissue destruction and fibrosis.

Phase 3: Adaptive Immune Response

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Media 14.3 Immune System, Part 2: Crash Course A&P #46 [Online video]. Copyright 2015 by CrashCourse.

Benefits of the Adaptive Immune Response

• Specificity
  • The ability to specifically recognize and mount a response against almost any pathogen.
  • Antigens, are recognized by receptors on the surface of B and T lymphocytes.

• Immunological Memory
  • The first exposure to a pathogen is called a primary adaptive response.
  • Symptoms of a first infection, called primary disease, are always relatively severe because it takes time for an initial adaptive immune response to a pathogen to become effective.
  • Upon re-exposure to the same pathogen, a secondary adaptive immune response is generated, which is stronger and faster that the primary response, often eliminating the pathogen before it can cause damage or even symptoms.
  • This secondary response is the basis of immunological memory, which gives us immunity.

Figure 14.12 Primary and Secondary Antibody Responses. Antigen A is given once to generate a primary response and later to generate a secondary response. When a different antigen is given for the first time, a new primary response is made. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

• Self Recognition
  • The ability to distinguish between self-antigens, those that are normally present in the body, and foreign antigens, those that might be on a potential pathogen.
  • As T and B cells mature, there are mechanisms in place that prevent them from recognizing self-antigen, preventing a damaging immune response against the body. When these mechanisms fail, their breakdown leads to autoimmune diseases.

Lymphocytes: B Cells, T Cells, Plasma Cells

As stated above, lymphocytes are the primary cells of adaptive immune responses. These cells were introduced in the previous chapter and are summarized in the following table:

Table 14.1 Cells of the Adaptive Immune Response. From Betts, et al., 2013. Licensed under CC BY 4.0.

CELL TYPE	DESCRIPTION AND DETAILS
Plasma Cell	B cell (lymphocyte) that has been activated through exposure to an antigen and produces antibodies against that antigen (see the figure below) There are 5 classes of antibodies (IgM, IgG, IgE, IgA, IgD), each functioning in different ways: IgM promotes chemotaxis, opsonization, and cell lysis, making it a very effective antibody against bacteria at early stages of a primary antibody response IgG is the one that crosses the placenta to protect the developing fetus from disease and exits the blood to the interstitial fluid to fight extracellular pathogens IgA is the only antibody to leave the interior of the body to protect body surfaces. IgA is also of importance to newborns, because this antibody is present in mother’s breast milk (colostrum), which serves to protect the infant IgE is associated with allergies and anaphylaxis
T Cell	Different T cell types have the ability to either secrete soluble factors that communicate with other cells of the adaptive immune response or destroy cells infected with intracellular pathogen Cytotoxic T Cell (Tc) kill target cells by inducing apoptosis using the same mechanism as NK cells: killing a virally infected cell before the virus can complete its replication cycle results in the production of no infectious particles Helper T Cell (Th) release cytokines, which help to develop and regulate other immune system cells Suppressor T Cell (also called regulatory T cell) control T Cell response, in order to prevent too many T cells from being formed during an immune repsonse
Memory Cell	B cells and T cells formed during primary exposure to a pathogen (see the figure below) Remain in the body for a long time after an infection and are able to mount a fast and effective immune response to a pathogen if it is encountered a second time, preventing the pathogen from causing disease

Figure 14.13 Clonal Selection of B Cells. During a primary B cell immune response, both antibody-secreting plasma cells and memory B cells are produced. These memory cells lead to the differentiation of more plasma cells and memory B cells during secondary responses. From Betts, et al., 2013. Licensed under CC BY 4.0. [Image description.]

Active Versus Passive Immunity

Immunity to pathogens, and the ability to control pathogen growth so that damage to the tissues of the body is limited, can be acquired by:

1. The active development of an immune response in the infected individual.
   or
2. The passive transfer of immune components from an immune individual to a non-immune one.

The downside to this passive immunity is the lack of the development of immunological memory. Once the antibodies are transferred, they are effective for only a limited time before they degrade.

Table 14.2 Active Versus Passive Immunity. From Betts, et al., 2013. Licensed under CC BY 4.0.

IMMUNITY	NATURAL	ARTIFICIAL
Active: resistance to pathogens acquired during an adaptive immune response	Result of memory cells formed during the adaptive immune response to a pathogen	Vaccine response. Through vaccination, one avoids the disease that results from the first exposure to the pathogen, yet reaps the benefits of protection from immunological memory.  Vaccination was one of the major medical advances of the twentieth century and led to the eradication of smallpox and the control of many infectious diseases, including polio, measles, and whooping cough
Passive: transfer of antibodies from an immune person to a nonimmune person	Trans-placental antibodies from mother to fetus and maternal antibodies in breast milk protect newborn from infections	Immunoglobulin injections taken from animals previously exposed to a specific pathogen; a fast-acting method of temporarily protecting an individual who was possibly exposed to a pathogen

Evasion of the Immune System by Pathogens

The immune system and pathogens are in a slow, evolutionary race to see who stays on top. Early childhood is a time when the body develops much of its immunological memory that protects it from diseases in adulthood. Pathogens have shown the ability, however, to evade the body’s immune responses, as described below.

• • Protective adaptations: It is important to keep in mind that although the immune system has evolved to be able to control many pathogens, pathogens themselves have evolved ways to evade the immune response. An example is in Mycobactrium tuberculosis, which has evolved a complex cell wall that is resistant to the digestive enzymes of the macrophages that ingest them, and thus persists in the host, causing the chronic disease tuberculosis.

• • Multiple strains: Bacteria sometimes evade immune responses because they exist in multiple strains, each having different surface antigens and requiring individual adaptive immune responses. One example is a small group of strains of S. aureus, called methicillin-resistant Staphylococcus aureus (MRSA), which has become resistant to multiple antibiotics..

• • Antigen mutation: Because viruses’ surface molecules mutate continuously, viruses like influenza change enough each year that the flu vaccine for one year may not protect against the flu common to the next. New vaccine formulations must be derived for each flu season.

• • Genetic recombination: An example is the influenza virus, which contains gene segments that can recombine when two different viruses infect the same cell. Recombination between human and pig influenza viruses led to the 2010 H1N1 swine flu outbreak.

• • Immunosuppression: Pathogens, especially viruses, can produce immunosuppressive molecules that impair immune function.

Tissue Transplantation

With the use of tissue typing and anti-rejection drugs, transplantation of organs and the control of the anti-transplant immune response have made huge strides in the past 50 years. 

Immunosuppressive drugs such as cyclosporine A have made transplants more successful, but tissue matching is still key. Family members, since they share a similar genetic background, are much more likely to share MHC molecules than unrelated individuals do.

One disease of transplantation occurs with bone marrow transplants, which are used to treat various diseases, including SCID and leukemia. Because the bone marrow cells being transplanted contain lymphocytes capable of mounting an immune response, and because the recipient’s immune response has been destroyed before receiving the transplant, the donor cells may attack the recipient tissues, causing graft-versus-host disease. Symptoms of this disease, which usually include a rash and damage to the liver and mucosa, are variable, and attempts have been made to moderate the disease by first removing mature T cells from the donor bone marrow before transplanting it.

Immune Responses Against Cancer

It is clear that with some cancers, like Kaposi’s sarcoma (see Figure 14.14), for example, that a healthy immune system does a good job at controlling them. This disease, which is caused by the human herpes virus, is almost never observed in individuals with strong immune systems. Other examples of cancers caused by viruses include liver cancer caused by the hepatitis B virus and cervical cancer caused by the human papilloma virus. As these last two viruses have vaccines available for them, getting vaccinated can help prevent these two types of cancer by stimulating the immune response.

Figure 14.14 Karposi’s Sarcoma Lesions. (credit: National Cancer Institute). From Betts, et al., 2013. Licensed under CC BY 4.0.

On the other hand, as cancer cells are often able to divide and mutate rapidly, they may escape the immune response, just as certain pathogens such as HIV do.

There are three stages in the immune response to many cancers:

1. 1. Elimination occurs when the immune response first develops toward tumor-specific antigens specific to the cancer and actively kills most cancer cells.
   2. Equilibrium is the period that follows, during which the remaining cancer cells are held in check.
   3. Escape of the immune response, and resulting disease, occurs because many cancers mutate and no longer express any specific antigens for the immune system to respond to.

This fact has led to extensive research in trying to develop ways to enhance the early immune response to completely eliminate the early cancer and thus prevent a later escape. One method that has shown some success is the use of cancer vaccines. These differ from other vaccines in that they are directed against the cells of one’s own body. Treated cancer cells are injected into cancer patients to enhance their anti-cancer immune response and thereby prolong survival. The immune system has the capability to detect these cancer cells and proliferate faster than the cancer cells do, thus overwhelming the cancer in a similar way as they do for viruses. Cancer vaccines are being developed for malignant melanoma and renal (kidney) cell carcinoma.

Immune Responses and Stress

In order to protect the entire body from infection, the immune system is required to interact with other organ systems, sometimes in complex ways. For example, hormones such as cortisol (naturally produced by the adrenal cortex) and prednisone (synthetic) are well known for their abilities to suppress T cell immune mechanisms, hence, their prominent use in medicine as long-term, anti-inflammatory drugs.

One well-established interaction of the immune, nervous, and endocrine systems is the effect of stress on immune health. In the human vertebrate evolutionary past, stress was associated with the fight-or-flight response, largely mediated by the central nervous system and the adrenal medulla. This stress was necessary for survival since fighting or fleeing usually resolved the problem in one way or another. It has been found that short-term stress diverts the body’s resources towards enhancing innate immune responses. This has the ability to act fast and would seem to help the body prepare better for possible infections associated with the trauma that may result from a fight-or-flight exchange.

On the other hand, there are no physical actions to resolve most modern day stresses, including short-term stressors like taking examinations and long-term stressors such as being unemployed or losing a spouse. The effect of stress can be felt by nearly every organ system, and the immune system is no exception (see Table 14.3). Chronic stress, unlike short-term stress, may inhibit immune responses even in otherwise healthy adults. The suppression of both innate and adaptive immune responses is clearly associated with increases in some diseases.

Table 14.3 Effects of Stress on Body Systems. From Betts, et al., 2013. Licensed under CC BY 4.0.

SYSTEM	STRESS-RELATED ILLNESS
Integumentary system	Acne, skin rashes, irritation
Nervous system	Headaches, depression, anxiety, irritability, loss of appetite, lack of motivation, reduced mental performance
Muscular and skeletal systems	Muscle and joint pain, neck and shoulder pain
Circulatory system	Increased heart rate, hypertension, increased probability of heart attacks
Digestive system	Indigestion, heartburn, stomach pain, nausea, diarrhea, constipation, weight gain or loss
Immune system	Depressed ability to fight infections
Male reproductive system	Lowered sperm production, impotence, reduced sexual desire
Female reproductive system	Irregular menstrual cycle, reduced sexual desire

Anatomy Labeling Activity

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Medical Terms not Easily Broken into Word Parts

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Lymphatic and Immune System Abbreviations

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Diseases and Disorders of the Lymphatic and Immune Systems

The immune response can be under-reactive or over-reactive, leading to a state of disease. The factors that maintain immunological homeostasis are complex and incompletely understood.

Underactive Immune System: Immunodeficiencies

Suppressed immunity can result from inherited genetic defects or by acquiring viruses (Betts, et al., 2013).

Inherited Immunodeficiencies/SCID

While many inherited immunodeficiencies exist, the most serious is severe combined immunodeficiency disease (SCID). This complex disease is caused by many different genetic defects which result in impaired B cell and T cell arms of the adaptive immune response. Children with this disease usually die of opportunistic infections within their first year of life unless they receive a bone marrow transplant. Such a procedure had not yet been perfected for David Vetter, the “boy in the bubble,” who was treated for SCID by having to live in a sterile plastic cocoon for the 12 years before his death from infection in 1984. One of the features that make bone marrow transplants work as well as they do is the proliferative capability of hematopoietic stem cells of the bone marrow. Only a small amount of bone marrow from a healthy donor is given intravenously to the recipient. It finds its own way to the bone where it populates it, eventually reconstituting the patient’s immune system, which is usually destroyed beforehand by treatment with radiation or chemotherapeutic drugs (Betts, et al., 2013).

New treatments for SCID using gene therapy, inserting nondefective genes into cells taken from the patient and giving them back, have the advantage of not needing the tissue match required for standard transplants. Although not a standard treatment, this approach holds promise, especially for those in whom standard bone marrow transplantation has failed (Betts, et al., 2013).

Acquired Immunodeficiency/HIV and AIDS

 Although many viruses cause suppression of the immune system, only HIV wipes it out completely. HIV is transmitted through semen, vaginal fluids, and blood, and can be caught by risky sexual behaviors and the sharing of needles by intravenous drug users. There are sometimes, but not always, flu-like symptoms in the first 1 to 2 weeks after infection. The presence of anti-HIV antibodies indicates a positive HIV test. Because seroconversion takes different lengths of time in different individuals, multiple HIV tests are given months apart to confirm or eliminate the possibility of infection.

After seroconversion, the amount of virus circulating in the blood drops and stays at a low level for several years. During this time, the levels of CD4 T cells decline steadily, until at some point, the immune response is so weak that opportunistic disease and eventually death result.

Treatment for the disease consists of drugs that target virally encoded proteins that are necessary for viral replication but are absent from normal human cells. By targeting the virus itself and sparing the cells, this approach has been successful in significantly prolonging the lives of HIV-positive individuals (Betts, et al., 2013).

Overactive Immune System: Hypersensitivities and Autoimmune Diseases

Hypersensitivities

Over-reactive immune responses include the hypersensitivities: allergies and inflammatory responses to nonpathogenic environmental substances (Betts, et al., 2013). The table below compares different hypersensitivities.

Table 14.4 Table Summarizing Types of Hypersensitivities. From Betts, et al., 2013. Licensed under CC BY 4.0.

TYPE OF HYPERSENSITIVITY	DETAILS AND EXPLANATION
Type I	Allergies and allergic asthma Major symptoms of inhaled allergens are the nasal edema and runny nose caused by the increased vascular permeability and increased blood flow of nasal blood vessels ‘Immediate Hypersensitivity’: usually rapid and occur within just a few minutes Mild allergies are usually treated with antihistamines Severe allergies that may cause anaphylactic shock, which can be fatal within 20 to 30 minutes if untreated; epinephrine raises blood pressure and relaxes bronchial smooth muscle and is routinely used to counteract the effects of anaphylactic shock
Type II	Occurs during mismatched blood transfusions and blood compatibility diseases such as erythroblastosis fetalis
Type III	Occurs with diseases such as systemic lupus erythematosus
Type IV	‘Delayed hypersensitivity’-takes 24-72 hours to develop A standard cellular immune response in which the first exposure to an antigen is called sensitization, such that on re-exposure, an immune response results The classical test for delayed hypersensitivity is the tuberculin test for tuberculosis, where bacterial proteins from M. tuberculosis are injected into the skin. A couple of days later, a positive test, as indicated by an induration, means that the patient has been exposed to the bacteria and exhibits a cellular immune response to it Another type of delayed hypersensitivity is contact sensitivity, where substances such as the metal nickel cause a red and swollen area upon contact with the skin in an individual who was previously sensitized to the metal.

Autoimmune Responses

The worst cases of the immune system over-reacting are autoimmune diseases in which the immune systems begin to attack cells of the patient’s own body, causing chronic inflammation and significant damage. The trigger for these diseases is often unknown, although environmental and genetic factors are likely involved. Treatments are usually based on resolving the symptoms using immunosuppressive and anti-inflammatory drugs. Figure 14.15 below provides two examples of autoimmune diseases: rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) (Betts, et al., 2013).

Figure 14.15 Autoimmune Disorders: Rheumatoid Arthritis and Lupus. (a) Extensive damage to the right hand of a rheumatoid arthritis sufferer is shown in the x-ray. (b) The diagram shows a variety of possible symptoms of systemic lupus erythematosus.  From Betts, et al., 2013. Licensed under CC BY 4.0.. [Image description.]

Overall, there are more than 80 different autoimmune diseases, which are a significant health problem in the elderly. Table 14.5 below lists several of the most common autoimmune diseases, the antigens that are targeted (autoantigen or “self” antigen), and the resulting tissue damage (Betts, et al., 2013).

Table 14.5 Autoimmune Diseases. From Betts, et al., 2013. Licensed under CC BY 4.0.

DISEASE	AUTOANTIGEN	SYMPTOMS
Celiac disease	Tissue transglutaminase	Damage to small intestine
Diabetes mellitus type I	Beta cells of pancreas	Low insulin production; inability to regulate serum glucose
Graves’ disease	Thyroid-stimulating hormone receptor (antibody blocks receptor)	Hyperthyroidism
Hashimoto’s thyroiditis	Thyroid-stimulating hormone receptor (antibody mimics hormone and stimulates receptor)	Hypothyroidism
Lupus erythematosus	Nuclear DNA and proteins	Damage of many body systems
Myasthenia gravis	Acetylcholine receptor in neuromuscular junctions	Debilitating muscle weakness
Rheumatoid arthritis	Joint capsule antigens	Chronic inflammation of joints

Lymphoma

Lymphoma was briefly discussed in the previous chapter.

Medical Terms in Context

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Medical Specialties and Procedures Related to the Lymphatic and Immune Systems

Clinical Immunology/Allergy is a medical specialty that diagnoses and treats diseases of the immune system (Canadian Medical Association, 2018). For more information, please visit the Canadian Medical Association Specialty Profiles Clinical Immunology page (PDF File).

Skin testing (for allergies) is done by a clinical immunologist/allergist to identify allergens in Type I hypersensitivity. In skin testing, allergen extracts are injected into the epidermis, and a positive result of the wheal and flare response usually occurs within 30 minutes. The soft center is due to fluid leaking from the blood vessels and the redness is caused by the increased blood flow to the area that results from the dilation of local blood vessels at the site (Betts, et al., 2013).

Lymphatic System and Immune System Vocabulary

Active immunity

Immunity developed from an individual’s own immune system.

Acute inflammation

Inflammation occurring for a limited time period; rapidly developing.

Adaptive immune response

Relatively slow but very specific and effective immune response controlled by lymphocytes.

Afferent lymphatic vessels

Lead into a lymph node.

Allergens

Antigens that evoke type 1 hypersensitivity (allergy) responses.

Anaphylactic Shock

Also called anaphylaxis. An inhaled, ingested or injected (bee sting) allergen causes a significant drop in blood pressure along with contractions of smooth muscles of the airways.

Antibody

Antigen-specific protein secreted by plasma cells, immunoglobulin.

Antigen

Molecule recognized by the receptors of b and t lymphocytes.

Apoptosis

Programmed cell death.

B cells

Lymphocytes that act by differentiating into an antibody-secreting plasma cell.

Barrier defenses

Antipathogen defenses deriving from a barrier that physically prevents pathogens from entering the body to establish an infection.

Bone marrow

Tissue found inside bones, the site of all blood cell differentiation and maturation of b lymphocytes.

Bronchus-associated lymphoid tissue (balt)

Lymphoid nodule associated with the respiratory tract.

CD4 T Cells

CD4 is the receptor that HIV uses to get inside T cells and reproduce. CD4+ helper T cells play an important role in T cell immune responses and antibody responses.

Chemokine

Soluble, long-range, cell-to-cell communication molecule.

Chemotaxis

Movement in response to chemicals; a phenomenon in which injured or infected cells and nearby leukocytes emit the equivalent of a chemical “911” call, attracting more leukocytes to the site.

Chronic inflammation

Inflammation occurring for long periods of time.

Chyle

Lipid-rich lymph inside the lymphatic capillaries of the small intestine.

Cisterna chyli

Bag-like vessel that forms the beginning of the thoracic duct.

Complement

Enzymatic cascade of constitutive blood proteins that have antipathogen effects, including the direct killing of bacteria.

Crypts

Histologically, tonsils do not contain a complete capsule, and the epithelial layer invaginates deeply into the interior of the tonsil to form tonsillar crypts.

Cytokine

Soluble, short-range, cell-to-cell communication molecule.

Deep Lymphatic Vessels

Lymphatic vessels of the organs.

Efferent lymphatic vessels

Lead out of a lymph node.

Erythroblastosis fetalis

Disease of rh factor-positive newborns in rh-negative mothers with multiple rh-positive children; resulting from the action of maternal antibodies against fetal blood.

Genetic mutation that affects both t cell and b cell arms of the immune response.

Genetic Recombination

The combining of gene segments from two different pathogens.

Graft-versus-host disease

In bone marrow transplants, occurs when the transplanted cells mount an immune response against the recipient.

Histamine

Vasoactive mediator in granules of mast cells and is the primary cause of allergies and anaphylactic shock.

HIV

Human Immunodeficiency Virus. An infectious disease usually transmitted via blood or sexual fluids. It attacks the immune system and can lead to AIDS.

Hypersensitivities

Reacting to something that would not normally evoke a reaction.

Immune system

Series of barriers, cells, and soluble mediators that combine to response to infections of the body with pathogenic organisms.

Immunity

After an infection, memory cells remain in the body for a long time and can very quickly mount an immune response against the same pathogen if it tries to re-infect. This protects us from getting diseases from the same pathogen over again.

Immunological memory

Ability of the adaptive immune response to mount a stronger and faster immune response upon re-exposure to a pathogen.

Induration

A firm, raised reddened patch of skin.

Inflammation

Basic innate immune response characterized by heat, redness, pain, and swelling.

Innate immune response

Rapid but relatively nonspecific immune response.

Intercellular

Between cells.

Interferons

Early induced proteins made in virally infected cells that cause nearby cells to make antiviral proteins.

Interstitial Fluid

Fluid that has leaked out of blood capillaries into the tissue spaces.

Interstitial

Between cells of the tissues, often used interchangeably with ‘intercellular’.

Interstitial Space

Spaces between individual cells in the tissues.

Intracellular

Inside the cell membrane or within the cell.

Leukemia

A cancer involving an abundance of leukocytes. It may involve only one specific type of leukocyte from either the myeloid line (myelocytic leukemia) or the lymphoid line (lymphocytic leukemia). In chronic leukemia, mature leukocytes accumulate and fail to die. In acute leukemia, there is an overproduction of young, immature leukocytes. In both conditions the cells do not function properly.

Lymph

Fluid contained within the lymphatic system.

Lymph node

One of the bean-shaped organs found associated with the lymphatic vessels.

Lymphatic capillaries

Smallest of the lymphatic vessels and the origin of lymph flow.

Lymphatic system

Network of lymphatic vessels, lymph nodes, and ducts that carries lymph from the tissues and back to the bloodstream.

Lymphatic trunks

Large lymphatics that collect lymph from smaller lymphatic vessels and empties into the blood via lymphatic ducts.

Lymphocytes

White blood cells characterized by a large nucleus and small rim of cytoplasm.

Lymphoid nodules

Unencapsulated patches of lymphoid tissue found throughout the body.

Lymphoma

A form of cancer in which masses of malignant T and/or B lymphocytes collect in lymph nodes, the spleen, the liver, and other tissues. These leukocytes do not function properly, and the patient is vulnerable to infection.

Macrophage

Ameboid phagocyte found in several tissues throughout the body.

Mast cell

Cell found in the skin and the lining of body cells that contains cytoplasmic granules with vasoactive mediators such as histamine.

Memory t cells

Long-lived immune cell reserved for future exposure to an pathogen.

MHC

Major Histocompatibility Complex molecules, also called Human Leukocyte Antigen (HLA) are protein structures found on the outside of cells that help the immune system recognize non-self antigens.

Monocyte

Precursor to macrophages and dendritic cells seen in the blood.

Mucosa-associated lymphoid tissue (malt)

Lymphoid nodule associated with the mucosa.

Mucosal

Mucous membranes line body cavities that open to the outside world, including the respiratory tract, gastrointestinal tract, urinary tract and reproductive tracts.

Naïve lymphocyte

Mature b or t cell that has not yet encountered antigen for the first time.

Natural killer cell (nk)

Cytotoxic lymphocyte of innate immune response.

Neutrophil

Phagocytic white blood cell recruited from the bloodstream to the site of infection via the bloodstream.

Opsonization

An antibody or an antimicrobial protein binds to a pathogen, thereby marking it as a target for phagocytes.

Passive immunity

Transfer of immunity to a pathogen to an individual that lacks immunity to this pathogen usually by the injection of antibodies.

Pathogens

Disease causing agents.

Phagocytosis

Movement of material from the outside to the inside of the cells via vesicles made from invaginations of the plasma membrane.

Plasma cell

Differentiated b cell that is actively secreting antibody.

Primary adaptive response

Immune system’s response to the first exposure to a pathogen.

Primary lymphoid organ

Site where lymphocytes mature and proliferate, red bone marrow and thymus gland.

Right lymphatic duct

Drains lymph fluid from the upper right side of body into the right subclavian vein.

S. aureus

Staphylococcus aureus is a bacterium that is commonly found in minor skin infections, as well as in the nose of some healthy people.

Secondary adaptive response

Immune response observed upon re-exposure to a pathogen, which is stronger and faster than a primary response.

Secondary lymphoid organs

Sites where lymphocytes mount adaptive immune responses, examples include lymph nodes and spleen.

Seroconversion

The reciprocal relationship between virus levels in the blood and antibody levels. As the antibody levels rise, the virus levels decline, and this is a sign that the immune response is being at least partially effective (partially, because in many diseases, seroconversion does not necessarily mean a patient is getting well).

Severe combined immunodeficiency disease (scid)

Genetic mutation that affects both t cell and b cell arms of the immune response.

Spleen

Secondary lymphoid organ that filters pathogens from the blood (white pulp) and removes degenerating or damaged blood cells (red pulp).

Superficial Lymphatics

Lymphatic vessels of the subcutaneous tissues of the skin.

Systemic Lupus Erythematosus

SLE is an autoimmune disease in which the immune system recognizes its own cell antigens as being “non-self” and mounts an immune response against them. As a result, many body tissues and vital organs become chronically inflamed and damaged.

T cell

Lymphocyte that acts by secreting molecules that regulate the immune system or by causing the destruction of foreign cells, viruses, and cancer cells.

Thoracic duct

Large duct that drains lymph from the lower limbs, left thorax, left upper limb, and the left side of the head.

Thymocytes

Lymphocytes that develop into T-cells in the thymus gland.

Thymus

Primary lymphoid organ, where t lymphocytes proliferate and mature.

Tonsils

Lymphoid nodules associated with the nasopharynx.

Tissue typing

The determination of MHC molecules in the tissue to be transplanted to better match the donor to the recipient.

Vaccine

A killed or weakened pathogen or its components that, when administered to a healthy individual, leads to the development of immunological memory (a weakened primary immune response) without causing much in the way of symptoms.

Vasodilation

The smooth muscle layer in the wall of the blood vessel relaxes, allowing the vessel to widen. This decreases blood pressure in the vessel.

Wheal and flare response

A soft, pale swelling at the site surrounded by a red zone.

Test Yourself

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References

Canadian Medical Association. (2018, August). Clinical immunology/allergy profile. Canadian Medical Association Specialty Profiles. https://www.cma.ca/sites/default/files/2019-01/immunology-allergy-e.pdf.

[CrashCourse]. (2015, November 30). Lymphatic system: Crash course A&P #44 [Video]. YouTube. https://youtu.be/I7orwMgTQ5I

[CrashCourse]. (2015, December 8). Immune system, part 1: Crash course A&P #45 [Video]. YouTube. https://youtu.be/GIJK3dwCWCw

[CrashCourse]. (2015, December 14). Immune system, part 2: Crash course A&P #46 [Video]. YouTube. https://youtu.be/2DFN4IBZ3rI

Image Descriptions

Figure 14.1 image description: The left panel shows a female human body, and the entire lymphatic system is shown Labels read (clockwise from top): thymus, lymph nodes, thymus, spleen, lymph vessel, bone marrow, right lymphatic duct, entering vein, tonsil, adenoid. The right panel shows magnified images of the thymus and the lymph node. Labels read (clockwise from top): tissue cell, interstitial fluid, lymphatic capillary, blood capillary, lymphatic vessel. Label of lymph node reads masses of lymphocytes and macrophages. [Return to Figure 14.1].

Figure 14.2 image description: This image shows the lymph capillaries in the tissue spaces. Labels read (clockwise, from top): lymph capillary, tissue cells, venule, lymphatic vessel, tissue fluid, arteriole). It also shows a magnified image shows the interstitial fluid and the lymph vessels. Labels read (clockwise, from top): collagen fiber, interstitial fluid, lymph, lymph vessel endothelial cells, backflow prevention valve, endothelial flaps. [Return to Figure 14.2].

Figure 14.3 image description: This figure shows the lymphatic trunks and the duct system in the human body. Labels read (clockwise from top) thoracic duct, cisterna chyli of thoracic duct, drained by thoracic duct, drained by right lymphatic duct. Callouts to the left and right show the magnified views of the left and right jugular vein respectively. Labels read (right lymphatic duct): right internal jugular vein, right subclavian vein, right lymphatic duct; (left jugular vein): left internal jugular vein, thoracic duct drains into subclavian vein, left subclavian vein.[Return to Figure 14.3].

Figure 14.4 image description: The left panel of this figure shows the head and chest of a woman and the location of the thymus is marked. Labels read (clockwise, from top) lymph nodes, spleen, heart, thymus, right lymphatic duct entering vein, tonsil, adenoid. The top right panel shows a micrograph of the thymus. Labels read (from left to right): medulla, cortex, trabeculae, fibrous capsule. The bottom right panel shows a magnified view of the structure of the thymus. Labels read (clockwise, from top): thymocytes, trabecula, fibrous capsule, cortex, medulla (layers), medullary epithelial cell, blood vessel, macrophage, dendritic cell, cortical epithelial cell.[Return to Figure 14.4].

Figure 14.5 image description:This flowchart shows the process in which a naïve T cell become activated T cells in the left part of the pathway and memory cells in the right part of the pathway. A naive T cell becomes an activated T cell when an antigen-presenting cell is introduced. The antigen is extracted from a pathogen and then either activated T cells are cloned and destroy the infected cells in the body, and/or memory T cells are produced and are activated if this antigen is encountered again. [Return to Figure 14.5].

Figure 14.6 image description: The left panel of this figure shows a micrograph of the cross section of a lymph node. Labels indicate the connective tissue capsule, cortex, and subcapsular sinus. The right panel shows the structure of a lymph node. Labels indicate (from top, clockwise) the efferent lymphatic vessels, connective tissue capsule, subcapsular sinus, cortex, afferent lymphatic vessels, trabecula, germinal centers. [Return to Figure 14.6].

Figure 14.7 image description: The top left panel shows the location of the spleen in the human body. The top center panel shows a close up view of the location of the spleen. Labels read (clockwise, from top): hilum, spleen, diaphragm, splenic vein, splenic artery. The top right panel shows the blood vessels and spleen tissue. Labels read (from left to right, top then bottom) red pulp, trabecula (bottom) white pulp, arteriole, venule. The bottom panel shows a histological micrograph Labels read (clockwise, from top): trabecula, marginal zone, central artery or arteriole, germinal center, venuous sinus, red pulp, arterial capillaries. [Return to Figure 14.7].

Figure 14.8 image description: The top panel of this image shows the locations of the tonsils. Labels read (clockwise from top):palatine tonsil, palatine bone, tongue, mandible, hyoid, trachea, esophagus. Callout shows the location of the pharyngeal tonsil. Labels read (from top): brain, sphenoidal sinus, sphenoid bone, pharyngeal tonsil, nasopharynx. Another callout details the location of the palatine tonsil. Labels read (from top): palatine tonsil, lingual tonsil, epiglottis. Another callout shows a photograph of the back of the throat where the tonsils are located. Labels read (from top) hard palate, soft palate, uvula, palatine tonsils (swollen due to infection) and tongue. The bottom panel shows the histological micrograph of the tonsils. Labels read (from top): crpyt, stratified squamous epithelium, germinal centers. [Return to Figure 14.8].

Figure 14.9 image description: This figure shows a micrograph of a mucosa associated lymphoid tissue (MAST) nodule. Labels indicate the mucosa and Peyer’s patches (which appear to be dark purple). [Return to Figure 14.9].

Figure 14.12 image description: This graph shows the antibody concentration as a function of time in primary and secondary response. Initial exposure indicates a low concentration of antibody, which then elevates over time during the primary immune response. It decreases a little during secondary exposure, but then spikes during the secondary immune response. [Return to Figure 14.12].

Figure 14.13 image description: This flow chart shows how the clonal selection of B cells takes place. The left panel shows the primary response and the right panel shows the secondary response. During a primary B cell immune response, both antibody-secreting plasma cells and memory B cells are produced. These memory cells lead to the differentiation of more plasma cells and memory B cells during secondary responses. [Return to Figure 14.13].

Figure 14.15 image description: The left panel of this figure shows an x-ray image of a person’s hand with rheumatoid arthritis, and the right panel of this figure shows a woman’s body with labels showing the different responses in the body when the patient suffers from lupus. Labels (from top, clockwise) read: psychological: fatigue, loss of appetite, face butterfly rash, pleura inflammation, pericardium inflammation, fingers and toes poor circulation, joints arthritis, muscles aches, mouth and nose ulcers, systemic: low-grade fever photosensitivity.[Return to Figure 14.51].

Unless otherwise indicated, this chapter contains material adapted from Anatomy and Physiology (on OpenStax), by Betts, et al. and is used under a a CC BY 4.0 international license. Download and access this book for free at https://openstax.org/books/anatomy-and-physiology/pages/1-introduction.