REMEMBER TO LOOK AT THE COURSE GUIDE FOR PAGES LIKE PAGE 40 that aren’t EVEN IN SESSION
LEARNING OBJECTIVES etc and stuff on simbryo etc.
Session 4 – Thursday 15 May 2008
Radiological Anatomy, Kidneys and Ureters
1. Demonstrate in dissections and draw the principal relations of the duodenum,
pancreas and kidneys including major vascular relations.
The duodenum
Relations of the Duodenum:
Part
Anterior
Posterior
Superior
Inferior
First
Liver
Gall
bladder
Portal vein
Gastroduodenal
artery
Bile duct
Lesser sac
IVC
Liver
(quadrate)
Hepatic
artery
Neck of gall
bladder
Pancreatic
head
Bifurcation
of gastroduodenal
artery
Second
Liver
Gall
bladder
Transverse
colon
Small
intestine
Right renal
vessels
Right
kidney
IVC
Psoas
major
Right
ureter
Third
Superior
mesenteric
vessels
Root of
mesentery
Right and
left psoas
major
Right
ureter
IVC
Aorta
Inferior
mesenteric
artery
Fourth
Root of
Aorta
mesentery Left psoas
major
Pancreatic
head
Inferior
pancreaticoduodenal
artery
Medial
Lateral
Pancreatic
head
Branches of
pancreaticoduodenal
artery
Ascending
colon
Right
colic
flexure
•
•
•
•
First Part - partially in foregut mesenteries. Common Bile duct and Portal Vein pass
posterior to it
Second Part - Common Bile Duct and Pancreatic Ducts open into it, root of
Transverse Mesocolon crosses it
Third Part - Superior Mesenteric Vein lies anterior to it
Fourth Part - leads into Jejunum
2. Name the main organs in contact with each of the left and right kidneys
•
•
•
•
•
•
•
•
Adrenal glands on both sides
Liver on right
2nd part of duodenum on right
Ascending colon on right
Descending colon and stomach on left
Spleen on left
Tail of pancreas on left
Coils of small bowel especially on left
3. Describe the arterial supply of the kidneys and adrenal (suprarenal) glands
4. Name the principal macroscopic components of the kidney and relate these to
microscopic organisation.
For further information see kidney lectures.
5. Mark the likely positions of the kidneys and ureters in a living subject and
demonstrate their positions in appropriate plain and contrast radiographs and
in CT images.
See Gray’s anatomy page 352 and 38-42 of course guide for details
Courtesy of Ghannam et all the following website should be used for CT
http://www.med.wayne.edu/diagradiology/Anatomy_Modules/Abdomen.html
6. Demonstrate how to palpate the kidneys in a living subject.
An attempt should be made to palpate both the right and left kidneys.
The ballottement method is normally used.




Keep your anterior hand steady in the deep palpation position in the right upper quadrant lateral
and parallel to rectus muscle.
Attempt to ballot the kidney with the other hand in costophrenic angle.
An enlarged kidney should be palpable by the anterior hand.
Repeat the same maneuver for the left kidney.
Alternate method for the right kidney:



Place your left hand behind the patient between the rib cage and iliac crest and place your right hand
below the right costal margin.
While pressing your hands firmly together, ask the patient to take a deep breath. Attempt to feel the
lower pole of the right kidney.
Repeat the same maneuver for the left kidney.
Normal:
In an adult, the kidneys are not usually palpable, except occasionally for the inferior pole of the right kidney.
The left kidney is rarely palpable. An easily palpable or tender kidney is abnormal. However, the right kidney is
frequently palpable in very thin patients and children.
7. Demonstrate the main components of the posterior abdominal wall from diaphragm
to pelvic inlet.
Page 314 of Gray’s anatomy is a useful diagram. A summary will be given of this objective
with further information below for understanding and further revision.
The Posterior Abdominal Wall
The posterior abdominal wall lies at the back of the abdomen, behind the
posterior peritoneum. With the anterior structures removed (the stomach,
jejunum and ileum) the retroperitoneal parts of the gut tube can be more easily
identified.
The duodenum
The first part of the duodenum continues on from the pylorus of the stomach
suspended in a mesentery. As the duodenum changes direction it becomes
retroperitoneal in its descending second part and transverse third part. On the
left the third part of the duodenum passes anteriorly and cranially to form the
fourth part of the duodenum, continuous with the jejunum. The fourth part of
the duodenum is suspended in a fold of pertitoneum, the ligament of Trietz. The
first and second parts of the duodenum receive their blood supply from the
anterior and posterior pancreaticoduodenal arteries which branch from the
gastroduodenal artery. The third and fourth parts of the duodenum receive their
arterial supply from the anterior and posterior inferior pancreaticoduodenal
arteries. The pancreaticoduodenal arteries form an anastomoses between the
celiac trunk and superior mesenteric artery. The portal vein is formed behind the
neck of the pancreas and passes to the porta hepatis behind the first part of the
duodenum. The superior mesenteric artery and vein lie anterior to the third part
of the duodenum.
The colon
The ascending colon is retroperitoneal. The ileum enters the cecum at the
ileocolic valve. The appendix is attached to the cecum and may lie in a variety of
positions, including behind the cecum and within the pelvis. At the hepatic
flexure the cecum is suspended in a mesentery as the transverse colon. The
greater omentum is draped over the transverse colon. The descending colon
begins at the splenic flexure, becoming retroperitoneal. As the descending colon
reaches the iliac fossa it forms the sigmoid colon which has a short mesentery.
The sigmoid colon moves towards the midline to form the rectum in the pelvis.
The ileocolic artery, a terminal branch of the superior mesenteric artery, supplies
the terminal ileum, caecum and appendix. A branch from the ileocolic or superior
mesenteric, the right gastric, supplies the ascending colon. An early branch from
the superior mesenteric, the middle colic, supplies the transverse colon. The
inferior mesenteric artery supplies the descending and sigmoid colon and the
rectum. The ascending left colic branch of the inferior mesenteric runs upwards
to the splenic flexure and forms an anastomosis with the middle colic artery
through the formation of the marginal artery.
The abdominal aorta
The aorta passes into the abdomen from the thorax in the midline lying on the
vertebral bodies. The crura of the diaphragm form an opening so that the aorta
passes behind the diaphragm under the median arcuate ligament. The aorta
gives off four pairs of lumbar arteries that supply the abdominal wall (similar to
the intercostal arteries of the thorax). Four other pairs are also given off: The
inferior phrenic arteries supplying the diaphragm; the middle suprarenal
arteries; the renal arteries; the gonadal arteries. There are three unpaired
arteries which arise from the anterior aorta: the celiac trunk; the superior
mesenteric artery; the inferior mesenteric artery. At the lower border of the L4
lumbar vertebra the aorta bifurcates into the common iliac arteries.
The inferior vena cava
The IVC lies on the right side of the aorta. The IVC is formed by the left and
right common iliac veins which lie behind the right common iliac artery. The vein
ascends the abdomen on the right side of the lumbar vertebrae and receives the
right gonadal vein(s), the renal veins (the left gonadal vein drains into the left
renal vein), the adrenal veins, the inferior phrenic veins. The IVC passes behind
the liver being clasped in a groove at the back of the liver by the caudate lobe.
Within the groove the IVC receives the hepatic veins. The lumbar veins drain
into a pair of ascending lumbar veins which pass behind the diaphragm to
become the azygos venous system in the thorax. There are connections between
the ascending lumbar veins and the IVC so that blood from the
azygos/ascending lumbar system can either drain through the azygos vein into
the superior vena cava or through the connections to the inferior vena cava.
(Note: all of the intra-abdominal gut drains through the hepatic portal vein.)
The adrenal glands
The adrenal glands lie on the superior pole
of each kidney, with the left adrenal gland
lying more on the medial aspect. The
glands are separate from the capsule of
the kidney. Each gland receives arterial
supply from three sources: the renal
artery; aorta; inferior mesenteric artery.
As these branches reach the gland they
break up into many small vessels. Venous
drainage of the right adrenal is directly to
the IVC. Venous drainage of the left
adrenal is to the left renal vein.
Pancreas
The pancreas is for the most part
retroperitoneal but becomes suspended
in a mesentery (the lienorenal ligament)
as the tail reaches the hilum of the
spleen. The uncinate process, head and
neck of the pancreas lie within the
curvature of the duodenum. The
pancreatic ducts drain into the
duodenum. The main pancreatic duct
drains the tail, body, uncinate process
and part of the head. In the head the
main pancreatic duct joins the bile duct
to form the ampulla of Vater to drain into the second part of the duodenum. The
sphincter of Oddi controls flow into the duodenum through the major duodenal
papilla. The accessory pancreatic duct drains part of the head, either joining the
main pancreatic duct or entering the duodenum separately as the minor
duodenal papilla. The portal vein is formed behind the neck of the pancreas. The
superior mesenteric artery and vein lie anterior to the uncinate process. The
splenic artery supplies the body and tail of the pancreas. The neck and head of
the pancreas are supplied by the anterior and posterior superior
pancreaticoduodenal arteries which branch from the gastroduodenal artery. The
uncinate process and part of the head are supplied by the anterior and posterior
inferior pancreaticoduodenal arteries which arise from the superior mesenteric
artery. The pancreatic veins drain into the portal vein.
The sympathetic system
The lumbar sympathetic trunk is a continuation of the sympathetic chain in the
thorax.
The splanchnic nerves arise from the thoracic sympathetic chain as preganglionic
fibres. The greater splanchnic nerve arises from T5-T9 and passes into the
abdomen through the crura of the diaphragm to synapse in the celiac ganglia.
The celiac ganglia lie on either side of the celiac trunk and send postganglionic
fibres with all of the branches of the celiac trunk. Similarly the lesser splanchnic
(T10,11) and the least splanchnic nerves (T12) arise as preganglionic fibres in
the thorax, pass to the abdomen where they synapse in preaortic ganglia (celiac,
superior mesenteric, inferior mesenteric ganglia) before being distributed with
the arteries to the tissues. A preaortic plexus of autonomic fibres is formed by
sympathetic fibres from the preaortic ganglia and from the lumbar sympathetic
chain, and by parasympathetic fibres from the vagus and S2,3,4. The pelvic
organs receive their autonomic innervation from the superior and inferior
hypogastric plexuses formed by extension of the preaortic plexus into the pelvis.
The muscles
The muscles of the posterior abdominal
wall are the psoas, quadratus lumborum
and the iliacus.
The psoas muscle arises from the sides
of the upper lumbar vertebrae and the
intervertebral discs. The muscle runs
downwards into the pelvis and out again
under the inguinal ligament. It inserts
into the lesser trochanter of the femur
in common with the iliacus muscle. The
psoas is innervated by the L2,3,4
lumbar nerves. The muscle is enclosed
within the psoas fascia, a compartment which may limit the spread of a psoas
abscess. The psoas muscle flexes the hip, or flexes the lumbar spine. Several
structures such as the kidney and ureter, gonadal vessels, appendix and lumbar
nerves have a close relationship to the muscle. Patients attempt to immobilize
the psoas muscle when there is pain from any of these structures. This is
accomplished by drawing the knees upwards passively.
The quadratus lumborum muscle arises from the medial half of the twelfth rib
and inserts into the iliac crest. It forms a bed for the kidney. It is innervated by
the T12 and lumbar nerves. Its action is to fix the twelfth rib during inspiration.
The iliacus muscle arises from the iliac fossa in the pelvis. It runs below the
inguinal ligament to insert together with psoas into the lesser trochanter. It is
innervated by the femoral nerve.
The nerves
The nerves of the posterior abdominal
wall are the subcostal (T12), the
ilioinguinal and iliohypogastric (L1), the
lateral cutaneous nerve of the thigh
(L2,3) and the femoral (L2,3,4)
emerging from the lateral side of the
psoas muscle; the obturator nerve
(L2,3,4) emerging in the pelvis from the
medial side of the psoas muscle; the
genitofemoral nerve(l1,2) emerging
through the psoas muscle onto its
anterior surface.