Lecture 11: Posterior Abdominal Viscera

• Kidneys

• Ureters

• *Bladder (subperitoneal)

components of the urinary system

Adrenal Glands

-retroperitoneal endocrine organs

-at the superior pole of the kidneys between the kidneys and the diaphragm

Right

Which Adrenal gland is more pyramidal and partially posterior to the IVC?

Left

Which adrenal gland is crescent shaped and extends medial from the superior half of the kidney

Adrenal Cortex

• Outer portion of gland

• Derived from mesoderm

• Secretes: Corticosteroids, Androgens

• Disorders of excess or deficient secretion of above

Corticosteroids and Androgens

what does the adrenal cortex secrete?

Adrenal Medulla

• Inner part of gland

• Derived from neural crest cells

• Secretes catecholamines (Epinephrine & norepinephrine)

• Some adrenal tumors secrete catecholamines

Catecholamines (Epinephrine & norepinephrine)

What does the Adrenal Medulla secrete?

Renal a.

Inferior Suprarenal a comes from what?

Abdominal Aorta

Middle Suprarenal a. comes from what?

Inferior Phrenic a.

Superior Suprarenal a. comes from what?

IVC

the R. suprarenal v drains into the ___________________

L. Renal v.

the L Suprarenal v. drains into the _____________

Superior, Middle, and Inferior Suprarenal aa.

arterial blood supply to the adrenal glands

Thoracic Splanchnic nn. (Greater and Lesser)

Adrenaline ("fight-or-flight") response triggered from what nerves?

Chromaffin Cells

-act like post-synaptic sympathetic neurons in the adrenal gland

-release catecholamines

Lumbar Lymph Nodes

what lymph nodes are next to the adrenal glands?

Kidneys

• Retroperitoneal organs

• Capsule, cortex, medulla, & collecting system

• Often impalpable

Kidneys

Functions:

• Filter blood and produce urine

• Blood pressure regulation via renin

• Role in RBC production via erythropoietin

• Vitamin D activation

Lower Pole of Right Kidney

what part of kidney can you SOMETIMES palpate in lean adults

T12-L3

at what vertebral levels are the kidneys

transpyloric plane

the kidneys lie on what plane?

Renal

Costovertebral angle (CVA) tenderness associated with __________ pathology

Liver

why is there a height difference in the kidneys?

Anterior

R lobe of liver _____________ to R kidney

Anterior

Spleen ______________ to superior pole of L kidney

Renal Cortex

-periphery of the kidneys

-extends centrally as renal columns

Renal Medulla

-multiple fan-shaped renal pyramids

-the apex is the renal papilla

Renal Papilla

the apex of the renal pyramid

Minor Calyx

collects urine from a single renal papilla

Major Calyx

formed by 2-3 minor calyces coming together

Renal Pelvis

• Funnel-shaped structure

• Receives urine from major calyces

• Continuous with ureter

Renal Hilum

Medial cleft where structures enter/exit renal sinus

Renal sinus

Space in the kidney containing fat, neurovasculature, & collecting system

Perirenal space

• Space containing perinephric fat around kidneys & adrenals

• Enclosed by renal fascia

• Exception: opening in fascia inferiorly

• Perinephric abscess or hematoma may extend inferiorly into pelvis through opening

• Nephroptosis

Pararenal Space

Space containing paranephric fat superficial to renal fascia

Renal aa.

blood supply to the kidneys

IVC

the right renal a. travels posterior to the ________________

Left

which renal artery is shorter?

Segmental aa.

at the hilum, the renal aa. divide into 5 _________________

Segmental aa.

• Supply non-overlapping areas of kidney

-allow segments of the kidney to be surgically resectable

Right

which renal vein is shorter?

L adrenal v & L gonadal v.

the left kidney receives inflow from which veins?

Aorta; SMA

the left renal vein courses OVER the ___________ and UNDER the _____________

Left Renal Vein

-vulnerable to entrapment

-Nutcracker syndrome

Vagal Trunks

parasympathetics of kidneys

Thoracic Splanchnic nn

sympathetics of kidneys

Sympathetics

Cause vasoconstriction which decreases renal blood flow during "fight or flight"

T10-L1

visceral afferents of kidneys:

pain fibers travel to ____________ levels

Horseshoe kidney

• Lower poles of kidneys fused or connected by fibrous bridge

• Usually ~L3-L5 level b/c IMA root

Ectopic kidney

• Kidney located outside of renal fossa

• Usually in pelvis

Bifid renal pelvis

Duplication of renal pelvis and one ureter

Unilateral renal agenesis

One kidney congenitally absent

Renal Transplantation

• Preferred treatment for selected cases of chronic renal failure

• Removed from donor without adrenal gland - separated by fascia

Iliac Fossa

-location of kidney transplantation

-support

-ease of access to anastomosis for grafting to external iliac vessels and bladder

Renal vein entrapment ("nutcracker") syndrome

• L renal v traverses midline to reach IVC - crosses under acute angle b/t SMA and aorta

• Traction on SMA compresses L renal v

Renal vein entrapment ("nutcracker") syndrome

• Symptoms: hematuria or proteinuria, abdominal (left flank) pain, nausea & vomiting (if duodenum compressed), & L testicular pain in men

• L-sided varicocele may occur in rare cases

Calculi

"stones" of salts of inorganic/organic acids or of other materials

Ureteric Calculus

-may cause over-distension of tube

• Severe intermittent pain ("ureteric colic") with peristalsis as moved

Renal/Ureteric Calculi (obstruction of urinary flow)

• level of referred pain in lumbar/inguinal regions (T11-L2)

• Pain passes inferioanteriourly "from loin to groin"

• Accompanied by digestive upset and generalized sympathetic response that can mask specific symptoms

• Hydronephrosis - can also happen

Renal Calculi

Ureters

-Muscular tubes coursing from renal pelvis to urinary bladder

-propel urine to the bladder

Intrinisic Pacemakers

what regulates peristalsis of the ureters?

• Ureteropelvic junction (UPJ)

• Crossing iliac vessels/pelvic brim

• Ureterovesical junction (UVJ)

3 anatomic constrictions of the ureters and common sites for ureter stones to lodge

Inferior

(water under the bridge)

the ureters cross _____________ to the uterine a. in females

Ureter

possible injury during hysterectomy and oophorectomy

• Renal aa

• Gonadal aa

• Abdominal aorta

• Common iliac aa

arterial blood supply of abdominal part of ureters

Renal & gonadal vv

venous drainage of abdominal part of ureters

Internal Iliac vv.

venous drainage of pelvic part of ureters

Internal iliac aa & their brs

arterial blood supply of pelvic part of ureters

T11-L2

visceral afferents of ureters:

pain from __________ levels

Ureteric Calculus

Ureteral stone pain "colicky" & referred to back, flank, or groin

Lumbar nodes

lymph nodes near proximal ureters

Common Iliac Nodes

lymph nodes near mid ureters

Internal/External Iliac Nodes

lymph nodes near distal ureters

Bifid ureter

2 proximal ureters on same side that converge before bladder

Duplicated ureter

2 ureters on same side remain separate entire

way to urinary bladder

Obstruction; Reflux

in a duplicated ureter, the upper pole ureter is prone to ________________ while the lower pole ureter is prone to _______________

Retrocaval ureter

R ureter courses posterior to IVC then descends along its medial & anterior aspect

Trigone

• Triangular area between these 3 orifices

• Formed by incorporation of mesonephric ducts into bladder wall

Ureteric orifices

• Openings of the ureters

• Encircled by detrusor muscle which acts as sphincter

• Occlusion leads to hydronephrosis