Category Archives: Gastroenterology (digestive)

The Digestive System, with Animation.

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The digestive system is composed of 2 main components: the gastrointestinal tract, or GI tract, where digestion and absorption take place; and accessory organs which secrete various fluids/enzymes to help with digestion. The GI tract is a continuous chain of hollow organs where food enters at one end and waste gets out from the other. These organs are lined with layers of smooth muscles whose rhythmic contractions generate waves of movement along their walls, known as peristalsis. Peristalsis is the force that propels food down the tract.
Digestion is the process of breaking down food into smaller, simpler components, so they can be absorbed by the body. Basically, carbohydrates such as sugars and starch are broken down into glucose, proteins into amino acids, and fat molecules into fatty acids and glycerol.
Digestion starts in the oral cavity where the food is moistened with saliva and chewed, food bolus is formed to facilitate swallowing. Saliva is secreted by the salivary glands and contains the enzyme amylase, which breaks down starch into maltose and dextrin that can be further processed in the small intestine. Saliva also contains salivary lipase, which starts the process of fat digestion.
The food bolus is propelled down the esophagus by peristalsis into the stomach, the major organ of the GI tract. The stomach produces gastric juice containing pepsin- a protease, and hydrochloric acid which act to digest proteins. At the same time, mechanical churning is performed by muscular contraction of the stomach wall. The result is the formation of chyme – a semi-liquid mass of partially digested food. Chyme is stored in the stomach and is slowly released into the first part of the small intestine – the duodenum. The duodenum receives the following digestive enzymes from accessory organs:
Bile, produced in the liver and stored in the gallbladder; bile emulsifies fats and makes it easier for lipase to break them down.
Pancreatic juice from the pancreas. This mixture contains proteases, lipases and amylase and plays major role in digestion of proteins and fats.
The small intestine also produces its own enzymes: peptidases, sucrase, lactase, and maltase. Intestinal enzymes contribute mainly to the hydrolysis of polysaccharides.
The small intestine is where most of digestion and absorption take place. The walls of the small intestine absorb the digested nutrients into the bloodstream, which in turn delivers them to the rest of the body. In the small intestine, the chyme moves more slowly allowing time for thorough digestion and absorption. This is made possible by segmentation contractions of the circular muscles in the intestinal walls. Segmentation contractions move chyme in both directions. This allows a better mixing with digestive juices and a longer contact time with the intestinal walls.
The large intestine converts digested left-over into feces. It absorbs water and any remaining nutrients. The bacteria of the colon, known as gut flora, can break down substances in the chyme that are not digestible by the human digestive system. Bacterial fermentation produces various vitamins that are absorbed through the walls of the colon. The semi-solid fecal matter is then stored in the rectum until it can be pushed out from the body during a bowel movement.

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Deglutição, Fases e Visão Geral do Controle Neural, com Animação.

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A deglutição é o processo pelo qual os alimentos passam da boca para o esôfago, através da faringe. Pode parecer simples para as pessoas saudáveis, no entanto, a deglutição é um processo muito complexo que requer uma coordenação extremamente precisa com a respiração, já que ambos os processos compartilham a mesma entrada – a faringe. Falha nessa coordenação resultaria em asfixia ou aspiração pulmonar.
A deglutição envolve mais de vinte músculos da boca, garganta e esôfago, que são controlados por diversas áreas corticais no cérebro e pelo centro da deglutição, localizado no tronco cerebral. O encéfalo se comunica com os músculos através de vários nervos cranianos.
A deglutição consiste em três fases:
1. Fase oral ou bucal: esta é a parte voluntária da deglutição. A comida é humedecida com a saliva e mastigada, formando o bolo alimentar, que é empurrado pela língua para a parte posterior da garganta – a faringe. Este processo está sob controle neural de várias áreas do córtex cerebral, incluindo o córtex motor.
2. A Fase faríngea começa com a estimulação dos receptores tácteis na orofaringe pelo bolo alimentar. O reflexo da deglutição é iniciado e está sob controle neuromuscular involuntário. As seguintes ações ocorrem para assegurar a passagem de comida ou bebida para o esôfago:
– A língua bloqueia a cavidade oral para evitar que a comida retorne para a boca.
– O palato mole bloqueia a entrada para a cavidade nasal.
– As pregas vocais se fecham para proteger as vias aéreas.
– A laringe é puxada para cima e ocorre a inclinação da epiglote, fechando a entrada da traqueia. Este é a etapa mais importante, pois, a passagem de alimentos para os pulmões pode ser potencialmente fatal.
– O esfíncter superior do esôfago se abre para permitir a passagem para o esôfago.
3. Fase esofágica: o bolo alimentar é impulsionado para o esôfago pelos movimentos peristálticos – ondas de contração muscular que empurram o bolo alimentar pera frente. A laringe se move para baixo, retornando à posição inicial.

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Le Réflexe de Déglutition, Phases et Contrôle Neuronal, avec Animation.

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L’action d’avaler, ou la déglutition, est le processus par lequel les aliments passent de la bouche dans le pharynx puis dans l’œsophage. Aussi simple que cela puisse paraître pour les personnes en bonne santé, la déglutition est en fait une action très complexe qui nécessite une coordination extrêmement précise avec la respiration puisque ces deux processus partagent la même entrée – le pharynx. L’absence de coordination se traduirait par l’étouffement ou les fausses routes. La déglutition implique plus de vingt muscles de la bouche, de la gorge et de l’oesophage qui sont contrôlés par plusieurs aires corticales et par les centres de déglutition dans le tronc cérébral. Le cerveau communique avec les muscles à travers plusieurs nerfs crâniens.
La déglutition se compose de trois phases:
1. Phase orale ou buccale: ceci est la partie volontaire de déglutition, la nourriture est humidifiée avec de la salive et mâchée, bol alimentaire est formé et la langue le propulse à l’arrière de la gorge – le pharynx. Ce processus est sous contrôle neuronal de plusieurs aires du cortex cérébral, y compris le cortex moteur.
2. Phase pharyngée commence par la stimulation des récepteurs tactiles dans l’oropharynx par le bol alimentaire. Le réflexe de déglutition est déclenché et est sous contrôle neuromusculaire involontaire. Les mesures suivantes sont prises pour assurer le passage de la nourriture ou des boissons dans l’œsophage:
– La langue ferme la cavité buccale pour empêcher les aliments de revenir à la bouche.
– Le palais mou couvre la cavité nasale pour éviter que les aliments remontent dans le nez.
– Les cordes vocales se resserrent et bouchent les voies aériennes. L’élévation du larynx se traduit par l’abaissement de l’épiglotte et cela couvre le passage vers la trachée. Ceci est l’étape la plus importante car l’entrée de la nourriture ou des boissons dans les poumons peut être potentiellement mortelle.
– Le sphincter oesophagien supérieur s’ouvre pour permettre le passage à l’oesophage.
3. Phase oesophagienne: bol alimentaire est propulsé dans l’œsophage par péristaltisme – des ondes de contraction musculaire qui poussent le bol jusqu’à l’estomac. Le larynx descend à sa position initiale.

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Reflejo de la Deglución, Fases y Descripción General del Control Neural, con Animación.

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Tragar, o deglución, es el proceso mediante el cual la comida pasa desde la boca, a través de la faringe y hacia el esófago. Tan simple como podría parecer a las personas sanas, la deglución es en realidad una acción muy compleja que requiere de una coordinación extremadamente precisa con la respiración, ya que estos dos procesos comparten la misma entrada – la faringe. Fallas en la coordinación pueden resultar en atragantamiento o broncoaspiración. La deglución involucra más de veinte músculos de la boca, garganta y esófago que son controlados por diversas áreas corticales del cerebro y por los centros de la deglución en el tallo cerebral. El encéfalo se comunica con los músculos a través de varios nervios craneales.
La deglución consiste en tres fases:
1. La fase oral o bucal: Esta es la parte VOLUNTARIA de la deglución, la comida es humedecida con saliva y es masticada, el bolo alimenticio se forma y la lengua lo empuja hacia la parte posterior de la garganta – la faringe. Este proceso está bajo el control neural de diferentes áreas de la corteza cerebral incluyendo la corteza motora.
2. La fase faríngea empieza con la estimulación de receptores táctiles en la orofaringe por el bolo alimenticio. El reflejo de la deglución es iniciado y está bajo control neuromuscular INVOLUNTARIO. Se toman las siguientes acciones para asegurar el paso de comida o bebida hacia el esófago:
-La lengua bloquea la cavidad oral para prevenir que la comida se devuelva a la boca. -El paladar blando bloquea la entrada a la cavidad nasal. -Las cuerdas vocales se cierran para proteger la vía aérea a los pulmones. La laringe es halada hacia arriba y la epiglotis se rebate hacia atrás CUBRIENDO la entrada hacia la tráquea. Este es el paso más importante ya que la entrada de comida o bebida en los pulmones puede ser potencialmente peligrosa para la vida.
-El esfínter esofágico superior se abre para permitir el paso hacia el esófago.
3. La fase esofágica: El bolo alimenticio es impulsado en el esófago por peristalsis – una onda de contracción muscular que empuja el bolo por delante de esta. La laringe se mueve hacia abajo de nuevo a su posición original.

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Gallstones and Cholecystectomy

Below is a narrated animation about gallstones and surgical treatment. Click here to license this video and/or other digestive system videos on Alila Medical Media website.

Bile production and storage

The gallbladder is a small sac located underneath the liver. The gallbladder serves to store and concentrate bile. Bile is a yellowish-green fluid secreted by the liver and contains bile acids which aid in fat digestion and absorption. Bile flows through the bile duct into the duodenum – the first part of the small intestine. After filling the bile duct, it overflows into the gallbladder where it is stored for later use. After a high-fat meal, the gallbladder contracts to pump bile into the duodenum.
Digestive organs and bile ducts, labeled diagram.

Fig. 1: Anatomy of the liver, gallbladder, pancreas, duodenum and the biliary tree. Click on image to see it on Alila Medical Media website where the image is also available for licensing (together with other related images and videos).

Gallstones and Complications

Gallstones are hard masses formed in the gallbladder. Gallstones may cause obstruction of the cystic duct and excruciating pain when the gallbladder contracts. This usually happens after a fatty meal and is commonly referred to as gallbladder attack. Blockage of the cystic duct is a common complication caused by gallstones.
Gallstones
Fig. 2: Gallstones block cystic duct. Click on image to see it on Alila Medical Media website where the image is also available for licensing (together with other related images and videos).

 

 

 

 

Other less common but more serious problems occur when gallstones become lodged down the path of the biliary tree. When gallstones block the common bile duct, they prevent bile from reaching the intestine. This causes jaundice, poor fat digestion and subsequently leads to infection of the bile duct or cholangitis. Gallstones may also obstruct the pancreatic duct, forcing pancreatic enzymes to back up in the pancreas. This damages the pancreatic tissue and triggers inflammatory response. This condition is known as acute pancreatitis or sudden inflammation of the pancreas.
Acute Pancreatitis caused by gallstone
Fig. 3: Acute pancreatitis caused by gallstones. Click on image to see it on Alila Medical Media website where the image is also available for licensing (together with other related images and videos).

Surgical treatment

The most common treatment for gallstones is the surgical removal of the gallbladder or cholecystectomy. Laparoscopic cholecystectomy is currently the standard procedure for gallbladder removal. This minimally invasive procedure requires only several small incisions in the abdomen and thus results in less pain and quicker recovery. The cystic duct and cystic artery are clipped with tiny titanium clips and cut. The gallbladder is then dissected and removed through one of the incision.
Cholecystectomy
Fig. 4: Gallbladder removal surgery.  Click on image to see it on Alila Medical Media website where the image is also available for licensing (together with other related images and videos).

 

 
After surgery, bile enters the intestine without being concentrated in the gallbladder and may not be sufficient after a high-fat meal. A low-fat diet is therefore recommended after removal of gallbladder.

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Swallowing and Dysphagia (with Animation)

Swallowing

Below is a narrated animation about swallowing reflex, phases and overview of neural control. Click here to license this video on Alila Medical Media website.

Swallowing, or deglutition, is the process by which food passes from the mouth, through the pharynx and into the esophagus. As simple as it might seem to healthy people, swallowing is actually a very complex action that requires an extremely precise coordination with breathing since both of these processes share the same entrance: the pharynx. Failure to coordinate would result in choking or pulmonary aspiration. Swallowing involves over twenty muscles of the mouth, throat and esophagus that are controlled by several cortical areas and by the swallowing centers in the brainstem. The brain communicates with the muscles through several cranial nerves.

Swallowing consists of three phases

1. Oral or buccal phase: this is the voluntary part of swallowing, the food is moistened with saliva and chewed, food bolus is formed and the tongue  pushes it to the back of the throat (pharynx). This process is under neural control of several areas of cerebral cortex including the motor cortex.
2. Pharyngeal phase starts with stimulation of tactile receptors in the oropharynx by the food bolus. The swallow reflex is initiated and is under involuntary neuromuscular control. The following actions are taken to ensure the passage of food or drink into the esophagus:
– The tongue blocks the oral cavity to prevent going back to the mouth.
– The soft palate blocks entry to the nasal cavity.
– The vocal folds close to protect the airway to the lungs.The larynx is pulled up with the epiglottis flipping over covering the entry to the trachea (the windpipe). This is the most important step since entry of food or drink into the lungs may potentially be life threatening.
– The upper esophageal sphincter (UES) opens to allow passage to the esophagus.
3. Esophageal phasefood bolus is propelled down the esophagus by peristalsis – a wave of muscular contraction that pushes the bolus ahead of it. The larynx moves down back to original position.

Click here to see an animation of the swallowing process on on Alila Medical Media website where the video is also available for licensing.
Swallowing, labeled
Fig. 1: Anatomy of swallowing. See text for details of phases. The blue arrows represent breathed air. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

 

 

Dysphagia (swallowing disorders)


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Dysphagia refers to a group of conditions characterized by difficulty swallowing. There are two main classes of problems that can lead to swallowing disorders:


 1. 
Neuromuscular problems: 

– Muscular disorders that affect skeletal muscles, such as muscular dystrophy, myasthenia gravis…

– Diseases of the nervous system that compromise the way the brain controls the swallowing reflex, such as stroke, Parkinson’s disease, multiple sclerosis…

Weakened muscles and/or impaired coordination as a result of aging.

This class commonly affects the first two phases of swallowing.

2. Narrowing of the throat or esophagus due to throat cancer, esophageal cancer and formation of small sacs or rings in the walls of the esophagus.  Gastroesophageal reflux disease – GERD – is also a common cause. In GERD, scars resulted from stomach acid injuries may obstruct the esophagus and cause difficulty swallowing.

This class mostly affects the third phase of swallowing.

Schatzki ring blocks esophagus
Fig. 2: Schatzki ring makes the lumen of esophagus smaller. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

 

 

 

For people with dysphagia, eating becomes a challenge. The consequences may be serious. Someone who cannot swallow safely is at high risks of choking, pulmonary aspiration and may not be able to eat enough to stay healthy.

Treatment depends on the cause of the condition:

– Muscle strength and coordination exercises may be recommended for some.

– A change in the position of the head and neck when eating could be beneficial to others.

– Right choice of food and drink is important for most. Soft textured food and thickened drinks are recommended for safe swallowing.

– Surgery may be needed to remove narrowed parts of the esophagus.

– Finally, patients with severe dysphagia and recurrent aspiration may have to resort to tube feeding to get nutrition to the body.

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Vertical Sleeve Gastrectomy and Gastric Lap Band Surgeries

This is a continuation to the main article about bariatric surgery .

Below is a narrated animation of Gastric Sleeve and Gastric Lap Band procedures. Click here to license this video on Alila Medical Media website.

Vertical sleeve gastrectomy (VSG)

In this procedure a cut is made vertically and the larger part of the stomach (up to 85% of its volume) is removed from the body. The remaining is closed with staples to create a “new stomach” that is now having the shape of a tube (see Fig. 1). The procedure preserves both sphincters at the two ends of the stomach and therefore has minimum effect on the functioning of the digestive process.This reduces the risk of malabsorptive complications commonly associated with intestinal bypass. The procedure is irreversible.

Click here to see an animation of VSG procedure  on Alila Medical Media website where the video is also available for licensing.

Vertical Sleeve Gastrectomy (VSG)
Fig. 1: Vertical sleeve gastrectomy procedure. Click on image to see a larger version on  Alila Medical Media website where the image is also available for licensing.

 

 

 

 

VSG procedure is gaining more and more popularity thanks to its simplicity and good results on initial weight loss. However, due to the lack of long-term data, it is yet to be endorsed by bariatric surgery societies and is not covered by some insurance companies.

 

Adjustable gastric band (Lap band)


In this procedure an inflatable silicon band is placed around the top of the stomach to create a small stomach pouch (Fig. 2). During a meal, the pouch is filled up quickly with a small amount of food and releases it slowly into the lower part of the stomach due to the restriction by the band. As the pouch is full, it gives a feeling of satiety (fullness). Slow passage of the food makes the patient feel full for a longer period of time and thus reduces the amount of food intake. The band is connected to a port placed under skin of the abdomen. Through this port, a saline solution (salt water) is injected to adjust the diameter of the band and thus making the passage between the pouch and the lower part of the stomach smaller or larger accordingly to the needs of patient.

Click here to see an animation of gastric band procedure  on Alila Medical Media website where the video is also available for licensing.

Gastric Band Weight Loss Surgery

 

 

Fig. 2: Adjustable lap band procedure. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

 

 

As the procedure involves no cutting or stapling of the stomach, it is minimal invasive and reversible. The surgery can be performed laparoscopically (as opposed to open surgery) through small incisions with the aid of a camera. Recovery time is significantly shortened compared to gastric bypass procedures. Also, as there is no intestinal bypass, the risks of nutritional deficiencies, dumping syndrome and other complications associated with it are significantly reduced.
In terms of weight loss efficiency, however, patients who undergo gastric lap band surgery typically lose less weight than those who have had gastric bypass procedures.

                                                                                              > See Gastric bypass procedures

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Bariatric surgery

Below is a narrated animation of body mass index and Roux-en-Y gastric bypass. Click here to license this video on Alila Medical Media website.

Bariatric surgery, or weight loss surgery, refers to a variety of surgical procedures for treatment of morbid obesity. Obesity is determined by Body Mass Index (BMI) which is calculated as the ratio of body weight over square of body height. The higher the BMI the higher the extend of obesity.  A normal BMI is between 20 and 25. An individual is considered morbidly obese if he or she has a body mass index of 40 or more, or of 35 or more and with obesity-related health problems such as diabetes, sleep apnea or hypertension.

Weight loss is achieved by reducing the size of the stomach. Smaller stomach makes you feel full faster and therefore makes it easier to reduce the amount of food intake.

Roux en-Y Gastric bypass (RNY)

This is the most commonly performed bariatric surgical procedure and is considered the gold standard for weight loss treatment. This procedure includes two steps:
1. The stomach is divided into two part : one small pouch at the top of the stomach where it is connected to the esophagus (gastric pouch in Fig. 1) and the rest of the stomach which will be “bypassed”, the two parts are separated and stapled.
2. Rerouting of the intestine: the intestine is cut at about 45cm (18in) down from the end of the stomach. The first part of the intestine (the duodenum) will be “bypassed”. The top end of the second part (the jejunum) is pulled up and connected to the gastric pouch created in step 1. The lower end of the duodenum is reconnected to the jejunum at a lower point (Fig.1). The new configuration has a shape of an Y, hence the name of the procedure.

Click here to see a video animation of gastric bypass procedure on Alila Medical Media website where the video is also available for licensing.

Roux-en-Y Gastric Bypass (RNY) surgery
Fig. 1: Roux-en-Y gastric bypass diagram. Note the passage of food and digestive juice after surgery. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

 

 

How weight loss is achieved?
Firstly, the volume of the stomach is now greatly reduced to a small pouch (usually less than 10% of the original volume) which is filled up fast after a small amount of food intake. This sends a signal to the brain that the stomach is full and generates a feeling of fullness (satiety). This helps to stop eating. Also, if eating continues, vomiting and discomfort may follow. Secondly, as the first part of the intestine (the duodenum) is bypassed, the amount of nutrition absorbed by the body is greatly reduced. In normal digestion, this is where most of the nutrition is absorbed. Malabsorption contributes to weight loss effect.

Complications
While this procedure is proven as an efficient long term weight loss treatment, it associates with significant complication risks. These include: leakage along the staple lines and surgical connections leading to infection and abscess formation; stricture and obstruction of digestive tract due to scar formation; dumping syndrome; nutritional deficiencies; and other general surgical risks  due to complexity of the procedure.

Mini Gastric bypass (MGB)

This is a modification of the more common RNY procedure described above. Here are the differences: (see Fig. 2)
1. In step 1 a long tube is created instead of a pouch.
2. In step 2, the intestine is NOT cut, it is pulled up and hooked up with the new stomach tube.

Mini gastric bypass surgery

Fig. 2: Mini gastric bypass diagram. Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

 

 

 

Click here to see a video animation of mini gastric bypass procedure on Alila Medical Media website where the video is also available for licensing.

This procedure is becoming more and more popular as it produces good weight loss results and is simpler than the original procedure resulting in less complication risks. Less cutting and stapling lowers the risk of leakage and infection. It also reduces the bile reflux possibility  as the intestinal rerouting is set at a lower point on the stomach.

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GERD and Heartburn (with video)

Gastroesophageal reflux disease

This video and other animations of the digestive system are available for licensing on Alila Medical Media website. Click here!



Gastroesophageal reflux disease (GERD) or gastric reflux disease is  a chronic condition where acid from the stomach flows up and damages the mucosa of the esophagus.
At the junction between the esophagus and the stomach is the lower esophageal sphincter (LES). The LES is a ring of muscle that is generally closed tight to prevent stomach acid from coming up. In normal digestion, the LES opens shortly to allow food bolus passing down to the stomach and closes back tight instantly. GERD occurs when the LES is abnormally relaxed and can not close properly (Fig. 1). Heartburn is a burning sensation in the chest associated with each regurgitation of gastric acid and is the most prominent symptom of GERD. 

Gastric reflux, labeled diagram.
Fig. 1: Abnormal relaxation of the lower esophageal sphincter as cause of GERD. Click on image to see a larger version on  Alila Medical Media website where the image is also available for licensing.

 

 

 

Hiatus hernia is believed to be another cause of GERD. Hiatus hernia or hiatal hernia is a condition where the top portion of the stomach is pulled up forming a herniation above  the diaphragm. This situation somehow compromises the esophagus – stomach barrier and facilitates acid reflux.

Hiatal Hernia
Fig. 2: Types of hiatal hernia. Click on image to see a larger version on  Alila Medical Media website where the image is also available for licensing.

 

 

Treatment

Treatment includes dieting and medication. Proton-pump inhibitors, which act to reduce gastric acid production, are drugs of choice. If these fail, a surgery may be recommended. In a procedure called Nissen fundoplication, the top portion of the stomach is wrapped around the lower part of esophagus and sewn into place. This way, the muscles in the wall of the stomach reinforce the closure of the esophagus. This surgical procedure is particularly recommended when hiatus hernia is present as this can be fixed at the same time. The procedure can be done with minimal invasive laparoscopic technique through small incisions with the aid of a camera.
Nissen Fundoplication Surgery
Fig. 3: Nissen fundoplication procedure.  Click on image to see a larger version on Alila Medical Media website where the image is also available for licensing.

 

 

 

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