Dynamic Radiology of the Abdomen Normal and Pathologic Anatomy
Transcript of Dynamic Radiology of the Abdomen Normal and Pathologic Anatomy
Dynamic Radiology of the Abdomen Normal and Pathologic Anatomy
MORTON A. MEYERS
Dynamic Radiology of the Abdomen Normal and Pathologie Anatomy
with a contribution in ultrasonography by
Elias Kazam
638 figures including 14 color plates
Springer Science+Business Media, LLC
1976
Morton A. Meyers, M.D. Professor of Radiology Cornell University Medieal College New York, New York
Elias Kazam, M.D. Assistant Professor of Radiology Cornell University Medieal College New York, New York
Library of Congress Cataloging in Publieation Data
Meyers, Morlon A. Dynamie radiology of the abdomen.
Ineludes bibliographieal referenees and index. 1. Abdomen-Radiography. I. Kazam, Elias. 11. Title.
RC944.M48 617' .55'07572 76-18722
All rights reserved.
No part of this book may be translated or reprodueed in any form without written permission from Springer-Verlag.
© 1976 by Springer Science+Business Media New York
Originally published by Springer-Verlag New York Inc. in 1976.
Softcover reprint of the hardcover 1st edition 1976
ISBN 978-1-4757-3957-2 ISBN 978-1-4757-3955-8 (eBook)DOI 10.1007/978-1-4757-3955-8
To my wife, Bea, and my children, Richard and Amy
There are some things which cannot be learned quickly, and time, which is all we have, must be paid heavily for their acquiring. They are the very simplest things; and, because it takes a man's life to know them, the little new that each man gets from life is very costly and the only heritage he has to leave.
Ernest Hemingway (1898-1961), Oeath in the Afternoon
Preface
This book provides a systematie applieation of anatomie and dynamie prineiples to the praetieal understanding and diagnosis of intraabdominal diseases. Anatomie sections and injeetion studies form a basis for understanding the eharaeteristie features of many eommon and uncommon diseases and their spread and loealization in the abdomen. These relationships and speeifie eriteria provide a rational system for accurate radiologie analysis in plain films, eonventional eontrast studies, ultrasonography, and computerized transaxial tomography (CTT). This information leads to the uncovering of clinieally deeeptive diseases, the evaluation of the effeets of disease, the antieipation of eomplieations, and the determination of the appropriate diagnostie and therapeutie approaches.
The introductory atlas presents full color anatomie cross seetions of the abdomen and pelvis, eomplemented by labeled traeings, and detailed CTT seans at eorresponding levels. The seetions, whieh are approximately 3.8 em (1.5 in.) thiek, were obtained from fresh eadavers frozen in dry iee for 48 hours, in order to maintain the true intimate anatomie relationships. The aeeompanying text of the atlas stresses normal gross relationships, eommon variants, and the basis of their radiologie identifieation, partieularly in plain films. The subsequent ehapters deal with the diagnosis and the pathways of spread of infeetion, malignaneies, and traumatie and inflammatory effusions within the intra- and extraperitoneal spaees. Emphasis is plaeed on the specifie loealizing features based on the anatomie planes and reeesses and the dynamies of extension of disease. Sagittal and coronal as weIl as horizontal anatomie seetions support the findings in eonventional radiologie proeedures, ultrasonography, and eomputerized transaxial tomography throughout. Correlation with the clinieal findings and management underscores the value of the radiologie observations. Diagnostie eriteria whieh are easily applied are established for the eharaeteristie features of speeifie disease processes ranging from loealized abseesses to dis semina ted metastases.
Many of the insights detailed in this book have been made only in the past few years. The applieation of peritoneography as a clinieal diagnostie study, for example, first indieated the dynamie cireulation of fluid states within the peritoneal reeesses and permitted an insight into the spread of infeetion and malignaneies. Similarly, the signifieanee of the anatomie and radiologie definition of the extraperitoneal spaees, the small
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bowel mesentery and other peritoneal refleetions, the haustral eontours of the large intestine, and the eontiguity of eertain organ relationships has only reeently been appreciated.
Acknowledgments
I first learned my basie gross anatomy as a medieal student at The State University of New York Upstate Medieal Center in Syraeuse. It is a partieular pleasure to thank Dr. Donald Goodman, Chairman of the Department of Anatomy, for permission to reproduee many of the anatomie seetions skillfully prepared by Mr. Lou Rimmler. Alfred S. Berne, M.D., an intelleetually demanding radiologist who has always stressed anatomie and pathologie eorrelation, has provided eontinued support and eneouragement.
Many of the illustrations have been reprodueed, with permission of the publishers, from articles of mine whieh have first appeared in Radiology and The American Journal 0/ Roentgenology, Radium Therapy and Nuclear Medicine. David H. Stephens, M.D., Robert R. Hattery, M.D. and Patriek F. Sheedy 11, M.D., Mayo Clinie, Roehester, Minnesota, and Stuart S. Sagel, M.D. and Robert J. Stanley, M.D., Washington University Sehool of Medicine, St. Louis, Missouri, have graciously allowed me the use of some of their material of eomputerized transaxial tomography of the abdomen.
A grant from E. R. Squibb and Sons made possible mueh of the art work neeessary for the graphie exposition of the anatomie relationships.
Last, I would like to thank the editorial staff of SpringerVerlag, New York, for their helpful suggestions and eonsistent cooperation through the preparation of this work.
Morton A. Meyers, M.D.
Foreword by Richard H. Marshak, M.D.
Few books present so fresh an approach and so clear an exposition as does Dynamie Radiology 0/ the Abdomen: Normal and Pathologie Anatomy.
This well-doeumented, clearly written, and beautifully illustrated book details the answers not only to "what is it?" but also "how?" and "why?" Such fundamental information regarding the pathogenesis of disease within the abdomen reinforces and simplifies accurate radiologie analysis. The eharaeteristie radiologie features of intraabdominal diseases are shown to be easily identified, expanding the praetieal applieation of the term "pattern recognition." It eertainly is of praetieal value in daily clinieal experienee and will be of considerable help for furt her advanees.
The traditional dissectional method of learning anatomy disturbs the intimate relationships of struetures. The sectional anatomy presented in this book is the framework for understanding the findings in eonventional radiology-in plain films and routine eontrast studies-as weIl as in ultrasonography and computerized tomography of the abdomen.
This is not just a review of others' experienees, but a erystallization of the author's contributions over the past several years. Dr. Meyers' coneept of dynamie cireulation within the peritoneal eavity is a breakthrough in our understanding of the spread of intraabdominal disease, partieularly abseesses and malignaneies. Peritoneography, the opaeifieation of the largest lumen in the body, offers a potential yield of vast diagnostie information. The precise definition of the three extraperitoneal spaees represents a eharting of previously unexplored territory. Awareness of the renointestinal and duodenoeolie relationships, the spread of pancreatitis along mesenterie planes, and the pathways of extrapelvie spread of disease again underscores the praetieal importanee of anatomie features. The approach to the mesenterie and antimesenterie borders of the small bowel and to the haustral pattern of the colon adds a new dimension to the interpretation of abdominal radiology.
This book eonfirms Dr. Meyers' reputation as one of the authorities in normal and pathologie radiologie anatomy of the abdomen.
Riehard H. Marshak, M.D. Clinieal Professor of Radiology Mount Sinai Sehool of Medieine New York City
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Foreword by Lloyd M. Nyhus, M.D., F.A.C.S.
Dr. Morton A. Meyers indeed has developed adynamie text relating to radiologie aspeets of abdominal disease. But this statement, with its emphasis on radiology, is misleading. This book is an important reading souree for surgeons. Dr. Meyers' observations have not been confined to those arising from a purely radiologie study of the abdomen. The inclusion of observations based on injeetion studies both in the eadaver and in vivo has given this work a noteworthy eomprehensiveness.
The insights provided by both the atlas of full-page color anatomie cross seetions of the abdomen and pelvis and the exeellent anatomie-radiologie eorrelations found in the text make the book indispensable. The atlas establishes the basis for intimate anatomie relationships which are then applied to the practieal areas of clinieal diagnosis and treatment of intraabdominal pathology. Presentations of these diagnostic and therapeutie eonsiderations are enhanced by illustrated discussions relative to the new techniques of ultrasonography and eomputerized transaxial tomography.
Dr. Meyers' presentation of this timely information is valuable, but what makes this book invaluable is the vast personal experienee he is able to bring to it. This is not "just another" book purporting to give us something new in this important field. I believe the special approach given to this subjeet by Dr. Meyers is truly innovative. The radiologist and surgeon looking for the latest techniques in angiography for the diagnosis and treatment of massive bleeding from the gastrointestinal tract will not find it here. What they will find is major help in the understanding of, and indeed, therapeutie approach to a number of common intraabdominal problems, including infeetion and malignancy.
Lloyd M. Nyhus, M.D., F.A.C.S. Warren H. Cole Professor and The Abraham Lineoln School of Medieine University of Illinois at the Medical Center Chieago, Illinois
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Contents
Prefaee vii
Foreword by Riehard H. Marshak, M.D. ix
Foreword by Lloyd M. Nyhus, M.D. xi
Normal Anatomie Relationships and Variants xvii
Chapter 1 Intraperitoneal Spread of Infeetions
General Introduetion 1
Anatomie Considerations 2 The Posterior Peritoneal Attaehments 2 Detailed Anatomy of the Right Upper Quadrant 3
The Right Subhepatie Spaee 3 The Right Subphrenie Spaee 6
The Left Subphrenie Spaee 7 The Lesser Sae 8
Radiologie Features 10 The Spread and Loealization of Intraperitoneal
Abseesses 1 0 Pelvie Abseesses 11 Right Subhepatie and Subphrenie Abseesses 12 Lesser Sae Abseesses 21 Left'Subphrenie Abseesses 23 Summary 33
Management 33
Referenees 34
Chapter 2 Intraperitoneal Spread of Malignaneies
General Introduetion 37
Direet Invasion from Noneontiguous Primary Tumors 38 Invasion along Mesenterie Refleetions 38
Careinoma of the Stomaeh 39 Careinoma of the Panereas 43 Careinoma of the Colon 44
Invasion by Lymphatie Permeation and Extension 47
Direet Invasion from Contiguous Primary Tumors 48
Intraperitoneal Seeding 54 Anatomie Features 55 Pathways of Aseitie Flow 56 Seeded Sites 57
Poueh of Douglas (Reetosigmoid Junetion): Radiologie Features 58
Lower Small Bowel Mesentery (Terminal Ileum and Ceeum): Radiologie Features 59
Sigmoid Colon: Radiologie Features 69 Right Paraeolie Gutter (Ceeum and Aseending
Colon): Radiologie Features 71
Embolie Metastases 71 Metastatic Melanoma 71 Breast Metastases 75 Bronehogenie Careinoma 79 Renal Carcinoma 80
Referenees 80
Chapter 3 Peritoneography: Normal and Pathologie Anatomy
General Introduetion 83
Safety of Intraperitoneal Water-Soluble Contrast Media 84 Investigational Evidenee 84 Clinieal Evidence 85
Historical Development of Peritoneography 85
Indieations and Contraindications 86
Teehnique of Peritoneography 87 Adjunet to Peritoneoscopy 89
Findings on Peritoneography 90 Right Upper Quadrant 91
Liver: Right Lobe 91 Liver: Left Lobe 95 Gallbladder 97
Stomaeh and Supporting Mesenteries 97 Left Upper Quadrant 101
Spleen 101 Tail of Pancreas 101
Colon 103 Pelvie Area 104
Urinary Bladder 104 Female Pelvic Organs 109
References 110
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Chapter 4 The Extraperitoneal Spaees: Normal and Pathologie Anatomy
General Introduetion 113
Anatomie Considerations 115 The Three Extraperitoneal Compartments 116 The Psoas Museie 121 The Hepatic and Splenic Angles 122
Anterior Pararenal Spaee 123 Roentgen Anatomy of Distribution and Localization of
Collections 123 Sources of Effusions 125
Extraperitoneal Perforations of the Colon and Appendix 126
Perforations of the Duodenum 129 Retroduodenal Hematoma 131 Pancreatitis 133 Bleeding from Hepatic or Splenic Artery 135
Perirenal Spaee 139 Roentgen Anatomy of Distribution and Localization of
Collections 139 Sources of Effusions 141
Perirenal Gas-Producing Infection 142 Perirenal Abscess 145 Uriniferous Perirenal Pseudocyst (Urinoma) 151 Distinction between Perirenal and Subcapsular
Collections 157
Posterior Pararenal Spaee 172 Roentgen Anatomy of Distribution and Localization of
Collections 172 Clinical Sources of Effusions 174
Spontaneous Bleeding 174 Abscess 174 Lymphatic Extravasation 174 Posterior Spread of Pancreatitis 179 Diffuse Extraperitoneal Gas 181
Rectal Perforation 185 Sigmoid Perforation 185 Extraperitoneal Gas of Subdiaphragmatic
Origin 187 Differential Diagnosis of Small Amounts of
Subdiaphragmatic Gas 187
Psoas Abseess 189
Referenees 192
Contents
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Chapter 5 The Renointestinal Relationship_s: Normal and Pathologie Anatomy
General Introduetion 195
Anatomie Considerations 195 The Right Kidney 195 The Left Kidney 197
Radiologie Observations 199 Characteristic Mass Displacements 199
The Right Kidney 199 The Left Kidney 206
Ptosis and Rotation 213 Invasive Hypernephroma 214 Perinephritis and Renointestinal Fistulas 214 Renal Agenesis and Ectopia 220
The Right Side 224 The Left Side 228
Direct Intestinal Effects Unique to Renal Ectopia 231
Referenees 234
Chapter 6 The Duodenoeolie Relationships: Normal and Pathologie Anatomy
General Introduetion 237
Anatomie and Normal Radiologie Features 237
Abnormal Radiologie Features 243 Masses within the Mesocolic Leaves 243 Effect on the Descending Duodenum by Carcinoma of
the Hepatic Flexure 243 Duodenocolic Fistulas 247 Effect of Gallbladder Disease on the Duodenocolic
Relationships 247 Duodenocolic Displacements from Right Renal
Masses 249 Effect on Colon of Mass Arising in Descending
Duodenum 249 Inframesocolic Extension of Neoplasm of Third
Duodenum 253 Acute Pancreatitis 253 Abscess of Morison's Pouch versus Inframesocolic
Abscess 253 Duodenojejunal Junction: Relation to Colon 256
Referenees 260
Chapler 7 Intestinal Effeets of Panereatitis: Spread along Mesenterie Planes
General Introduetion 261
Anatomie Considerations 261
Effeets of Panereatitis on Colon: Spread along the Transverse Mesoeolon 265 Hepatic Flexure 265 Transverse Colon and Splenie Flexure 269
Effeets of Panereatitis on the Duodenum, Small Bowel, and Ceeum: Spread along Small Bowel Mesentery 273 Duodenum 273 Small Bowel and Cecum 273
Referenees 277
Chapler 8 The Small Bowel: Normal and Pathologie Anatomy
General Introduetion 279
Anatomie Considerations 279
Normal Radiologie Observations 283 Axis of Root of the Small Bowel Mesentery 283 Undulating Changeable Nature of Coils of Bowel
Loops 283 Identification of Mesenteric and Antimesenteric Borders
of Sm all Bowel Loops 286
Abnormal Radiologie Features 288 Diverticulosis of the Small Intestine 289 Meckel's Diverticulum 292 Intestinal Duplication 293 Seeded Metastases 295 Hematogenous Metastases 295 Regional Enteritis 296 Lymphoma 301 Intramural and Mesenteric Bleeding 303
Referenees 303
Chapler 9 The Colon: Normal and Pathologie Haustral Anatomy
General Introduetion 305
Anatomie Considerations 306 Classification of Organization of Haustral Rows 309
Normal Radiologie Observations 309
Abnormal Radiologie Features 315 Lesions within the Gastrocolic Ligament 315 Lesions within the Transverse Mesocolon 318 Distinction between Intra- and Extraperitoneal
Processes 325 Diverticulosis and Diverticulitis 328
Summary 330
Referenees 332
Chapler 10 Pathways of Extrapelvie Spread of Disease
General Introduetion 333
Anatomie Considerations 335
Radiologie Findings 337
Referenees 345
Index 347
Contents
XV
Normal Anatomie Relationships and Variants
General Introduction
Abasie knowledge of normal anatomie relationships and variants is essential to understanding the effeets of pathologie processes. Fundamental eonsiderations include constant anatomie landmarks, variations in positions of struetures, relationships maintained and bounded by peritoneal and faseial attaehments, distribution of intra- and extraperitoneal fat providing the eontrasting interfaces of organ and viseus eontours, and governanee of the configuration of the hollow viscera by specifie anatomie eharaeteristies and general physieal laws.
Figure 1 illustrates that the image one first sees is determined by the relationship established between individual features (7). In a similar manner, clinieal and radiologie diagnosis is based on the extraetion of a set of features eharaeteristie of a partieular proeess. Deviation from the normal, however, must be reeognized before alesion ean be suspeeted.
This atlas provides a detailed overview of the eomplex anatomie relationships within the abdomen. Its aeeompanying text stresses normal radiographie features. Cadavers, frozen in dry iee for 48 hours, were seetioned into horizontal slices approximately 3.8 em (1.5 in.) thiek with a band saw (Seetions 1 through 12). Tracings of the anatomie seetions, appropriately labeled, are included to faeilitate identifieation. The clarity of the features demonstrated in the anatomie seetions readily provide eorrelation with the struetures now identifiable by computerized transverse tomography (CTT 1 through 9).
The Liver
The RIGHT LOBE is mueh larger than the left and extends from its domed surfaee near the diaphragm to its inferior viseeral surfaee whieh faees posteriorly and has complex relationships to
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FIG. 1. W. E. Hill's "My Wife and My Mother-in-Iaw." 80th images are present in the drawing. The viewer first sees either an old woman or a young lady. The old woman's prominent nose in profile is the young woman's chin. This drawing illustrates that perception is determined by the relationships.
several intraperitoneal and extraperitoneal structures. The anterior third of the inferior surface of the right lobe is inden ted by the hepatic flexure of the colon. A fossa for the right kidney lies posterior to the colonic impression. The gallbladder lies just under the anterior-inferior edge of the liver. Medial to the gallbladder lie the first and second portions of the duodenum. The gallbladder cannot be seen on plain films because it is not invested by or adjacent to any significant adipose tissue, but its position may be inferred from the gas-containing hepatic flexure or duodenal bulb. The segment between the gallbladder fossa and the ligamentum teres is known as the quadrate lobe which is in relation to the pyloric end of the stomaeh, the superior portion of the duodenum and the transverse colon. Posteriorly, the caudate lobe lodges the inferior vena cava against the bare area of the liver. A process of the caudate lobe forms the upper border of the epiploic foramen of Winslow and thus faces the superior recess of the lesser sac. A common variant in females is a Riedel's lobe, a conspicuous inferior tonguelike extension of the right lobe of the liver. Normally, the lower edge of the right lobe of the liver does not cross the right psoas margin or extend below the iliac crest.
The nature of plain film visualization of the shadow of the liver's lower edge appears to be dependent on body habitus and the interfaces presented to the roentgen beam (1), but the
Normal Anatomie Relationships and Variants
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(a)
FIG. 2. Plain film visualization 01 the liver as determined by anatomie relationships.
anatomie relationships of the right lobe of the liver in the main determine the image. These are illustrated in Fig. 2. The anterior-inferior edge of the liver, which can be clinically palpated, is generally not directly visualized radiographically but only indirectly by its known relationship to the hepatic flexure of the colon. Occasionally, suflicient omental and pericolic fat may exist to outline it only along its lateral margin (1). The posterior aspect of the right lobe, in relationship to the kidney, and the hepatic angle abut the extraperitoneal adipose tissue, accounting for visualization of their contours which present as a soft tissue-fat interface (10). The peritoneal cavity extends between the right kidney and the visceral surface of the right lobe of the liver as the hepatorenal fossa (right posterior subhepatic space, or Morison's pouch). The posterior parietal peritoneum reflects to form the right coronary ligament which suspends the liver intraperitoneally (Fig. 3).
It is important to recognize that the pleural cavity posteriorly extends down ward to come into relationship to the bare area of the liver, the upper portion of the right kidney, and the posterior subhepatic space (Fig. 4). Althoughthe pleura extends in front as low as the seventh costal cartilage, posteriorly the costophrenic sulcus reaches as low as the twelfth rib and at times even to the transverse process of LI.
The porta hepatis separates the quadrate lobe in front from the caudate lobe and process behind. It transmits the portal vein, the hepatic artery, and the hepatic duct. The vascular and ductal structures of the liver course within the free edge of the lesser omentum. As shown in Fig. 5, the precise level of the porta may occasionally be determined on plain films. Extraperitoneal fat extends into the liver hilus, enveloping the common bile duct and its ramifications in a sleevelike fashion. This periductal fat
Posterior surface of right lobe outlined by extraperitoneal lat
Lateral surface of right lobe outlined by properitoneal lat
Under surface of anterior edge of right lobe outlined by perico lic fat
--.... ---~ Anterolnler ior edge of nght
lobe (not directly visualizedl
The Liver
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(b )
(a)
Normal Anatomie Relationships and Variants
XX
FIG. 3. The rellections 01 the right coronary ligament (arrows) suspending the right lobe of the liver are outlined by free intraperitoneal air in the lateral view. The inferior leaf is at the level of the 12th rib. The nonperitonealized bare area of the posterior surface of the right lobe lies between the reflections of the ligament.
FIG. 4. The inlerior extent 01 the right pleural space in relationship to the abdominal viscera is shown by the presence of a surgical clip (arrow) which has gravitated to the posterior costophrenic sulcus following an intrathoracic operation. (a) Intravenous urogram, oblique view. (b) Upper gastrointestinal series, prone view.
I
(b)
(a)
FIG. 5. Location of porta hepatis indicated by periductal fat. (a) Plain film. A curved tubular radiolucent band (arrows) projects with the liver shadow over the upper renal pole. (b) Intravenous cholangiography with tomography confirms sleevelike lucent periductal fat paralleling the contours of the common hepatic and common bile ducts. Extraperitoneal fat outlining the visceral border of the liver is continuous with the periductal hilar fat.
may produce a striking tubular radiolucent shadow which characteristically projects within the liver anterior to the upper pole of the right kidney and superior to the duodenal bulb, with a gentle lateral convexity and branching in its upper segment (2). Likewise, the approximate location of the porta hepatis may be recognized by a radiolucent li ne of variable diameter representing fat around the round ligament (ligamentum teres hepatis) in the free edge of the falciform ligament (3) (Fig. 6).
The LEFT LOBE is smaller and more ßattened than the right. It comes into its fullest dimensions superiorly in the epigastrium. Above, it is molded by the diaphragm. A tuberosity from its under surface fits into the concavity of the lesser curvature of the stornach, and the lobe may then extend anterior to the stornach for a variable distance into the left upper quadrant. Inferiorly, it typically becomes abruptly attenuated. The area of the left lobe of the liver has been best evaluated radiologically as the space anterior to the stornach on lateral views during an upper gastrointestinal series. Plain film identification is generally impossible, although occasionally an apicallordotic projection may permit it to be viewed tangentially (Fig. 7).
The Liver
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(b)
(a)
FIG. 6. Location of porta hepatis indicated by fat around the ligamentum teres. (a) Plain film. Fatty radiolucent streaks (arrows) project within the liver shadow. (b) Intravenous cholangiogram. The lucent shadows are distinct from the common hepatic and common bile ducts. The medial one outlines a portion of the left lobe (LL) of the liver.
FIG. 7. The leH lobe of the liver (LL) is seen in an apical lordotic projection. S = stomaeh, Sp = spleen.
FIG. 8. Positions of the spleen and axes of insertion of the tail of the pancreas. Schematic frontal view. The spleen is usually obliquely oriented (1) but may be vertical (2), or, rarely, horizontal (3). The tail of the pancreas inserts within the splenie hilus.
Normal Anatomie Relationships and Variants
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(b)
FIG. 9. The anterior notched border of the spleen (Sp) (arrows) is seen because of intraperitoneal fat. The posteromedial border of the spleen is in intimate relationship to the lateral border of the left kidney (LK), both of wh ich are seen because of extraperitoneal fat.
FIG. 10. The anterior notched border of the spleen produces scalloped indentations upon the distal transverse colon.
The Spleen
The spleen lies deep in the left upper quadrant between the fundus of the stomach and the diaphragm. Although it is an intraperitoneal organ, its extremely posterior position explains why only considerable enlargement allows it to become clinically palpable through the anterior abdominal wall. Generally, the main axis of the spleen is obliquely oriented between the lateral cusp of the diaphragm and the posterolateral abdominal wall (Fig. 8). Some variability exists, however. At times, the spleen is vertical, extending inferiorly in the flank. Rarely, it is horizontal between the gastric fundus and the diaphragm, radiologically simulating a mass widening the gastrophrenic interval.
The anterior notched border of the spleen separates its diaphragmatic and visceral surfaces. On plain films, this border can be visualized by virtue of the fatty contrast provided by the greater omentum (Fig. 9). At times, as the distal portion of the mesenteric transverse colon insinuates itself between the greater curvature of the stomach and the medial aspect of the spleen, the anterior notched border is indicated by a characteristic scalloping of the colonic surface (Fig. 10). The medial visceral surface of the spleen faces the posterior wall of the stomach anteriorly and the upper part of the left kidney posteriorly. The hilum of the spleen receives the reflections of its supporting mesenteries, the gastrosplenic and splenorenal ligaments. On plain films, the posteromedial border of the spleen can be visualized by virtue of
The Spleen
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FIG. 11. Plain film. The phrenicocolic ligament (arrows) is seen as a striplike density subtending the splenie angle at the level of the anatomie splenie flexure of the colon.
the contrast provided by extraperitoneal fat, against which this intraperitoneal organ abuts (10). The inferior tip, referred to as the splenie angle, extends down ward to the level of the anatomie splenic flexure of the colon where it tends to be supported by the phrenicocolic ligament. OccasionaHy, this peritoneal reflection can be seen on pl~in films of the abdomen (5) (Fig. 11).
The Pancreas
The head of the pancreas is cradled by the descending duodenum, its body lies in the bed of the stomaeh, and the tail near the spleen, creating complex anatomie relationships as the pancreas crosses the upper abdomen. The head in particular and the body of the pancreas are situated weH in front of the midcoronal plane of the body. This relatively anterior position of the pancreas is often surprising if one assurnes that extraperitoneal organs are necessarily posterior in the abdomen. An insufficient amount of adjacent extraperitoneal fat prevents plain film visualization of the pancreas. The duodenojejunal junction serves as a useful demarcation between the body and the tail of the pancreas. The tail curves posteriorly to cross the left kidney, usuaHy in its upper part (Fig. 12). It then enters the splenie hilus, being ensheathed within the splenorenal ligament. It is important to recognize that since it is here incorporated within a mesenteric reflection, the extreme tip of the pancreatic tail is, by definition, an intraperitoneal structure.
Postmortem and in vivo studies have documented considerable variation in the size, shape, and position of the pancreas. Its course across the abdomen may be oblique, sigmoid, transverse, or horseshoe-shaped (4,9). Much of this variation appears to be related not only to the descent of some organs with age because of the laxity of supporting structures, but to the axis of insertion of the tail of the pancreas as dictated by the position of the spleen (Fig. 8). As a gross landmark, however, the longitudinal axis of the pancreas can be projected along a line from the middescending duodenum to the central area between the spleen's posteromedial contour and anterior notched border.
The Gastrointestinal Tract
The stomach should be considered three-dimensionally. Rather than lying in one plane of the body, this organ is normally rotated about both the vertical and horizontal axes of the abdomen. In this way, the greater curvature of the stornach represents
Normal Anatomie Relationships and Variants
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(a)
Splenie vessels
Adrenal gland
Transverse mesocolon
Lelt paracolic groove
FIG. 12. (a and b) Retroperitoneal pneumography with tomography in the left posterior oblique position illustrates the tail of the pancreas (P) ventral to the upper half of the left kidney (K) as it inserts within the splenic hilus. The splenic flexure of the colon (C) is outlined by some residual barium.
a portion of its anterior wall and the lesser curvature a portion of its posterior wall. The fundus lies quite posteriorly in the left upper quadrant, whereas the distal body and antrum course anteriorly. The first and seeond portions of the duodenum are then redireeted posteriorly.
The jejunum and ileum are supported by the small bowel mesentery. The root of this mesentery extends for a distanee of only about lS em from the region of the duodenojejunal junetion to the eecocolie junetion. Jejunalloops, therefore, are most eommonly seen in the left upper quadrant and ilealloops in the lower midabdomen and right lower quadrant. A eommon variant is nonrotation of the small bowel, wherein jejunalloops are suspended from the mesentery in the right midabdomen.
The large intestine has eomp1ex anatomie relationships as it courses through the abdomen. The eeeum may be eompletely extraperitoneal, but is often suspended intraperitoneally. This is particularly common in females, the extreme of whieh is seen as the "mobile" eecum. The ascending colon is extraperitonea1 up to the anterior hepatic ßexure, wh ich marks the beginning of the transverse mesocolon. This peritoneal reßection permits the transverse colon to be suspended anteriorly in the abdomen. At the level of the anatomie splenie ßexure, the large intestine penetrates the posterior parietal peritoneum to eontinue as the
The Gastrointestinal Tract
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(b)
extraperitoneal descending colon. The sigmoid mesocolon refleets obliquely off the level of the left sacroiliac joint to suspend the redundant sigmoid loops anteriorly. The large intestine then penetrates the peritoneum at S2-S4 to continue as the subperitoneal rectum.
Gas in the intestinal tract provides a natural contrast of the luminal contours. Its normal distribution and localization is a consequence primarily of the effects of gravity and its relationship ro hydrostatic pressure. In the supine position, gas rises and fills the distal pars media and antrum of the stomaeh, the cecum and proximal ascending colon, the transverse colon and often the splenie flexure, and the distal descending and sigmoid colon. In the pro ne position, gas enters the gastric fundus, the duodenal bulb and often the descending duodenum, the distal ascending colon, hepatic flexure, the proximal descending colon, and the rectum. At times, advantage may be taken of such localization by intentionally positioning a patient to demonstrate optimally a particular area or lesion on plain films.
Normal variability in the position of portions of the bowel and their relationship to each other are determined largely by body habitus and differences in mesenteric attachments. In a tall, thin female the stornach may be J-shaped and the transverse colon may curve into the lower abdomen or pelvis. In contrast, a short, stocky male typically has a stornach horizontally oriented in the upper abdomen with the duodenal bulb directed posteriorly, accompanied by a straight and high transverse colon. Individual differences in length of their major peritoneal reflections -the greater (gastrocolic ligament) and lesser (gastrohepatic ligament) omenta and the transverse mesocolon-which are somewhat related to body habitus, and their increased laxity with age result in variability. Nevertheless, the greater curvature of the stornach maintains a generally parallel, if not dose, relationship to the superior aspect of the transverse colon. Any localized increase should be viewed with suspicion.
The Extraperitoneal Structures The extraperitoneal region is anatomically divided by well
defined fascial extensions into three compartments (6, 8). These are discussed in detail in Chapter 4. The anterior para renal space contains litde fat, explaining why the oudines of the major extraperitoneal portions of the alimentary tract within it (ascending and descending colon, the entire duodenalloop, and the pancreas) are not direcdy seen on plain films. The central perirenal space contains abundant fat and permits visualization of the kidneys and, occasionally, the adrenal glands. The most dorsal
Normal Anatomie Relationships and Variants
xxvi
extraperitoneal compartment, the posterior pararenal space! contains no major organs, but its properitoneal fat continues laterally around the flanks, where it is visualized radiographically as the "flank stripe."
The lateral borders of the psoas muscles are normally seen because of extraperitoneal fat, but different portions of it contribute to visualization of specific segments (6, 8). In its upper portion at the level of the kidneys, the psoas muscles are seen because of the contrast provided by perirenal fat. The lower portions, however, are visualized because they are outlined by posterior pararenal fat.
Extraperitoneal fat also outlines the inferior contours of the diaphragms. At times, it may appear radiologically as a strikingly lucent, thin subdiaphragmatic crescent and should not be mistaken for free intraperitoneal air or other abnormalities. The same fat can be traced medially where it permits plain film visualization of the medial crura of the diaphragms.
In the pelvis, subperitoneal fat frequently outlines the dome of the urinary bladder. Its identification on plain films may be very helpful in distinguishing atme supravesical soft tissue mass from a distended urinary bladder. Visualization of the levator ani and obturator internus muscles bordering the bony pelvis is common.
REFERENCES
1. Gelfand D: The liver: Plain film diagnosis. Semin Roentgenol 10:177-185, 1975
2. Govoni AF, Meyers MA: Pseudopneumobilia. Radiology 118:526, 1976 3. Haswell DM, Berne AS, Schneider B: Plain film recognition of the
ligamentum teres hepatis. Radiology 114:263-267, 1975 4. Kreel L, Sandin B, Slavin G: Pancreatic morphology: A combined
radiological and pathological study. Clin Radiol 24:154-161, 1973 5. Meyers MA: Roentgen significance of the phrenicocolic ligament. Radi
ology 95:539-545, 1970 6. Meyers MA: Acute extraperitoneal infection. Semin Roentgenol 8:445-
464, 1973 7. Meyers MA, Oliphant M: Pitfalls and Pickups in Plain-film Diagnosis of
the Abdomen. Current Problems in Radiology. Year Book Medical Publ., Chicago, Vol. IV, No. 2, pp. 1-37, March-April 1974
8. Meyers MA, Whalen JP, Peele K, Berne AS: Radiologie features of extraperitoneal effusions: An anatomie approach. Radiology 104:249-257, 1972
9. Varley PF, Rohrmann CA Jr, Silvis SE, Vennes JA: The normal endoscopic pancreatogram. Radiology 118:295-300, 1976
10. Whalen JP, Berne AS, Riemenschneider PA: The extraperitoneal perivisceral fat pad. 1. Its role in the roentgenologic visualization of abdominal organs. Radiology 92:466-472, 1969
References
xxvii
~. _. _.
Ung
ular
seg
men
t of
lef
t up
per
lobe
of
lun
g
Eso
phag
us
Lef
t lo
wer
lo
be o
f lu
ng
Rig
ht m
iddl
e lo
be o
f lu
ng
Inte
rnal
mam
mar
y ve
ssel
s
peri
card
ial
fat
Rig
ht l
obe
of l
iver
sym
pat
het
ic t
runk
\-I
emia
zVgo
s ve
in
KEY
Ao
" ao
rta
I\le
" in
feri
or v
ena
cava
\-1
\1 "
hepa
tic
vein
s
Xip
hoid
pro
cess
Fal
cifo
rm l
igam
ent
Inte
rcos
tal
vess
els
Per
iton
eal
cavi
tY
Dia
phra
gm
Rig
ht l
ower
lo
be o
f lu
ng
Infe
rior
ph
reni
c ve
ssel
s
Ple
ural
cav
itY
!11 .... .0 2 .... Q) > u ·0 !11 .... o .s .r:::. Ö
Q)
.s -o ä) > ~ Q)
.s Ci! c Q)
E o "C .0 !11 .... Q) Cl. Cl.
:::>
.... z o j: U 111 U)
xxix
s
ESO
Phag
US
Ca
rdia
Me
dia
l eru
ra
ofl
he
dia
ph
rag
ms
Oia
Phr
agm
Pe
rilo
neal
ca
Vily
(per
iSP
/eni
e SP
ace)
Le
fl/ u
ng
POS
leri
or p
arar
enal
eX
lra
pe
rilo
ne
al
fal
Inte
rna
l m
am
ma
ry v
esse
ls
Xip
ho
id p
rOC
ess
Re
ctu
s aO
dom
inis
mU
SC
le
Fa
/eif
orm
lig
am
en
t
KE
Y
Ao
" aO
rta
~:\.'~,
-----",
-,\"--
Pe
rito
ne
ale
aV
ity
I Vc
" in
feri
or
vena
eav
a
HV
" h
epat
ie v
ein
t:?
~~
o;'"''''''
Lef
l lO
be o
f liv
er
~oo
c::e::
:P
o 00
C)
Azy
gos
ve;n
S
Ym
path
eliC
Iru
nk
~
Rig
ht
lob
e o
f liv
er ,
Ri9
hl/
un
g
less
er
om
en
tum
(gaS
lrOhe
pa H
e
liga
me
nt)
7 C
JJ
/ ) I
-O
iaph
ragm
Rig
ht
lun
g
Inle
reo
Sta
l veS
sels
a _. S
EC
TIO
N 2
. U
pp
er
ab
do
me
n a
t th
e l
evel
of
the
lo
we
r b
ord
er
of
the
10
th t
ho
rae
ie v
ert
eb
ra.
a _. _.
Less
er o
me
ntu
m
(gas
troh
epat
ic
ligam
ent)
Per
itone
al
Xip
ho
id p
roce
ss
cavi
ty
11 (~
n /
Bo
dy
of
the
,I ,
I f
,','/'-'
b
/ /
~ pa
ncre
as
Gre
ate
r o
me
ntu
m
Gas
tros
plen
ie
ligam
en
t
Spl
enie
ves
sels
Pos
teri
or p
arar
enal
ext
rap
eri
ton
ea
l la
t
Inte
rna
l m
am
ma
ry v
esse
ls
Per
itone
al c
avi
ty
Fa
lcif
orm
lig
amen
t
olliv
er ~
KE
Y
Ao
~ A
ort
a
I VC
"
inle
rio
r ve
na c
ava
Pos
teri
or p
arar
enal
e
xtra
pe
rito
ne
al
lat
I nle
rio
r p
hre
nic
a
rte
ry
ai ctl .... .0 Q)
t:: Q) > o .(3 ctl .... o
.s::::. -:5 ......
"C C ctl
.s::::. (5
Q) .s::::. -c Q) Q)
~ Qj .0 C Q)
E o "C .0 ctl ..... Q) a. a. .:l
cwi Z o j: (,) 111 CI)
xxxiii
s -. c
lell
gas
lric
Gre
aler
omen
lum
SP
leni
c
vess
els
GaS
lroc
olic
lig
amen
l
Peri
lOne
al
ea
vily
(per
isP
leni
e ---
--r-t-
-++-
I $p
ace)
left
ad
ren
al
gla
nd
Per
i ren
al f
al
Sup
erio
r m
esen
leri
c ar
lery
less
er s
ac
Aec
lus
abcl
Om
inis
mus
ele
Falc
ifO
rm l
igam
enl
Qua
drat
e lo
be 0
1 liv
er
Per
ilOne
al
cavi
lY
Key
Ao
" a
orl
a
I vc
" inf
erio
r ve
na c
ava
less
er o
men
lum
(ga
Slr
oh
ep
alic
lig
amen
t)
Hep
alic
art
ery
POrt
al v
ein
~
;' ~l~ \
) C~d,,,,o
~
=-V
O""O
,"OI/""
"j: I
= ::~=,
~" H
em,a
zygO
S
vein
;~ Di
ap
hra
gm
Ple
ura
l CaV
ily
Inle
rcoS
lal
arre
ry
,
Infe
rior
Phr
en ie
art
ery
Me
dia
l cr
ura
of
Ihe
dia
ph
ragm
s
Infe
rio
r P
hre
n ie
art
ery
and
SUpe
rior
adre
nal
arte
ry
tÜ .... .0 .a! .... Q) > .2 o tU .... o :5 J::. -,... Q) J::. --o ä) > Q)
Q)
:5 -tU c: Q)
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:::> .; z o i= () 111 CI)
xxxv
5 _.
Sh
ort
gas
tric
Du
od
en
oje
jun
al
Phr
en ic
oco
lic
liga
me
nt
Le
ft g
astr
ic a
rte
ry
and
coro
na
ry v
ein
Po
rta
l ve
in
Fa
lcif
orm
lig
am
en
t
:.::::::
:-\\\t
tr~l~
(\ .~
vein
l' \
11\
~ .A
"
" I
Spl
enor
enal
lig
am
en
t
Per
itone
al
\ \ \'
, ... ~ j
cavi
ty
4~"
( ,
Tran
!>V
ersa
lis f
asci
a L
eft
adr
enal
gla
nd
Med
ial
cru
ra o
f th
e d
iap
hra
gm
s
KE
Y
Ao
" a
ort
a
I VC
.,
infe
rio
r ve
na c
ava
TC
.,
tran!
>Ver
se c
olo
n
Ga
stro
du
od
en
al
~G'
''b'
'dd~
'-
".
Co
mm
on
: b
ile d
uct
Des
cend
ing
du
od
en
um
R
igh
t lo
be
o
f liv
er
~~
~ rt~
l) P
ort
al
vein
I"
r
-C
auda
te l
ob
e
~
0 rJlß
J_
Rig
hta
dre
na
l gl
and
Pso
as m
uscl
e O
uadr
atus
lu
mb
oru
m
mus
cle
Infe
rio
r p
hre
nic
art
ery
Th
ora
cic
du
ct
<1i ... .c 2 ... Q)
> ... III .c E ::J
-cn T""
-o (j) > Q)
c Q)
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:::>
.,; Z o t= u 111 (I)
xxxvii
s _. _. -. R
ectu
s a
bd
om
inis
mus
cle
Su
pe
rio
r m
esen
teric
vei
n
Su
pe
rio
r
11
t
( )~
\ ~%
Mes
ente
ry
T7
i i
""""
\
Gre
ater
o
me
ntu
m
Des
cend
ing
colo
n
Du
od
en
oje
jun
al
jun
ctio
n
Le
t! r
enal
art
ery
Pyl
oru
s K
EY
Ao
~ a
ort
a
I VC
~ i
nfe
rio
r ve
na c
ava
J =
;e
jun
um
TC
~ t
rans
vers
e co
lon
He
pa
tic f
1exu
re
of
colo
n
Ga/
lbla
dder
\ ~{
f //
~ ~
\~\ \
Gas
trod
uode
nal
o '\ ~
f.{
~
\\
art
ery
YU1
=;;= '~0~\
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dena
l bu
lb
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bile
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c!
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om
mo
n
~ \
c
\ PA
\ \ \
Des
cend
ing
du
od
en
um
Si ~
) 1
1)
I R
igh
tre
na
l ve
ln
~~~~J-
------~~~-
------
----1~
--J-~~L-__
Righ
tre
na
l
art
ery
Peri
tone
al c
avi
ty
(rig
h t
po
ste
rio
r
sUbh
epat
ic s
pace
)
Pso
as m
uscl
e
Qua
drat
us l
um
bo
rum
mus
cle
ca .... .0 Q)
t:: Q) > .... ca .0 E ::J
"0 C
C\I Q)
S '0 äi > ~ Q)
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E o "0 .0 « cD z o i= u 11 CI)
xxxix
>c -
Tra
nsve
rse
mes
ocol
on
Des
cend
ing
colo
n
Su
pe
rio
r m
esen
teri
c R
ectu
s a
bd
om
inis
mus
cle
Mid
d le
col
ic a
rte
ry
Med
ial
crus
of
diap
hrag
m
Tra
nsve
rse
KEY
Ao
= a
orta
I V
C =
infe
rio
r ve
na c
ava
TC
= tra
nsve
rse
colo
n
J =
jeju
nu
m
Gas
trod
uode
nal
~
l/ L
)!
Peri
tone
al
cavi
ty
,/,'
/ R
enal
fas
cia
Tra
nsve
rsal
is f
asci
a
Ou
ad
ratu
s lu
mb
oru
m m
usei
e
ca .... .0 Q)
t:: Q) > .... ca .0 E :::J
"0 .... CI)
Q)
:5 -o Gi > ~ Q)
s:::. -1U t: Q)
E o "0 .0 « . ... Z o ~ () 111 fI)
xli
~ _. _.
iran
!Ner
se d
uode
nuro
supe
rior
roe
sent
eric
"ei
n
supe
rior
roe
sent
eric
art
eN
tJ\e
sent
er'i
Asc
endi
\"19
duod
enur
o f\en
al l
aSC
·,a
peri
rena
l la
t
f\e ct
US
abO
oroi
nis
rou
scle
iran
!Ner
saliS
laSC
ia
i ra
n!N
erse
ro
eSO
colo
n
\<.E.'
< A
O"
aort
a \\J
C"
inle
rior
~ena ca
~a
iC "
tra
n!N
erse
col
on
J"
ieiu
nuro
~\
\ \
'>~
f\ig
ntl
Obe
\ \
' \\
01 \i
~er
Asc
endi
ng
colo
n
oua
drat
US
luro
bOfU
ro
rous
cle
ai tU .... .0 Q)
1:: Q) > .... tU .0 E ::J
.s::. -"<t
-0 C tU
-0 .... C')
Q)
oS c Q) Q)
~ a> .0
c Q)
E o -0 .0 « cO z o j: U 111 U)
xliii
!!. _. <
Rec
tuS
abd
omin
us m
uscl
e
wit
h inte
stinal
~'iJl ~
Mes
ente
ry ~ ~
vess
els
r-Le
lt c
olie
ve
in
post
erio
r pa
riet
al
peri
tone
um
Ant
erio
r re
nal
fasc
ia
Des
cend
ing
colo
n Lat
eroc
onal
la
scia
Peri
rena
l la
t
post
erio
r re
nal
lasc
ia
Sym
path
etic
tru
nk
Mes
ente
ry
Ure
ter
Pso
as m
uscl
e
KE
Y
Ao ~ a
orta
I v
C "
inf
erio
r ve
na c
ava
J"
jeju
num
I ~ i
leum
T
C "
tra
nsve
rse
colo
n
Ext
erna
l ab
dom
inal
ob
liqu
e m
uscl
e po
ster
ior
pari
etal
pe
rito
neum
In
tern
al a
bdom
inal
ob
liqu
e m
uscl
e
Per
iren
al
lat
Tra
nsve
rse
abdo
min
al
mus
cle
Ant
erio
r re
nal
fasc
ia
Asc
endi
ng
colo
n
cri .... .0 Q)
1:: Q) > .... III .0 E :J
.r: -"'" Q)
.r: -'0 Qi > ~ Q)
oS Qj c Q)
E o
"'C .0 « Gi z o ~ Co) 11 .,
xlv
.. - < -.
Co
mm
on
ilia
c a
rte
ry
Inte
rna
l abd
omin
al
ob
liqu
e m
uscl
e
Tra
nsve
rse
abdo
min
al
mus
cle
Ure
ter
Ilia
c bo
ne
Des
cend
ing
colo
n
lIiac
us m
uscl
e
Glu
teu
s m
ediu
s
Pso
as m
uscl
e
Mes
ente
ry
Per
itone
al c
avi
ty
Uri
na
ry b
ladd
er
Fem
oral
and
ob
utr
ato
r ne
rves
Infe
rio
r ep
igas
tric
art
ery
Mes
ente
ry w
ith
in
test
ina
l ve
ssel
s
Asc
endi
ng c
olo
n
KE
Y
I =
ile
um
TC
= t
rans
vers
e co
lon
SC
= sig
moi
d co
lon
Per
itone
al c
avity
(r
igh
t pa
raco
lic g
utt
er)
~(
I /1
1\
lIeo
colic
:;
I I
vess
els
Co
mm
on
il
iac
art
ery
Com
mon
ili
ac v
ein
Lu
mb
ar
art
ery
<ci ... .0 Q)
t:: Q)
> ... C'Cl .0 E ::J
.I:: -IJ")
Q) .I:: --o Qj > 2 Q) .I:: --C'Cl
C Q)
E o
"'0 .0 « ci ,. z o i= u MI U)
xlvii
>c - C _. _. _. T
rans
vers
e a
bd
om
ina
l
Ext
ern
al
iliac
a
rte
ry
Ext
ern
al
ilia
c ve
in
Hyp
og
asl
ric
art
ery
Gre
ale
r o
me
ntu
m
Re
clu
s a
bd
om
inis
mus
cle
Ext
ern
al
ab
do
min
al
Uri
na
ry b
ladd
er
Hyp
og
ast
ric
vein
Sac
ral
fora
men
and
ner
ve
Ure
ter
Asc
endi
ng c
olo
n
mus
cle
Sa
cro
ilia
c jo
int
KE
Y
I =
ile
um
S
C =
sig
mo
id c
olo
n
An
teri
or
sup
eri
or
ilia
c sp
ine
Pso
as
mus
cle
lIiac
us
c o U c .~ (ij .... () «I (/)
o .0 E :::J
Q)
oS '0 äi ~ Q)
oS 1ii c Q)
E o "0 .0 « . ... ... z o i= Co) 111 CI)
xlix
-
Ext
erna
l ili
ac
arte
ry
Sig
moi
d
mes
ocol
on
Rec
tus
abdo
min
is m
uscl
e
Ure
ter
) \\ ~~
)~
Ext
erna
l il
iac
vein
Hyp
ogas
tric
vei
n
Infe
rior
epi
gasl
ric
vess
els
Uri
nary
bla
dder
Sac
rum
Cec
um
KE
Y
sc =
sigm
oid
colo
n
An
teri
or
infe
rior
iliac
spi
ne
lIio
psoa
s m
uscl
e
llia
c b
ane
Glu
teus
~(
/ (
I m
inim
us
C
r J
musc~
Sac
roil
iac
join
t
Glu
teus
m
ediu
s m
uscl
e
Glu
teus
max
imus
mus
cle
Sup
erio
r gl
utea
l ve
ssel
s
cO .... .c Q)
t:: Q) > (ij .... U !1l Cf) -Cf)
Q)
S '0 Qi > ~ Q) ..c -n; c Q)
E o
"'C .c !1l .... Q)
3: o
...J
&'<i ... z o t= u 111 cn
Ii
museie
Lelt lobe __ _.. olliver
Stornach
Spleen
Proximal superior mesenteric artery
Ouodenojejunal junction
Jejunal loops
Pancreas
cn 1. At the level 01 the 11th thoraeie vertebra. The left lobe of the liver extends anterior to the stomach. The posterolateral margin of the left kidney is in intimate relationship to the posteromedial border of the spleen. The anterior border of the spleen is normally notched.
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Caudate lobe
Right lobe 01 liver
Aorta
1i~~~ti'~~g--Ri9ht kidney
Falcilorm ligament
Leh lobe 01 ---liver
Right lobe ~--of liver
Aorta
cn 2. At the level 01 the 1 st lumbar vertebra. The neck of the pancreas bridges the superior mesenteric artery near its origin from the aorta. The duodenojejunal junction provides a land mark to separate the body from the tail of the pancreas. In this patient. the latter is at a higher level.
Proximal superior mesenteric artery
Aorta
Leh renal artery-~I:II""""
Left kidney
Colon
Jejunum
Left renal artery --1'-....-r
Lelt kidney
Psoas muscle -~ ... _~
lumborum museie
CTT 3. At the level of the upper bord er of the 2nd lumbar vertebra. The tail of the pancreas extends behind the body of the stomach. The colon descends anterolateral to the left kidney.
Falciform L-~'k----ligament
Gallbladder
R ight lobe 01 liver
~~~~~j-:€.~--~L1l- Head 01 pancreas
t:-;;--;=;-!:.:o..;.;==-;:::~-tiL_ I nlerior vena cava
Medial Crura of diaphragms
Right kidney
Falciform ligament
Gallbladder
;7,:-~;::?,~~t.:-a- Pa ncreas
Right lobe olliver
~~-;:;~;j~h_lnferior vena cava
Right renal vein
Aorta
CTT 4. At the level of the midportion of the 2nd lumbar vertebra. The left lobe of the liver has become attenuated but still extends anterior to the stomach. The head and body of the pancreas remain anterior to the midcoronal plane of the abdomen. The left renal artery lies behind the left renal vein, body of the pancreas, and the splenic vein.
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Jejunum
Superior mesenteric
artery
Stomach
Colon --1 .... +--:;~
Jejunum -.~rh~ Aorta
Spleen
Left lobe of liver Jej unal artery
Caudate lobe
~!:;~':"';=~:-7~,=--lnferior vena cava
Right lobe of liver
Quadratus lumborum museie Left renal ve in
CTT 5. At the level 01 the midportion 01 the 2nd lumbar vertebra. The vertical spleen in this patient is seen to extend inferiorly. The left renal vein passes in front of the aorta just below the origin of the superior mesenteric artery which crosses it anteriorly.
This study, performed after intravenous contrast injection, also demonstrates dilated intrahepatic bile ducts indicative of obstructive jaundice. A cyst projects posteriorly from the right kidney and a dromedary hump is present on the lateral margin of the left kidney. Calcification in the abdominal aorta is evident.
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CTT 6. At the level 01 the lower border 01 the 2nd lumbar vertebra. Virtually the full length of the pancreas is shown. The tail projects beyond the duodenojejunal junction anterior to the left kidney to insert within the splenic hilus. The caudate lobe of the liver extends behind the first portion of the duodenum near the inferior vena cava. The right renal artery passes behind the inferior vena cava and right renal vein.
CTT 7. At the level 01 the 3rd lumbar vertebra. The right lobe of the liver extends inferiorly in the flank. The third portion of the duodenum passes in front of the great vessels and is crossed by the superior mesenteric vessels and the mesentery.
Duodenojejunal junction
Aorta
Spleen
Left kidney
Pancreas
Medial crura of the diaphragms
CTT 6
Stomach
Duodenal bulb
__ ~~-;;:':;';::::i~~r-T- Caudate lobe
;':;;';;;':~~~~~§~J;fl_ Inferior vena cava
Right renal artery
Right lobe of liver
Superior mesenteric artery Superior mesenteric vein
Aorta
Quadratus lumborum muscle
CTT 7
Psoas muscle Inferior vena cava
Third (horizontal) duodenum
Right lobe of liver
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Pyramid mU5cle
Obturator
mU5cle
Femoral _-'IC=-__ :!Do:.-head
Urinary bladder
Femoral head
Levator ani muscle
Rectum
Coccyx
Obturator internus muscie
pyramid muscle
Gluteus maximus museie
Femoral vein
Obturator foramen
Seminal vesicles
Femoral artery
Symphysis pubis
Obturator foramen
Ischial tuberosity
Coccyx Gluteus maxi mus muscie
CTT 8. At the level lust above the symphysis pu bis. This male pelvis shows the seminal vesicles and the upper pole of the prostate gland. Air is present in the urinary bladder from a previous cystoscopy. The obturator internus and iliopsoas muscles as they insert on the lesser trochanter of the femur are clearly shown.
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CTT 9. At the level of the symphysis pu bis. The site of the enlarged prostate gland in this male pelvis would be occupied by the uterus in a eTT of a female pelvis.