BIOL226Lec10 Kidney,Adrenal

7/31/2019 BIOL226Lec10 Kidney,Adrenal

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KIDNEYS AND ADRENAL

GLANDS


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I. Introduction/General Information

A. Kidneys

1. Paired2. Located between T-12 & L-3/L-4

3. Between iliac crests & lower ribs

4. Right normally more inferior than left


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Relationship of the Kidneys to

Vertebra and Ribs


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Coronal Section, Right Kidney4. Normal adult kidney

measures:

superior inferior: 10 12 cm

medial lateral: 5 6 cm

anterior posterior: 3 4 cm


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Introduction/General Information, cont

6. Portions of kidneys lie in six regionsof the abdomen

1. right & left hypochondriac

2. epigastric

3. right & left lumbar

4. umbilical


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Organs of the Urinary System Kidneys

Ureters

Urinarybladder

Urethra


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B. Adrenal Glands

1. Small, difficult to see

2. Triangular glands

a. under ribs

b. not well capsulated

c. usually anterior & medial to kidney


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Introduction, cont

3. In Epigastric region

4. ~ T-12 to L-1/L-2

5. Right usually moresuperior than left

Why?

Left Adrenal gland


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C. Sonographic applications

1. Poorly functioning kidney

2. Cystic vs solid or complex mass3. Post Renal Transplant Evaluation

a. Cystic mass: may indicate fluid is

not being absorbedb. Signs of rejection


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Sonographic applications, continued

4. Congenital anomalies

5. Perirenal abscesses, adenopathy

6. Presence/absence of kidney

7. Ectopic kidney

8. Adrenal mass or cyst:

a. Difficult to visualize

b. Unless neonate or in utero


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II. Detailed Anatomy

A. Kidneys1. Paired, retroperitoneal

structures2. Immediately adjacent

to vertebral bodies3. Left: more superior

~ T-12 to upper L-4

4. Right: more inferior~ L-1 to lower L-4

Kidneys, in situ


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Position of the Kidneys

P

A

Transverse Sectionthrough R/L Kidneys


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Detailed Anatomy of Kidneys, cont

5. Not held by ligaments

-May be displaced 2.5 cm by

respiration6. Upper pole lies more

posterior thanlower pole (on L.S.)

-due to lumbar curve S

I


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7. Adjacent structures, Right kidney:

a. liver, GB

b. descending of duodenum, hepaticflexure

c. right adrenal, IVCd. right crus of diaphragm, psoas,

quadratus lumborum muscles


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Right Kidney: Relationships

Note:

Liver

Gallbladder

Duodenal bulb

IVC

A

P


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Right Kidney: Relationships

Note:

Liver

Descendingduodenum

Psoas muscle

Quadratus lumborummuscle

IVC


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8. Adjacent structures, Left kidney:

a. spleen, tail of pancreas, left adrenal

b. ascending duodenum,gastroesophageal junction,transverse colon, jejunum

c. psoas & quadratus lumborum m.

d. aorta, left crus of diaphragm


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Left Kidney: Relationships

Note:

Tail of pancreas

Splenic flexure ofcolon

Aorta

Psoas and quadratuslumborum muscles


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Detailed Anatomy, cont

9. Diaphragm lies superior &

posterior

10.Transversus abdominislies inferior

11. Separated from abdomen

proper byparietal peritoneum

12. Surrounded by fattycapsule

S

I


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13. Internal anatomy seen on ultrasound

a. Renal cortex

b. Renal medulla (pyramids)

c. Renal columns (of Bertin)

d. Renal pelvis

e. Papillae (apices of pyramids)f. Calyces (if dilated)


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Coronal Section, Right Kidney


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14. Pancreas & duodenum are indirect contact

a. pancreatic cancers & duodenal

ulcers can affect the kidney

b. all other organs in indirect

contact, intraperitoneal


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15. Posteriorly, right kidney separatedfrom pleura only by diaphragm

a. Why??

b. Kidney cancer can spread tolung, vice versa


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16. Fasciae:

a. Supportive C.T. layers

b. Fascia transversalis:

1. at lateral border of kidney

2. splits into prerenal &retrorenal layers

3. forms perirenal fascia (aka:Gerotas fascia)


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Position of the Kidneys on the Posterior

Abdominal Wall

Note:

FasciatransversalisPrerenal fasciaRetrorenal fascia

Perirenal(Gerotas)fascia


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c. Retrorenal layer

1. blends with fascia of psoasmajor & quadratuslumborum muscles

2. also with C. T. thatbinds vertebral column


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Fascial Coverings: Retrorenal Layer

Figure 23.2a

Retrorenallayer


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d. Prerenal layer

1. extends medially

2. anterior to renal vessels,aorta & IVC

3. blends with layer from otherside


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Fascial coverings: Prerenal Layer

Figure 23.2a

Prerenal layer


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e. Fatty capsule lies between the

layersf. Infections may spread via fascial

sheath

-- especially bacterial infections i.e., perinephritis


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Fatty Capsule

Figure 23.2a

Fatty Capsule(Perirenal fat)


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17. Kidney maintains position by intra-abdominal pressure & fasciae

a. Allows mobility during respiration

b. Allows abdominal palpation oflower pole in some patients


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18. Two layers of renal fascia

a. fuse at upper pole

b. separate at lower polec. if fat decreases, mobility

increases:

1. kidney may move betweenfascial planes

2. pelvic kidney


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d. Adrenals have own fasciae, will

not movee. Kidney may be removed without

disturbing adrenal gland

f. Pathological result:

1. kidney may descend

2. cause kink in ureter


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Detailed Anatomy of Adrenals

B. Adrenal Glands1. ~ T-12 to L-1 or L-2

2. Located in epigastricregion

3. Right adrenal liesmore superior

a. Related to visceralsurface of liver

b. IVC & right crus liemedial L. Adrenal Gland, in situ


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Detailed Anatomy of Adrenals, cont

c. Right kidney lies

posterior, inferior

& slightly lateral

1. Has linear,

pyramidal, orelongated shape

2. One limb extendsalong medialaspect


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4. Left adrenal

a. Lies posterior & medial to

cardiac sphincter, spleen, medial to tailof pancreas

b. aorta & left crus lie medial

c. left kidney lies posterior, inferior, &lateral


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Adrenal Gland In Situ Coronal Section / Adrenal Gland

Human Adrenal Gland


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d. More triangular in shape

e. One limb may extend alongmedial aspect of left kidney

f. Fourth part of duodenum is

caudad


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C. Blood supply1. Renal arteries:

a. arise from abdominal aortab. Divide into 2 or 3 branches before

entering kidney

c. If 3 branches, may form:1. vascular fork

2. may constrict ureter


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Renal Arteries with Vascular Fork Note the

numerous

branches ofthe renalartery priorto entering

the kidneyhilus


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d. R. renal artery courses from aorta

posteriorto IVC into hiluse. Left renal artery course is from

aorta directlyto hilusf. May see 2 or 3 pairs of renal

arteriesg. Gonadal arteries:

1. may arise from renal artery

2. usually arise from aorta


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Origin of Renal, Gonadal Arteries Note the

rightgonadal

arteryarising fromthe aorta,thenbranching

to form theinferiorcapsularartery.

R and LRenalArteries

GonadalArteries


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Variations in Renal Arteries The

presence of

multiplerenalarteriesrepresents

persistenceof fetalvessels


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2. Renal Veinsa. Right renal vein enters IVC

directlyb. Left renal vein passes anterior

to aorta, posteriortoSMA, then into IVC

c. Venous pattern complex


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Variations in Renal Veins

Note theduplication in

the Left RenalVein

Branchessurround aorta


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Pathway of Renal Vessels


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d. On the left side:

1. anastomosis of veins2. from left adrenal, pampiniformplexus of testis, perirenal fat,ureter

e. Surgery may permit spread ofinfection

f. Malignancies frequently spread viarenal vein


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3. Adrenal glands

a. Blood supply intensiveb. Superior adrenal artery arises

from inferior phrenic artery

c. Middle suprarenal artery arisesfrom aorta


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d. Inferior suprarenal artery arisesfrom renal artery

e. Only one vein drains each gland

1. right drains directly into IVC2. left drains into left renal vein


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Origin of Adrenal ArteriesNote the

superiorarteryarising from

the phrenic a.,the middleartery from theaorta, and theinferiorartery

from thesuperiorcapsular arteryviathe R. renalartery

SuperiorAdrenal

Artery MiddleAdrenalArteryInferior

AdrenalArtery


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D. Lymphatics

1. Renal lymphatic channels

follow veins2. Most drain into para-

aortic nodes

a. Lie inferior at ~ L-3 or L-4

b. Near bifurcation of aorta


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Detailed Anatomy, continued

E. In neonate kidney, note:a. Large size of adrenal vs

kidney

b. Lobulation of kidney (plastinatedspecimen)

c. Increased amount of perirenalfat

d. Paraganglia along aorta1. precursor to aortic nodes

2. degenerate in childhood

Lobulated FetalKidneys


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E. Innervation

1. Sensory nerve fibers of kidney &

ureter join spinal cord at T-11 to L-2

2. Passage of calculi causes peristaltic

action of ureter

a. Muscle spasms cause pain in regionssupplied by T-11 to L-2 nerves

b. Pain may refer to testis or anterior thigh


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III. Gray-scale anatomyA. U/S can differentiate renal pyramids,

cortex, columns, calyces, pelvis

1. Pyramids appear echodense regionswithin parenchyma

a. Apex of pyramid = papilla

b. Apex points toward pelvis

2. Cortex, columns less dense than liver


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IV. Renal PathologyA. Malpositioned (ectopic) kidney

1. Kidneys migrate cephalad during

development2. Ptosis (Gr. falling): kidney has

sunk from its usual site in fossa3. Pelvic Kidney:

a. lies in floor of pelvic cavityb. may be hypoplastic, distorted


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Pelvic Kidney

Note the

paths ofthe renalartery andrenal veinin pelvickidneys

Ectopic Kidneys


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Malpositioned Kidney, continued

2. If kidney not identified in renal fossa,scan lower abdomen & pelvis

3. If reniform mass is observed in abdomenor pelvis, check renal fossa

4. If pelvic or ectopic kidney seen in

pregnancy, C-section advised5. Crossed kidneys usually seen inpediatric age group


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Renal Pathology, continued

B. Hypoplasia

1. Kidney small, with poorfunction

2. Appears distorted withincreased lobulation

3. Differentiation fromdiseased kidneymay be difficult

Renal Hypoplasia


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4. Differentiation from true renal agenesismay be difficult

a. In agenesis, fossa may contain

bowel (simulates hypoplasia)b. Both may result in hypertrophy of

contralateral kidney


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C. Duplication/Fusion:

1. May be a duplex

collecting system or twoseparate components

2. If complete separationoccurs, upper pole ureter

may form ureterocele:

Duplex/FusedCollection Systems


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a. Leads to obstruction &

hydronephrosis

b. May have septations

c. Appears as triangular,sonolucent sac inupper aspect of kidney

Hydronephrosis


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3. Horseshoe Kidneya. Most common fusion anomaly

b. Usually fused at inferior polec. The isthmus may simulate aretroperitoneal mass

d. May be confused with para-aortic

lymph nodese. Look for malrotated pelvis


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Abnormal Kidney Structures

Note the

fusedlower poleandrotated

pelves

PancakeKidney

HorseshoeKidney

Malrotated

Kidneys


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Renal and Adrenal Diseases: In Patho

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BIOL226Lec10 Kidney,Adrenal