Transcript 04-kidney,aorta, symp.T.& aortic plexus2008-02

The Kidneys
Function :
1-excretion of urine.
2-control water & electrolyte balance.
3-maintain the acid –base balance of
blood.
They are retro-peritoneal , lie behind
parietal peritoneum on the post.abd.wall.
Right kidney is lower than the left one ,
due to large size of right lobe of liver.
The hilum lies at level
of transpyloric plane ,
(L1 vertebra).
The hilum of the kidney ( slit on the
concave medial border) transmits VAP =
from front backward : renal vein, renal
artery , pelvis of ureter….. Or VAUA=
renal vein,_ 2 branches of renal artery,
ureter, _ 3rd branch of renal artery. Some
lymph vessels & symp.Fs.also present.
The Kidneys :
The kidneys extend from T12V
to L3 vertebra. They recive some
protection from lower part of rib
cage.
Left kidney is slightly higher
than right one , it reaches 11th rib
, while the right kidney reaches
only 11th intercostal space (due to
presence of liver).
Coverings of the Kidney :
Fibrous capsule : it is closely
attached to its outer surface.
Peri-renal fat : it covers the fibrous
capsule.
Renal fascia : it is a condensation
of C.T. surrounding the peri-renal fat
and encloses the kidneys & suprarenal
glands.
Para-renal fat : lies external to
renal fascia.
Peri-renal fat , renal fascia ,and
para-renal fat support the kidneys
and held them in position on
post.abd.wal.
Renal Structure :
Each kidney has a light brown outer
cortex , and a dark brown inner medulla.
The medulla is composed of about
a dozen renal pyramids, with base toward
the cortex and apex ( renal papilla)
projecting medially.
The pyramids are separated by extensions
of cortex called renal columns. Extending
Fs.from the bases of renal pyramids into
cortex are striations called medullary rays.
A.ant.surface of Rt.kidney. B. coronal
section showing cortex, medulla, pyramids,
renal papillae and calyces.
C .showing the Nephrons & blood vessels
within the kidney.
Renal pelvis or (pelvis of ureter) is a
funnel-shaped dilatation, which is formed in
the sinus of kidney by union of 2-3 major
calyces, Each major calyx divides into 2 or 3
minor calyces. It passes through hilum.
Each minor calyx is indented by tha apex
of the renal pyramid ,(renal papilla).
Anterior relation of the Kidneys :
Right Kidney :
Suprarenal gland , liver ,
second part of duodenum ,
right colic flexure, coils of
jejunum.
Left Kidney :
Suprarenal gland , spleen ,
stomach, pancreas , left colic
flexure & descending colon ,
coils of jejunum.
Peritoneal Covering of the Kidney :
The anterior surface only of
right kidney is covered with
peritoneum except :
1- supra-renal area.
2- duodenal area.
3- colic area.
The anterior surface only of
left kidney is covered with
peritoneum except :
1- supra-renal area.
2- pancreatic area.
3- area of descending colon.
Posterior Relations of the kidneys :
Right Kidney :
Diaphragm ,, 12th rib ,
psoas ,quadratus lumborum &
transversus abdominis ms.
Subcostal (T12), iliohypogastric, &
ilioinguinal nerves (L1), run
downward and laterally.
Left Kidney :
Diaphragm, 11th & 12th ribs.
The other structures as the right
kidney.
Posterior Relations of Kidneys :
Blood Supply of the Kidney :
At level of L2 V.-renal artery arises
from aorta. Each renal artery divides into 5
segmental arteries 4- in front & 1- behind
the renal pelvis.
Lobar arteries arise from each segmental
artery, one for each renal pyramid.
2 or 3 -Interlobar arteries arise from each
lobar artery , running on each side of renal
pyramid.
At the junction of cortex & medulla,
interlobar arteries give off arcuate arteries
arching over the bases of pyramids, at
junction of cortex & medulla.
Several interlobular arteries arise from
arcuate arteries that ascend in the cortex.
Afferent glomerular arterioles arise as
branches of interlobular arteries.
Blood supply of Kidneys :
Afferent glomerular arterioles
break into capillaries that collect into
efferent glomerular arterioles.
Efferent G.arterioles breaks into
interlobular veins ending in arcuate
veins that collect to interlobar, lobar,
renal vein. Eff.G.arterioles also pass
deeply into medulla and breaks into
vasa recta which pass to apex of
pyramid and breaks into capillaries
which constitute the venous side and
end in arcuate veins, at junction of
cortex & medulla.
C-section of kidney, showing position of
nephrons & arrangement of Bl.vs. in kidney
Arcuate veins collect into interlobar veins which collect into lobar
then renal vein and finally I.V.C.
Venous , lymphatic drainage &
N.Supply :
Veins : Renal vein emerges from
hilum in front of renal artery and
drains into I.V.C.
Lymph drainage : lateral aortic
L.Ns. around origin of renal artery.
N.Supply :
-Sympathetic & parasympathetic via
renal plexus surrounding renal artery.
–afferent sympathetic Fs.in the renal
plexus enter spinal cord segments at
T10,11, 12
Ureter (Abdominal part) :
It is a muscular tube that extends
from hilum of kidney to post.surface
of urinary bladder.
It propels urine by peristaltic
contractions.
It has 3 constrictions : where renal
pelvis joins ureter, where it is kinked
as it crosses pelvic brim (bifurcation
of common iliac artery), where it
pierces bladder wall.
Renal pelvis is funnel-shaped upper
part of ureter, lies in the hilum of
kidney and receives major calyces.
Ureter :
Course of ureter :
It emerges from hilum of
kidney to run vertically downward
behind parietal peritoneum, on
the psoas major ms., which
separates it from lumbar
transverse processes.
It enters pelvis by crossing
bifurcation of common iliac artery
in front of sacroiliac joint, till it
reaches level of ischial spine.
It ends in U.B. by openning at
supero-lateral angle of trigone.
Anterior relations of Right Ureter :
Duodenum & terminal part of
ileum.
Superior mesenteric artery &
mesentry of small intestine.
Right gonadal vessels.
 Right colic & Iliocolic vessels
Posterior relations of Right Ureter :
Right psoas major which
separates it from lumbar
transverse processes.
Right psoas minor.
Genito-femoral N.
Bifurcation of right common
iliac artery.
Anterior relations of Left Ureter :
Sigmoid colon & mesocolon.
Sigmoid vessels.
Left gonadal vessels.
Left colic vessels.
Posterior relations of Left Ureter (as
the Right ureter) :
Left psoas major which
separates it from lumbar
transverse processes.
Psoas minor.
genito-femoral N.
Bifurcation of left
common iliac artery.
Blood Supply ,Lymph drainage & N. Supply :
Upper part : renal artery (L2 V.).
Middle part : gonadal artery
(testicular or ovarian).
Pelvic part : superior vesical artery.
Lymph drains to lateral aortic &
iliac L.Ns.
N.supply :
-Sympathetic & parasympathetic Via
Renal , gonadal & hypogastric
plexuses (in the pelvis).
-Afferent sympathetic Fs.enter spinal
cord segments at T11,12 & L1,2.
2 yellowish retro-peritoneal glands
that lie on upper poles of kidneys.
Suprarenal glands They are surrounded by renal fascia
but separated from kidneys by
perirenal fat.
Yellow cortex secrets mineral
corticoids & glucocorticoids & sex
hormones.
Medulla secrets catecholamines :
epinephrine & norepinephrine.
Rt,gland : caps upper pole of
Rt.kidney, lies behind Rt.lobe of liver,
I.V.C., anterior to diaphragm.
Left gland : reaches hilum of
kidney, lies behind pancreas, lesser sac
& stomach, anterior to diaphragm.
Blood Supply, Lymph & N. Supply of
Suprarenal glands :
Arterial supply :
inferior phrenic artery (upper
part),
aorta (middle
part) &
renal artery
(lower part).
Vein of right gland ends in I.V.C.,
while vein of left gland ends in left
renal vein.
Lymph drains into lateral aortic
nodes.
N.Supply : symp. Fibres from
splanchnic nerves &
parasympathetic Fs.
Clinical Notes : 1- Renal pain
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Type of pain : dull ache to severe pain in the flank
that may radiate into lower abdomen.
Causes : 1-stretching of kidney capsule.
2-spasm of smooth muscle in renal pelvis.
Pain is referred along distribution of subbcostal
N.(T12) …. to the flank & anterior abd. Wall.,
because afferent N.Fs.ascends from renal plexus to
spinal cord at level of T12, via lowest splanchnic
N.in thorax & symp.trunk.
2- Renal colic :
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In renal colic, strong peristaltic waves of contraction pass
through ureter in attempt to pass the stone onward, so the
spasm of smooth muscle causes an agonising colicy pain.
Renal pelvis & ureter send their afferent nerves into spinal
cord segments : T11,12 and L1,2
Colicy pain is referred to areas supplied by these seg.of spinal
cord, into flank, loin & groin.
When stone enters low part of ureter, pain is referred to testis
or tip of penis or labium majus in female.
Sometimes ureteric pain is referred to front of thigh along
femoral branch of genitofemoral N.(L1,2).
Pain is often so severe that spreads in C.N.S. giving nausea.
3-Ureteric Stone
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Ureteric stones are arrested in the ureteric
narrowing at these sites : 1-at pelvi-ureteral
junction. 2-at pelvic brim. 3-at its enterance to
urinary bladder.
Most of ureteric stones are not seen by plain
radiographic examination, so I.V.pyelography is
usually necessary by using of radiopaque compound
(iodine-containing compound), by injection into
subcut.arm vein, so the coarse of ureter is clearly seen
in front of tips of transverse processes of lumbar
vertebrae, crossing sacro-iliac joint then ends in bladder.
Abdominal Aorta :
It is a continuation of descending
thoracic aorta ,it enters abdomen
through aortic opening of diaphragm
at the level of T12 vertebra.
It descends behind peritoneum on the
bodies of lumbar vertebrae.
 it terminates at the level of L4
vertebra (inter-cristal plane) , into
2 common iliac arteries.
On the right side : I.V.C., azygos
vein ,lymph trunk (cisterna chyli) +
Rt.crus of diaphragm.
On the left side : sympathetic trunk
+ left crus of diaphragm.
Branches of Abdominal Aorta :
3 anterior visceral branches :
celiac, superior mesentric & inferior
mesenteric arteries.
3 lateral visceral branches :
suprarenal, renal & gonadal arteries.
5lateral abdominal wall branches
: inferior phrenic & 4 lumbar
arteries.
3terminal branches : 2 common
iliac + median sacral artery.
Single Branches of Abdominal Aorta :
Coeliac artery : from front of
aorta at the level of T12 V.
(or upper border of L1 V)
Superior mesentric artery : from
front of aorta at the level of L1 V.
(transpyloric plane).
Inferior mesenteric artery : from
front of abdominal aorta at level of
L3 V. (subcostal plane).
Median sacral artery : from
back of abdominal aorta at the level
of L4 V.
Paired Branches of Abdominal Aorta :
Phrenic arteries : at the sides of
coeliac artery (at level of upper border
of L1 V.,or T12V.)
Middle suprarenal arteries
(at lower border of L1 V.)
Renal arteries (at L2)
Testicular or ovarian arteries : on
the sides of inferior mesenteric artery
(at level of L3V).
Lumbar arteries : 4 pairs of
arteries, arising from back of aorta.
Common iliac arteries :
at level of L4 V. (inter-cristal plane)
Terminal Branches of Abdominal Aorta :
Common iliac arteries : they
arise at level of L4 V ,descend
downward and laterally along medial
border of Psoas major.
Each common iliac artery crossed
anteriorly by the ureter & ends in
front of sacro-iliac joint into
external & internal branches.
Branches of Common iliac artery:
1-External iliac artery :
runs along medial border of Psoas major.
It enters thigh behind inguinal ligament
to become femoral artery.
It gives off 2 branches above inguinal
ligament : 1-inferior epigastric artery.
2-deep circumflex iliac artery.
Inferior epigastric artery passes medially
along medial margin of deep inguinal ring and
enters rectus sheath behind rectus abdominis to
anastomose with superior epigastric artery to
supply anterior abd.wall.
Deep circumflex iliac artery ascends laterally
to iliac crest to supply Ms. of anterior Abd.wall
2-Internal iliac artery descends to
pelvis in front of sacro-iliac joint.
Obliteration of abdominal
aorta & iliac arteries :
Atherosclerosis leads to gradual
occlusion of bifurcation of abdominal
aorta & iliac arteries, results in pain in
leg during walking (claudication) due
to lack of blood in external iliac
artery & impotance due to lack of
blood in internal iliac arteries.
Some collateral circulation is
established, but it is physiologically
inadequate, so skin ulcer & tisssue
death may occur.
Surgical treatment by thrombo-endarterectomy or a bypass graft should be
done.
Obliteration of abdominal
aorta & iliac arteries :
Note the possible collateral
circulation of abdominal aorta.
Note great dilatation of
mesenteric arteries & their
branches, which occurs if the aorta
is slowly blocked just below level of
renal arteries (L2).
Course of I.V.C. :
It is formed by union of the 2
common iliac veins behind
right common iliac artery at
level of L5 vertebra
(intertubercular plane), 1 inch
to right of median plane.
It ascends on right side of
aorta to pierce central tendon
of diaphragm at level of T8
vertebra to drain into right
atrium of heart.
Tributaries of I.V.C :
2 anterior visceral tributaries
: the 2 hepatic veins.
3 lateral visceral tributaries :
-Rt.suprarenal V. (left drains into
left renal vein).
-renal veins.
-Rt.gonadal V. (left drains into
left renal vein).
5 lateral abdominal wall
tributaries :
-inferior phrenic veins.
-4 lumbar veins.
3 veins of origin : 2 common
iliac veins + median sacral vein.
Medial & lateral Relations of I.V.C. :
Medially( on left side) :
abdominal aorta.
Laterally (on right side) :
right ureter.
Anterior relations of I.V.C. :
Right common iliac artery.
Root of mesentry & superior
mesenteric vessels.
3rd part of duodenum.
Right testicular or ovarian Ar.
Head of pancreas.
1st part of duodenum.
foramen to lesser sac
separates I.V.C. from _ portal
vein, hepatic artery & bile duct
in free right margin of lesser
omentum.
Foramen to lesser sac :
Note that opening to lesser sac (epiploic foramen at level
of transpyloric plane L1) separates I.V.C. from portal vein.
Venous blood from abdominal part of G.I.T.drains to liver
by portal vein,then from hepatic veins to I.V.C.
Posterior relations of I.V.C. :
Bodies of lumbar vertebrae.
Right sympathetic trunk.
Right psoas major.
Right lumbar arteries.
Right renal, suprarenal &
phrenic arteries.
Right crus of diaphragm.
Inferior Mesenteric Vein :
It begins halfway down anal canal as a
continuation of superior rectal vein.
It is a tributary of portal circulation.
It joins splenic vein behind body of
pancreas.
It receives tributaries related to
branches to the artery
(left colic, sigmoid, & sup.rectal veins)
Splenic Vein :
It is a tributary of portal vein.
It begins at hilum of spleen by
union of several splenic veins and is
joined by short gastric & left gastroepiploic veins.
It passes within splenicorenal
ligament with splenic artery
( the artery lies along upper border
of pancreas) ,then runs behind body
of pancreas to join superior
mesentric V behind neck of
pancreas to form portal vein.
It is joined by pancreatic veins &
inferior mesenteric vein.
Superior Mesenteric Vein :
It is a tributary of portal vein.
It begins at ileocecal junction
lying within root of mesentry of
small intestine on right side of the
artery.
It passes in front of 3rd part of
duodenum , behind neck of
pancreas, where it joins splenic
vein to form portal vein.
It receives tributaries
correspond to the artery (middle
colic, right colic, iliocolic & jejunal
and ileal veins).
Note tributaries
of the Portal vein.
Portal vein drains blood
from abdominal part of
G.I.T. from lower 1/3 of
esophagus to halfway
down the anal canal, it also
drains blood from spleen,
pancreas, & gallbladder.
Portal vein enters liver
and breaks into sinusoids,
from which blood passes
into hepatic veins that
drain into I.V.C.
External iliac vein :
It begins behind inguinal ligament
as a continuation of femoral vein.
It ends by joining internal iliac
vein to form common iliac vein.
It receives inferior epigastric &
deep circumflex iliac veins.
Internal iliac vein :
It begins in the pelvis by joining
all tributaries that correspond to
branches of the artery.
It ends in front of sacroiliac joint
by joining external iliac vein to form
common iliac vein.
The 2 common iliac veins joined
together to form I.V.C. (at L5V.)
Collateral venous anastomoses
between I.V.C. & S.V.C. :
Temporary varicose veins , result from
compression of I.V.C. by enlarged uterus
during later stages of pregnancy.
Malignant retro-peritoneal tumors cause
blockage of I.V.C., resulting in dilatation of
extensive anastomoses of the tributaries of
I.V.C. (as lumbar, Azygos & hemiazygos veins).
This alternative pathway for blood to return to
right atrium is commonly referred to as cavalcaval shunt.
The same pathway results in case of
Sup.mediastinal tumor, compressing S.V.C
Clinically : enlarged subcutaneous anastomosis
is seen on thoracabdominal wall between lateral
thoracic vein (tributary of axillaryvein) &
superficial epigastric vein. (tributary of femoral
vein).
Collateral venous anastomoses
between I.V.C. & S.V.C. :
Note the alternative pathways for
blood to return to right atrium if
S.V.C. becomes blocked below
enterance of Azygos vein, through
azygos, internal or lateral thoracic veins
into I.V.C.
Similar pathways exist if
I.V.C.becomes blocked below renal
veins.
So,a number of anastomotic channels
connect both venae cavae indirectly in
case of thrombosis of any vein.
Note also anastomosis between
portal & systemic veins in anal canal.
Sympathetic trunk (Abdominal part) :
It is continuous above with thoracic part &
below with pelvic part of symp.trunk.
It enters abdomen behind medial arcuate
ligament.
It descends along medial border of
psoas major, lying on the bodies of lumbar
vertebrae.
it enters pelvis behind common iliac
vessels.
Right symp.trunk lies behind right
border of I.V.C., but left symp.trunk lies
close to left border of aorta.
Aorta and related
sympathetic plexuses.
It has 4 or 5 ganglia, 1st & 2nd ofen being
fused together.
Sympathetic Trunk
It enters abdomen behind medial arcuate ligament.
It descends along medial border of psoas major.
Note left symp.trunk lies close to left border of aorta..
Sympathetic trunk (Abdominal part) :
Branches :
White rami communicantes : the upper 2
ganglia receive a white ramus communicantes from 1st
& 2nd lumbar spinal nerves, they contain sensory N.Fs.
Gray rami communicantes join each ganglion
to a corresponding lumbar spinal nerve. These
postganglionic Fs.are distributed through the branches
of spinal nerves to : 1-blood vessels (vasomotor)
2-sweat glands
3-arrector pili muscles of skin.
Vascular Fibres pass medially to form
the symp. plexuses on abdominal aorta &
its branches. (these plexuses also receive Fs.from
Aorta and related
sympathetic plexuses.
splanchnic nerves & vagus).
Vascular Fibres pass downward & medially below
bifurcation of abdominal aorta, between common iliac
vessels to form Sup.hypogastric plexus
Aortic Plexuses
The nerve plexus around the
abdominal aorta (front &sides) is
formed of :
1-preganglionic & postganglionic
sympathetic fibres.
2-preganglionic para-sympathetic fibres
(from the vagus nerves).
3- visceral afferent fibres.
Aortic and related
sympathetic plexuses.
This plexus concentrates around
origin of certain blood vessels to form :
1-celiac plexus.
2-renal plexus.
3-Sup.mesenteric plexus.
4-Inferior mesenteric plexus.
Aortic Plexuses
Celiac plexus :
-it consists mainly of 2 celiac ganglia
Aortic and related
sympathetic plexuses.
connected together by a large network of
fibres which surround celiac trunk.
- the ganglia receive greater & lesser
splanchnic nerves, which arise from symp.
trunk in the thora (preganglionic symp.Fs).
- Postganglionic symp.Fs. arise from
ganglia and accompany the branches of
celiac trunk to supply structures supplied
by left gastric, hepatic & splenic arteries.
- Parasympathetic vagal Fs. From posterior
gastric N. also accompany the branches of
the artery.
Aortic Plexuses
Renal & Sup.mesenteric
plexuses :
- they are smaller than celiac plexus.
-they are distributed along the branches
of the corresponding arteries.
-it receives also parasymp. vagal Fs.
Aortic and related
sympathetic plexuses.
Inferior mesenteric plexus :
-it is similar to the above plexuses
but it receives parasymp.Fs. From
sacral parasymp. Nerves.
( pelvic splanchnic Nerves).
Abdominal part of parasympathetic
Trunk :
Anterior gastric Nerve :
Distribution of anterior
&posterior gastric N. Trunks.
-it arises from lower part of
esophageal plexus.
-it contains fibres mainly from
left vagus nerve in thorax.
-it descends in front of
esophagus & stomach to supply
abdominal viscera.
-A large hepatic branch passes
up to liver, and from this a
pyloric branch passes down to
pylorus.
Abdominal part of parasympathetic
Trunk :
Posterior gastric Nerve :
Distribution of anterior & posterior
gastric N.trunks.
-it arises from lower part of
esophageal plexus.
it contains Fs. mainly from right
vagus nerve in thorax.
-it descends behind esophagus &
stomach to supply abdominal
viscera.
-celiac branch of posterior
gastric nerve is distributed to
celiac & superior mesenteric
plexuses to supply intestine as
far down as the left colic
flexure.
Abdominal part of parasympathetic
The vagus nerves supply
Trunk :
parasympathetic fibres to :
1-esophagus.
2-stomach.
3-small intestine.
4-large intestine up to junction of
right 2/3 & left 1/3 of transverse
colon. 5-liver, pancreas, kidneys.
Visceromotor =
Secretomotor to glands.
Motor to walls of G.I.T.
Relaxation to the sphincters.
Left 1/3 of transverse colon
,descending colon ,pelvic colon &
rectum are supplied by
parasymp.Fs.from pelvic
splanchnic nerves,.which are formed
of S2,3,4 spinal nerves.
These parasympathetic fibres are
viscero-motor, but symp. Fs. carries
pain-transmiting N.Fs.
Spinal cord segments supplying Sympathetic
Nerves to Abdominal organs :
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Visceral stomach pain is reffered to epigastrium because
afferent sensory Fs.from the stomach ascend in company
with symp.nerves to enter spinal cord at segments T5-9, so
pain is reffered to lower chest & upper abdominal wall
Visceral pain from appendix is reffered to umbilicus
(T10 dermatome), because sensory N.Fs. in company with
sympathetic nerves enter spinal cord at segment T10.
Liver & Gallbladder (choecystitis or gallstone colic),
Symp.N.Fs. passing through celiac plexus & greater
splanchnic nerves enter spinal cord at T5-9 segments,
which is reffered to lower chest & upper abdominal wall.
Spinal cord segments supplying Sympathetic
Nerves to Abdominal organs :
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Central diaphragmatic peritonitis, which is
innervated by phrenic N.( C3,4,5), can give rise to
reffered pain over the shoulder because skin in
this area is innervated by supraclavicular nerves
(C3,4).
Kidney : T10,11,12
Ureter : T11,12 - L1,2
Suprarenal :T8 – L1
Good luck For My Students
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Dr.Sanaa