The abdomen 5

Objectives

In this chapter you will learn to:

• Appreciate the surface anatomy of the abdomen, including surface markings of organs.
• Describe the skeletal and muscular boundaries of the abdominal cavity.
• Discuss the arterial supply, venous drainage and nerve supply of the anterolateral abdominal wall.
• Describe the boundaries and contents of the inguinal canal.
• Describe the coverings and contents of the spermatic cord.
• Explain the structure, blood supply, innervation and lymphatic drainage of the testes.
• Appreciate the development of the gastrointestinal tract.
• Describe the arrangement of the peritoneum, including its innervation and recesses/pouches.
• Describe the major features of the oesophagus, stomach, duodenum, jejunum, ileum and colon.
• Describe the anatomy of the liver and the biliary tree.
• Discuss the blood supply, nerve supply and lymphatic drainage of the gastrointestinal tract.
• Describe the anatomy of the kidneys and suprarenal glands.
• Be able to review an abdominal X-ray, recognizing the major bony and soft-tissue structures.
• Identify major structures on a transverse section of a CT scan of the abdomen.

REGIONS AND COMPONENTS The anterolateral abdominal wall is composed of

three layers of muscle. These form an aponeurosis ante-
OF THE ABDOMEN riorly to surround the rectus abdominis muscle.
The abdominal cavity is lined by parietal perito-
The abdominal cavity is separated from the thoracic cav-
neum, with visceral peritoneum covering many of the
ity by the diaphragm. The domes of the diaphragm arch
organs. The cavity contains most of the gastrointestinal
above the costal margin, therefore some of the abdom-
tract, together with its accessory organs (liver, gall-
inal organs (liver, spleen, upper poles of the kidneys and
bladder and pancreas).
suprarenal glands) are protected by the bony thoracic
Abdominal pain is very common—knowledge of
cage. The bony pelvis surrounds the lower part of the
embryology and anatomy will help in diagnosis
abdominal cavity.
(Fig. 5.1).
Posteriorly, the vertebral column protects the con-
tents of the abdomen. The anterolateral wall is muscular
and is, therefore, more vulnerable to injury.
Over the anterior abdominal wall, the superficial fas-
SURFACE ANATOMY AND
cia is composed of two layers. The outer layer (Camper’s SUPERFICIAL STRUCTURES
fascia) is continuous with the superficial fascia of the
thigh. Deep to Camper’s fascia lies Scarpa’s fascia – a To aid description, the abdomen is divided into regions.
thin membranous layer. The arrangement of these The simplest method is to divide the abdomen into four
two layers allows Camper’s fascia to move freely, allow- quadrants by a vertical and a horizontal line through
ing the abdomen to expand. Scarpa’s fascia fades over the umbilicus; however, for more accurate description,
the thoracic wall superiorly, and inferiorly it fuses with it is divided into nine regions (Fig. 5.2) by:
the fascia lata of the thigh. In males it continues into the • Two vertical lines – extending inferiorly from the
scrotum and penis as the superficial perineal fascia (of midpoint of each clavicle
Colles) and the superficial fascia of the penis respec- • Two horizontal lines: the transtubercular plane
tively. In the female the superficial perineal fascia lines (passing horizontally between the two tubercles of
the labia majora and is perforated by the vagina. the iliac crest) and the transpyloric plane (passing

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 The abdomen

Fig. 5.1 Origin and blood supply of the abdominal viscera and sites of referred pain.

Part of Organs Blood supply Site of

fetal gut abdominal pain
Foregut Oesophagus, stomach, first and half of the second part of Coeliac trunk Epigastric region
duodenum, liver, gallbladder, spleen and pancreas
Midgut Remainder of duodenum, jejunum, ileum, caecum, appendix, Superior Umbilical region
ascending colon, and proximal two-thirds of transverse colon mesenteric artery
Hindgut Distal one-third of transverse colon, descending colon, sigmoid Inferior Suprapubic
colon, rectum,and part of the anal canal mesenteric artery region

The upper border runs between the left and right 5th
ribs; both in the midclavicular line.

Fundus of the gallbladder

midclavicular line
The fundus of the gallbladder lies posterior to the 9th
right costal cartilage, at the intersection of the trans-
hypochondrium pyloric plane with the costal margin.
9th costal cartilage
epigastric
transpyloric
umbilical plane L1 Spleen
lumbar
The spleen lies deep to the left 9th, 10th and 11th ribs,
transtubercular
plane L4
posterior to the midaxillary line. It is not palpable un-
suprapubic iliac less enlarged, in which case the spleen extends inferiorly
fossa and anteriorly below the costal margin.

Pancreas
Fig. 5.2 Regions of the abdomen. The head of the pancreas lies in the ‘C’ shaped concavity
of the duodenum at the level of the L2 vertebra. The
neck lies in the transpyloric plane (at the level of the
horizontally midway between the pubic symphysis L1 vertebra). The body of the pancreas extends left, curv-
and suprasternal notch). ing upwards towards the hilum of the spleen.
The linea alba is a midline depression running from
the xiphisternum to the pubis. The linea semilunaris is a
slightly curved line which represents the lateral margin Kidneys
of the rectus abdominis muscle on each side. The hilum of each kidney lies in the transpyloric plane.
The inguinal ligament lies between the anterior The upper pole of the kidneys lie deep to the 12th rib
superior iliac spine and the pubic tubercle. The deep posteriorly. They lie opposite the L1–L4 vertebrae (the
inguinal ring lies at the midinguinal point (halfway right lies slightly lower than the left due to the presence
between the anterior superior iliac spine and the pubic of the liver).
symphysis). The umbilicus lies at approximately the
level of the L3 vertebra.
Ureters
Each ureter begins at the hilum of the kidney, in the
Liver transpyloric plane. The ureter runs inferiorly over psoas
The inferior border of the liver extends from the 10th major muscle, anterior to the tips of the transverse pro-
costal cartilage on the right, in the midclavicular line, cesses of the lumbar vertebrae, as far as the sacroiliac
to the 5th rib on the left, in the midclavicular line. joint, where it enters the pelvis.

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 The abdominal wall 5

THE ABDOMINAL WALL Thoracolumbar fascia

The lumbar part of this fascia arises from the vertebrae
Osteology in three layers:
• The anterior layer – from the anterior aspect of the
Figure 5.3 shows the skeleton of the abdominal and
lumbar transverse processes
pelvic cavities (see Chapter 6).
• The middle layer – from the tips of the lumbar trans-
The costal margin and floating ribs have been
verse processes
described previously (see Chapter 4). The characteristics
• The posterior layer – from the tips of the lumbar spi-
of a typical lumbar vertebra are illustrated in Figure 2.3E.
nous processes.
The pelvic bones articulate with the sacrum at the
sacroiliac joint (a modified synovial joint) and with The anterior and middle layers enclose quadratus
each other at the pubic symphysis (a secondary lumborum; the middle and posterior layers enclose
cartilaginous joint). Each pelvic bone is formed from the erector spinae muscles. The three sheets fuse later-
the ilium, ischium and pubis. ally and provide attachment for the internal oblique
The ilia protect underlying structures and provide a and transversus abdominis muscles. The thoracic part
site for muscle attachment. The superior border of the of the fascia consists of the posterior layer only. This
ilium – the iliac crest – runs from the anterior superior attaches to the thoracic spinous processes and angles
iliac spine (ASIS) to the posterior superior iliac spine of the ribs (Fig. 4.6).
(PSIS). The ASIS is often visible and the PSIS is marked
by a dimple on the skin of the back. The iliac tubercle is Muscles of the anterolateral
the highest point of the crest. The three muscle layers of
the anterolateral abdominal wall originate from the iliac
abdominal wall
crest, as do latissimus dorsi, quadratus lumborum and Figure 5.4 outlines these muscles. The conjoint tendon
the thoracolumbar fascia. is formed by the lowest fibres of internal oblique and
The pectineal line lies on the superior ramus of transversus abdominis, inserting into the pubic crest
the pubic bone, and medial to it lie the pubic tubercle and most medial part of the pectineal line.
and pubic crest. The pectineal line continues post-
eriorly as the arcuate line, which forms part of the
pelvic brim.
Rectus sheath
Each rectus abdominis muscle is enclosed in a fibrous
sheath, formed by the aponeuroses of the three muscles
of the abdominal wall (Fig. 5.5). The composition of
the rectus sheath changes at three points:
xiphoid process
• Above the costal margin the sheath is composed of
costal margin an anterior layer only – formed by the aponeurosis
of external oblique. The posterior aspect of the rectus
muscle lies on the costal cartilages.
• Between the costal margin and a point midway be-
tween the umbilicus and pubic symphysis, the inter-
12th rib nal oblique splits into an anterior and posterior
layer. The anterior part of the sheath is formed by
lumbar the aponeurosis of external oblique along with the
vertebrae anterior layer of internal oblique. The posterior part
promontory 1−5
of sacrum of the sheath is formed by the aponeurosis of trans-
iliac crest versus abdominis, along with the posterior layer of
anterior
superior internal oblique. The lower limit of the posterior
iliac spine part of the sheath is known as the arcuate line.
anterior • Inferior to the arcuate line, all three aponeuroses
arcuate line
inferior
iliac spine pectineal line } pelvic
brim
pass anterior to the rectus muscle, and the posterior
wall of the sheath is composed only of transversalis
pubic tubercle pubic crest fascia and peritoneum.
symphysis pubis The inferior epigastric artery and vein enter the
sheath at the level of the arcuate line and pass superi-
orly, deep to the rectus abdominis, to anastomose with
Fig. 5.3 Skeleton of the abdomen and pelvis. the superior epigastric vessels.

VRG Release : tahir99

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 The abdomen

Fig. 5.4 Muscles of the anterolateral abdominal wall.

Name of muscle (nerve Origin Insertion Action

supply)
External oblique (outermost Lower eight ribs Becomes aponeurotic and Flexes and rotates
layer) (T6–T12 spinal attaches to the xiphoid process, trunk; pulls down ribs
nerves) linea alba, pubic crest, pubic in forced expiration
tubercle, and iliac crest
Internal oblique (spinal Thoracolumbar fascia, Ribs 10–12 and costal cartilages, Assists in flexing and
nerves T6–T12, iliac crest, lateral two- linea alba, pubic symphysis; rotating trunk; pulls
iliohypogastric and thirds of inguinal ligament forms conjoint tendon with down ribs in forced
ilioinguinal nerves) transversus abdominis expiration
Transversus abdominis Lower six costal cartilages, Xiphoid process, linea alba, Compresses
(innermost layer) (spinal thoracolumbar fascia, iliac pubic symphysis: forms abdominal contents
nerves T6–T12, crest, lateral third of conjoint tendon with internal with external and
iliohypogastric and inguinal ligament oblique internal oblique
ilioinguinal nerves)
Rectus abdominis (spinal Symphysis pubis and Costal cartilages 5–7 and Compresses abdominal
nerves T6–T12) pubic crest xiphoid process contents and flexes
vertebral column

Venous drainage of the

above costal margin
anterolateral abdominal wall
tendinous The superficial veins of the abdominal wall include the
EO intersection superficial epigastric and thoracoepigastric veins, which
RA ultimately drain into the femoral vein and axillary veins
rectus
abdominis respectively.
muscle The superior and inferior epigastric veins and the deep
EO
external circumflex iliac veins follow the course of the arteries and
IO oblique
RA muscle drain into the internal thoracic and external iliac veins.
T
Of the four lumbar veins, the lower two drain into
below arcuate line the inferior vena cava. The upper two join to form the
external
oblique
ascending lumbar vein and, with the subcostal vein,
EO
aponeurosis drain into the azygos vein on the right and hemiazygos
IO
cut edge
vein on the left.
T RA
of skin

pyramidalis muscle CLINICAL NOTE

Abdominal incisions
Fig. 5.5 Rectus sheath and rectus abdominis muscle. EO,
external oblique; IO, internal oblique; T, transversus abdominis; • A midline incision passes through the linea alba:
RA, rectus abdominis. this allows rapid access with minimal blood loss.
• A paramedian incision passes through the anterior wall
of the rectus sheath, the rectus muscle is displaced
Nerve and blood supply of the laterally and the posterior sheath is then divided.
anterolateral abdominal wall Postoperatively, the rectus muscle covers and
strengthens the scar on the posterior layer of the sheath.
The principal nerves and arteries of the anterolateral
• A subcostal incision is made 2.5 cm below and parallel
abdominal wall are shown in Figure 5.6. Nerves run
in a ‘neurovascular plane’ between the transversus abdo- to the costal margin (on the right for biliary surgery
minis and internal oblique muscles. All the nerves give and on the left to expose the spleen).
off anterior and lateral cutaneous branches, except • A gridiron incision is made centred at McBurney’s
for the ilioinguinal nerve, which gives off an anterior point. Each muscle layer is incised individually in line
branch only.

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 The abdominal wall 5

Fig. 5.6 Innervation (left) and arterial

xiphoid process supply (right) of the anterolateral
abdominal wall.

superior
T7 epigastric
artery
T8
lateral margin
T9 of rectus sheath
T10
T11 intercostal
T12 arteries
iliohypogastric
lumbar arteries
nerve (L1)

deep circumflex
ilioinguinal iliac artery
nerve (L1)
position of deep
inguinal ring

inferior epigastric artery

canal, but enters it by piercing the transversalis fascia,

with its fibres, so the strength of the wall is virtually i.e. it does not pass through the DIR. The superficial
unaffected, although there is a risk of damaging the inguinal ring is a triangular opening in the external
iliohypogastric and ilioinguinal nerves. oblique aponeurosis, superolateral to the pubic tuber-
• Transverse incisions are made across the rectus cle. The contents of the inguinal canal exit through this
ring. It has an anterior wall, a posterior wall, a roof and a
abdominis muscle – it is supplied segmentally, so
floor (Fig. 5.8).
there is no danger of denervation.

CLINICAL NOTE

Inguinal region Inguinal hernias

Inguinal ligament An inguinal hernia occurs when bowel, omentum or

another organ protrudes either through the deep
The inguinal ligament is formed from the lower edge of
inguinal ring (DIR) (indirect hernia) or the transversalis
the aponeurosis of external oblique. It extends from
fascia (direct hernia) of the abdomen.
ASIS to the pubic tubercle. It gives origin to the internal
oblique and transverse abdominis muscles, and the fas- • An indirect hernia is congenital. It occurs secondary to
cia lata of the thigh. a patent processus vaginalis. Herniation occurs
through the DIR and may extend along the inguinal
canal, through the superficial inguinal ring (SIR)
Inguinal canal (lateral to the inferior epigastric artery) and into the
This is a narrow passage, approximately 4 cm long, scrotum.
which lies superior and parallel to the medial half of • A direct hernia normally occurs in older males. The
the inguinal ligament. It runs inferomedially and ex- hernia passes through Hesselbach’s triangle (its
tends from the deep inguinal ring (DIR) to the superfi- boundaries are the rectus sheath, inferior epigastric
cial ring (SIR) (Fig. 5.7). The DIR is an opening in the vessels and the inguinal ligament), located in the
transversalis fascia approximately 1 cm superior to the
posterior wall of the inguinal canal, medial to
midinguinal point, and lateral to the inferior epigastric
the inferior epigastric artery. It then continues
artery. The spermatic cord in males, the round ligament
in females and the genitofemoral nerve in both sexes, through the inguinal canal and exits the superficial
pass through the DIR to enter the inguinal canal. The inguinal ring.
ilioinguinal nerve also passes through the inguinal

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 The abdomen

Fig. 5.8 Boundaries of the inguinal canal.

A hernia can normally be reduced back into the
abdominal cavity with gentle pressure or manipulation. Region Components
If a hernia cannot be reduced it is referred to as an Anterior wall External oblique aponeurosis;
incarcerated hernia and may produce symptoms of lateral one-third reinforced by
bowel obstruction, i.e. pain, nausea and vomiting. internal oblique
The blood supply to an incarcerated hernia is normally Floor Lower edge of the inguinal
not compromised. If the blood supply to a hernia ligament; reinforced medially by
the lacunar ligament, which lies
becomes compromised, it is referred to as a
between the inguinal ligament
strangulated hernia. The patient may present with and the pectineal line
symptoms similar to that of an incarcerated hernia.
Roof Lower edges of the internal
However, they are generally more unwell (tachycardic
oblique and transversus muscles:
and pyrexial). Strangulated hernias require emergency the muscles fibres arch over the
surgery to prevent necrosis of the bowel. front of the spermatic cord
laterally, and behind the cord
medially, where their joint
tendon – the conjoint tendon – is
inserted into the pubic crest and
A pectineal line of the pubic bone
linea alba
Posterior wall Conjoint tendon medially
and the transversalis fascia
external oblique superficial laterally
inguinal
ring
femoral sheath
femoral artery spermatic
femoral vein
cord Spermatic cord
pubic symphysis The structures entering the deep inguinal ring pick up a
tubercle pubis
covering from each layer of the abdominal wall as they
inguinal
ligament
pass through the canal to form the spermatic cord
(Fig. 5.9). The spermatic cord is not complete until it
B iliohypogastric nerve emerges from the superficial inguinal ring with all of
its coverings.
The coverings from superficial to deep are:
internal oblique • External spermatic fascia – derived from the aponeu-
conjoint
ilioinguinal nerve tendon rosis of external oblique muscle
cremaster muscle • Cremasteric fascia – derived from internal oblique
pectineal
line and the transversus abdominis muscles
• Internal spermatic fascia – derived from the transver-
transversus pubic crest salis fascia.
C abdominis
muscle inferior epigastric The contents of the spermatic cord are:
artery
• The ductus deferens
• Arteries – testicular artery (from the abdominal
aorta), the artery to the ductus deferens (from infe-
deep inguinal ring conjoint rior vesical arteries) and the cremasteric artery (from
tendon the inferior epigastric artery)
• Veins – the pampiniform plexus of veins
fascia transversalis • Lymphatics – accompany the veins from the testis to
the para-aortic nodes
• Nerves – the genital branch of the genitofemoral
nerve supplies the cremaster muscle and sympa-
thetic nerves supply arteries and smooth muscle of
Fig. 5.7 Inguinal canal viewed at different levels: A, Anterior the ductus deferens
view of the inguinal canal; B, Anterior view of the inguinal canal • The processus vaginalis – the obliterated remains of
with external oblique removed; C, Anterior view of the inguinal the peritoneal connection with the tunica vaginalis
canal with external and internal oblique removed. of the testis.

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 The abdominal wall 5

Blood supply, lymphatic drainage

Internal spermatic fascia
(from transversalis fascia) and nerve supply of the scrotum
Superficial Deep The arterial supply of the scrotum arises from ante-
inguinal ring inguinal ring
rior and posterior scrotal arteries (branches of the
external pudendal artery and internal pudendal artery
respectively). Venous drainage occurs via scrotal veins,
which drain into the external pudendal artery and,
eventually, into the great saphenous vein. Innervation
of the scrotum occurs via the genitofemoral, ilioingu-
inal, pudendal nerves and the posterior cutaneous
cremasteric muscle and fascia nerve of thigh. The ilioinguinal nerve supplies the an-
(from internal oblique and
transversus abdominis)
terior third of the scrotum. The posterior two-thirds is
innervated by the posterior scrotal branch of the peri-
external spermatic fascia
neal nerve (medially) and the perineal branch of the
(from external oblique)
posterior cutaneous nerve of thigh (laterally). Lymph
vessels drain to the medial superficial inguinal lymph
nodes of the thigh.
tunica
efferent vaginalis, CLINICAL NOTE
ductules parietal, and
visceral layers
Cremasteric reflex
rete testis
mediastinum
septula In the male, the genital branch of the genitofemoral
testis
tunica nerve supplies the cremaster muscle. Its femoral branch
albuginea supplies a small area of skin on the thigh. Stimulation of
seminiferous this skin causes the cremaster muscle to contract,
lobules tubules raising the testis towards the inguinal canal – testing L1.
of testis
This reflex is very active in children, often leading to a
posterior anterior misdiagnosis of undescended testes.

Fig. 5.9 Left testis and coverings of the spermatic cord.

Testis
The testis is suspended in the scrotum by the spermatic
cord (Fig. 5.9) and is surrounded by three layers (tu-
nics). The outermost layer is the tunica vaginalis, com-
Scrotum posed of a parietal and visceral layer. Testicular
development begins at approximately 6 weeks’ gesta-
The scrotum contains the testes, epididymis, vas defe- tion, on the posterior abdominal wall. In the third
rens and the distal part of the spermatic cord. The wall month of fetal development, a sock-like evagination
of the scrotum is composed of several layers: of the fetal peritoneum (processus vaginalis) passes
• Skin through the abdominal wall, into the developing
• Superficial fascia containing the dartos muscle. The scrotum. At 7–9 months’ gestation the testis descends
dartos muscle receives sympathetic innervation, retroperitoneally into the scrotum (preceded by the
and contracts in response to cold, pulling the testes gubernaculum) coming to lie posterior to the processus
closer to the body and wrinkling the skin. The vaginalis. After testicular descent is complete, the prox-
scrotum is divided into two compartments by imal part of the processus vaginalis is obliterated, leav-
the median raphe (composed of superficial fascia), ing a double layered, serous sac at the distal end – the
separating the testes. Deep to the dartos muscle lies tunica vaginalis. The tunica vaginalis covers the epi-
Colles’ fascia – a continuation of Scarpa’s fascia of didymis and the testis except for its posterior surface,
the abdomen where it reflects onto the wall of the scrotum.
• External spermatic fascia Deep to the tunica vaginalis lies the tunica albuginea,
• Cremasteric fascia a tough fibrous capsule, which gives rise to numerous
• Internal spermatic fascia septa, dividing the testis into 200–300 lobules. Within
• Parietal layer of the tunica vaginalis the lobules lie the seminiferous tubules (the site of

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 The abdomen

spermatogenesis). The seminiferous tubules open into

CLINICAL NOTE
the rete testis (a network of channels lying on the pos-
terior aspect of the testis). The rete testis converge upon Conditions affecting the testes
the efferent ducts, which in turn connect to the first part
of the epididymis (Fig. 5.9). Deep to the tunica albugi- Undescended testis
nea lies the tunica vasculosa, containing blood vessels • The testis may not descend completely, stopping at
and areolar tissue. any point along its descent. Undescended testes carry
a higher than normal risk of malignant change.
HINTS AND TIPS Testicular torsion
• Testicular torsion occurs when the spermatic cord
It is important to remember that the scrotum is part
becomes twisted. This compromises the blood supply
of the body wall and receives a local arterial and nerve
to the testicle. It results in acute, severe unilateral
supply, while the testis develops in the abdomen during
testicular pain, often with nausea and vomiting. The
fetal life and retains its vascular supply and abdominal
testicle is swollen, elevated within the scrotum and
lymphatic drainage. In the female, the ovaries are
extremely tender. This is a medical emergency and
retained within the abdominal cavity.
requires immediate treatment, usually involving
surgery.
Testicular swellings
• A hydrocele is an accumulation of serous fluid within
Epididymis
the tunica vaginalis, usually secondary to a persistent
The epididymis lies on the posterolateral border of processus vaginalis. It results in a painless enlarged
the testis. It is a tightly coiled single tube, the site of
scrotum.
sperm storage and maturation. It is composed of a
• A haematocele is an accumulation of blood within the
head (lying at the upper poles of the testis), a body
and a tail. The efferent ducts drain into the head of tunica vaginalis, usually as a result of trauma. It results
the epididymis. At its tail the epididymis becomes less in an enlarged scrotum, which may be painful.
coiled, wider and becomes known as the ductus (vas) • A varicocele is an abnormal dilatation of the veins of
deferens. the pampiniform plexus, usually secondary to failures
of valves in the testicular vein, or due to compression of
the venous drainage of the testicle (e.g. from a pelvic or
Ductus deferens abdominal malignancy). It causes a dragging sensation
Muscular contractions of the ductus transmit sperm or ache within the scrotum and may be visible or
from the epididymis to the prostatic urethra during palpable (often described as ‘a bag of worms’).
ejaculation (sympathetic innervation). Its arterial sup- • A spermatocele is a cystic structure which arises from
ply arises from a small branch of the superior vesical the epididymis and contains spermatozoa. It is
artery. normally asymptomatic. It lies superior and posterior
to the testis but is separate from it.
Blood supply and lymphatic drainage
The cause of most testicular swellings can be
of the testis diagnosed by ultrasound examination.
The testicular artery (a branch of the abdominal aorta at
the level of the T2 vertebra) enters the spermatic cord
and supplies the testis and epididymis. The pampini-
form plexus of veins drains these structures. In the ingui- THE PERITONEUM
nal canal, the plexus forms four veins. As they emerge
through the DIR, they merge to form two veins, which The peritoneum lines the abdominal and pelvic cavities.
subsequently join to form a single testicular vein. The It consists of a parietal and visceral layer. Parietal perito-
left testicular vein drains into the left renal vein and neum lines the anterior, posterior and lateral walls of the
the right directly into the inferior vena cava. The plexus abdomen, the inferior surface of the diaphragm and the
surrounds the testicular artery and cools the arterial walls of the pelvic cavity. It reflects off the body wall, to
blood, thereby providing the cooler environment re- surround some of the abdominal viscera. The perito-
quired for spermatogenesis in the testis. Lymphatic neum extending from the body wall to the organs forms
drainage of the testes is to the para-aortic nodes in the mesenteries and ligaments. Between the parietal and vis-
abdomen. ceral peritoneum lies a potential space, the peritoneal

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 The peritoneum 5

cavity, filled with a small amount of serous fluid, to Embryology of the gut
allow free movement of viscera. In males the peritoneal
cavity is completely closed; in females the uterine (Fal- In the embryo the gut begins development as a simple
lopian) tubes open into the peritoneal cavity and pro- tube-like structure. It develops into the foregut, midgut
vide a connection to the exterior through the uterus and hindgut, and invaginates into the peritoneal cavity
and vagina. (in a similar way to the lungs in the pleural cavity). The
gut tube is then suspended from the posterior abdominal
wall by the dorsal mesentery – the double layer of peri-
toneum connecting it to the body wall. Between the
two layers of peritoneum are blood vessels, lymphatics
A aorta and nerves (Fig. 5.10). The dorsal mesentery eventually
forms the dorsal mesentery of the small intestine
and other named mesenteries e.g. the greater omentum.
Organs suspended from these mesenteries (and so almost
kidney
dorsal
entirely covered by visceral peritoneum) are termed intra-
parietal mesentery peritoneal. Some organs develop or come to lie upon
peritoneum visceral
the posterior abdominal wall, posterior to the visceral
peritoneum peritoneum and are, therefore, termed retroperitoneal.
peritoneal
cavity The foregut is also connected to the body wall via the
ventral mesentery. Growth of the liver divides the ven-
tral mesentery into the falciform ligament anteriorly
intraperitoneal intestine and the lesser omentum posteriorly (Fig. 5.11).
B
Nerve supply of the peritoneum
dorsal The parietal peritoneum is supplied segmentally
mesentery
by the nerves supplying the overlying muscles and skin.
The peritoneum covering the inferior surface of the
ventral diaphragm is supplied by the intercostal nerves peri-
liver
mesentery pherally and by the phrenic nerve (C3,4,5) centrally. The
parietal peritoneum in the pelvis is supplied by the ob-
turator nerve. The visceral peritoneum does not have a
C dorsal mesentery
somatic innervation, so is insensitive to pain. However,
aorta it receives sympathetic innervation and so it is sensitive
to stretch, tension and ischaemia.
kidney intestine and
mesentery
visceral
lying adjacent
peritoneum falciform ligament
to parietal
parietal peritoneum lesser omentun liver
peritoneum

greater sac

D gastrosplenic
ligament

fused visceral
and parietal
retroperitoneal
peritoneum
intestine

stomach
spleen lesser sac
lienorenal (omental bursa)
ligament
Fig. 5.10 The embryonic (A) dorsal and (B) ventral
mesenteries (C and D) and the formation of the retroperitoneal Fig. 5.11 Division of the ventral mesentery, forming the
part of the intestines. falciform ligament and the lesser omentum.

95
 The abdomen

ligamentum teres (the remnant of the umbilical vein)

CLINICAL NOTE
in its free margin.
Diaphragm
The diaphragm develops opposite the cervical spine, and Greater and lesser sacs
its nerve supply is derived from spinal nerves C3,4,5.
During development, the peritoneal cavity is divided
Although it moves inferiorly during fetal development, it into greater and lesser sacs, by growth of the liver
retains this innervation. Irritation of the diaphragm by (which rotates the stomach and duodenum to the right),
thoracic or abdominal pathology (e.g. infection in the and elongation of the dorsal mesentery. The lesser sac
subphrenic recess) may cause pain in the C4 dermatome (omental bursa) is a sac of peritoneum lying posterior
which lies above the shoulder due to shared C4 root to the stomach. The remainder of the abdominal cavity
value – this is an example of ‘referred pain’. forms the greater sac. The lesser sac communicates
with the greater sac through the epiploic foramen. The
boundaries of the epiploic (omental) foramen are:
• Superiorly – caudate process of liver
Peritoneal folds of the • Anteriorly – portal vein, hepatic artery and bile duct,
anterolateral abdominal wall in the free edge of the lesser omentum
• Inferiorly – first part of the duodenum
Peritoneal folds are reflections of peritoneum, forming • Posteriorly – inferior vena cava.
ridges on the body wall. They are produced by an under-
For descriptive purposes, the greater sac is divided
lying vessel or duct, or the remnant of a fetal vessel.
into compartments. The supracolic compartment lies
There are five peritoneal folds on the abdominal wall
superior to the transverse mesocolon (containing the
(Fig. 5.12):
stomach, liver and spleen). It is divided into left and
• Median umbilical fold – contains the remnant of right regions by the falciform ligament. The infracolic
the urachus (median umbilical ligament) compartment lies inferior to the transverse mesocolon
• Two medial umbilical folds – containing remnants of (containing the small bowel, the ascending and des-
the umbilical arteries (medial umbilical ligaments) cending colon) (Fig. 5.13A). The infracolic compart-
• Two lateral umbilical folds – containing the inferior ment is further subdivided by the mesentery of the
epigastric vessels. small intestine into right and left divisions. The supra-
The falciform ligament is an anterior peritoneal fold colic and infracolic compartments communicate via
(originally the ventral mesentary), lying between the the paracolic gutters, lying lateral to ascending and des-
diaphragm and the umbilicus, which contains the cending colon.

Fig. 5.12 Peritoneal folds of the

anterior abdominal wall, viewed from ligamentum teres hepatis
the posterior aspect.
arcuate line falciform ligament umbilicus remnant
of urachus

rectus
abdominis
muscle

medial
obliterated umbilical
umbilical fold
artery

inferior
epigastric lateral
artery umbilical
and vein fold

ductus
deferens

bladder median
umbilical
fold

96
 The peritoneum 5

Fig. 5.13 A, Sagittal section of the

A upper abdomen to show recesses
of the right supracolic compartment.
right B, Posterior abdominal wall showing
subphrenic lines of peritoneal reflection and the
recess
compartments of the greater sac
diaphragm
(liver, stomach, small intestine, caecum,
visceral transverse and sigmoid colons have been
peritoneum removed). (Adapted from Williams P
inferior liver (ed.) (1995) Gray’s Anatomy, 38th
vena cava edition, Churchill Livingstone.)
B, Sagittal section of the upper abdomen
right kidney to show the recesses of the right
right subhepatic supracolic compartment.
recess

parietal
peritoneum

position of right
subphrenic
recess

position of bare
supracolic
area of liver
compartment
position of
right subhepatic
recess pancreas

right kidney

transverse
mesocolon

duodenum
infracolic
upper right compartment
infracolic
compartment

root of
mesentery

lower left
infracolic
compartment sigmoid
mesocolon

Between the upper surface of the liver and the dia- formed differ between genders. Males have a rectovesical
phragm lies the subphrenic recess, divided into left pouch. Females have vesicouterine and rectouterine
and right halves by the falciform ligament. Inferior to pouches (Ch. 6).
the liver and superior to the right kidney lies the right
subhepatic recess (the hepatorenal recess or Morrison’s
pouch), which communicates with the right paracolic
gutter (Fig. 5.13B). The left subhepatic recess forms part
Greater and lesser omenta
of the lesser sac. The greater omentum is the largest peritoneal fold, aris-
In the pelvic compartment the peritoneum lies over ing from the greater curvature of the stomach. It hangs
and between pelvic viscera. The peritoneal pouches like an apron over the intestines and is filled with fat.

97
 The abdomen

It is fused with the transverse mesocolon and with the Stomach

anterior aspect of the transverse colon.
The lesser omentum extends from the inferior border The stomach lies intraperitoneally, in the left hypogas-
of the liver to the lesser curvature of the stomach tric and epigastric regions of the abdomen. It is a dilated
(known as the hepatogastric ligament), and from the muscular bag, which is relatively mobile, fixed only to
proximal part of the duodenum to the liver (known the oesophagus and duodenum (Fig. 5.14). It is com-
as the hepatoduodenal ligament). posed of the cardia, fundus, body, antrum and pylorus.
Peritoneal folds, sacs, recesses and omenta are im- The gastro-oesophageal junction (between the oesoph-
portant as they determine the distribution of intra- agus and the cardia) lies at the level of T10 and the py-
peritoneal fluid and act as boundaries and conduits loric sphincter (gastroduodenal sphincter) lies at the
for disease (e.g. infection, tumours and trauma). level of L1.
The mucosal lining of the stomach is thrown
HINTS AND TIPS into folds or rugae, which allow considerable dila-
tion. The wall is muscular and comprises outer longi-
The greater omentum is the ‘policeman’ of the abdomen - tudinal, middle circular and inner oblique muscle
it has the ability to wall off areas of infection within layers.
the abdominal cavity, thereby preventing free peritonitis. The relations of the stomach are:
• Anteriorly – the anterolateral abdominal wall, left
costal margin, and diaphragm
• Posteriorly – the left suprarenal gland, upper pole of
THE ABDOMINAL ORGANS the left kidney, pancreas, spleen, splenic artery and
left colic flexure (forming the stomach bed).
The stomach and oesophagus are supplied by
Oesophagus branches of the coeliac trunk. Venous drainage of the
After passing through the diaphragm, accompanied by stomach accompanies the arteries. Smaller veins drain
the vagal trunks, the oesophagus turns anteriorly and into the superior mesenteric vein (SMV) and the splenic
left to enter the stomach. Its blood and nerve supply vein, which combine to form the hepatic portal
are shown in Figure 4.27. vein (some veins drain directly into the portal vein).

Fig. 5.14 Arterial supply and lymph

nodes of the stomach. abdominal part left gastric fundus
of oesophagus nodes body
oesophageal branch
pancreaticosplenic
left gastric artery nodes
abdominal aorta short
gastric
arteries
hepatic nodes
hepatic artery
right gastric
splenic
artery
artery
gastroduodenal
artery left
gastroepiploic
coeliac trunk artery
coeliac nodes

pyloric nodes
duodenum omental
branches

superior
pancreaticoduodenal
artery
pyloric part right greater
right gastroepiploic omentum
gastroepiploic nodes
artery

98
 The abdominal organs 5

The hepatic portal vein carries blood to the liver. Lymph

from the stomach drains to the coeliac nodes and even- symptoms are present. Treatment involves simple
tually into the thoracic duct. measures, such as avoiding caffeine, alcohol, etc., and
Innervation of the stomach is via the coeliac plexus medication, usually proton pump inhibitors, which
(part of the autonomic nervous system): sympathetic reduce the production of acid within the stomach.
supply arises from the greater and lesser splanchnic
nerves. Parasympathetic innervation arises from the an-
terior and posterior vagal trunks.
Duodenum
CLINICAL NOTE The duodenum is approximately 40 cm long and C-
shaped, curving around the head of the pancreas. It is
Gastro-oesophageal reflux disease
divided into four parts (the first part is intraperitoneal,
Gastro-oesophageal reflux disease (GORD) is a the remainder is retroperitoneal):
common problem in infants and adults. It normally • The first part passes anterolateral to the L1 vertebra,
occurs secondary to loss of tone of the lower and travels superiorly and posteriorly.
oesophageal sphincter. It is exacerbated by smoking, • The second part passes inferiorly. The major duode-
obesity, fatty food, caffeine, alcohol and some nal papilla (the opening of the bile duct and main
drugs (all of which affect the competence of the pancreatic duct) opens into this part at the level of
gastro-oesophageal junction). Adults commonly L2 vertebra.
present with a ‘burning’ sensation behind the • The third part lies horizontally and crosses the verte-
sternum (heartburn) and regurgitation of stomach acid bral column at the level of L3. It is crossed by the
into the back of the throat or the mouth. Infants superior mesenteric artery (SMA) and SMV.
• The fourth part travels superiorly to the level of the
present with vomiting and weight loss. GORD may
L2 vertebra and joins with the jejunum.
cause damage to the oesophageal mucosa, ranging
from oesophagitis to oesophageal stricture and, rarely, Figure 5.15 shows the relations of the duodenum. Its
blood supply arises from the superior and inferior pan-
metaplasia (Barrett’s oesophagus) or malignancy.
creaticoduodenal arteries, branches of the gastroduode-
Diagnosis is clinical (i.e. based upon symptoms) in
nal artery (a branch of the hepatic artery) and SMA
younger patients with no alarm symptoms, e.g. respectively. Venous drainage occurs via the SMV and
unintentional weight loss, dysphagia, gastrointestinal the splenic vein. Lymphatic drainage of the duodenum
bleeding. Endoscopy is performed if treatment is not is via the coeliac and superior mesenteric nodes. Its
beneficial, in older patients (over 55), or if alarm nerve supply arises from the vagus and sympathetic
nerves via the coeliac and superior mesenteric plexuses.

Fig. 5.15 Relations of the duodenum.

left gastric artery
left suprarenal gland Note the splenic vein runs posterior to
hepatic artery
inferior the pancreas and is, therefore, not
portal vein vena cava body of
pancreas
visible. The inferior mesenteric vein has
1st part of duodenum been omitted for clarity.
common bile duct spleen and
splenic artery
2nd part of
duodenum
accessory
pancreatic
duct
left kidney
main
pancreatic 4th part of
duct duodenum
uncinate process superior
right kidney aorta mesenteric
artery
ureter 3rd part of ureter and vein
duodenum

99
 The abdomen

The jejunum and ileum are supplied by jejunal and

CLINICAL NOTE
ileal arteries (branches of the SMA) which form anasto-
Gastric and duodenal ulcers motic loops known as arterial arcades. Vasa recta
(straight arteries) arise from the arcades to supply the
A gastric ulcer in the posterior stomach wall may erode walls of the intestine. The vasa recta are end arteries –
into the splenic artery, causing massive haemorrhage occlusion may result in infarction. Venous drainage oc-
into the lesser sac. It may also erode into the pancreas, curs via the SMV. Lymphatic drainage of the jejunum
causing referred pain in the back. and ileum is to the superior mesenteric nodes.
95% of duodenal ulcers occur in the posterior wall of Innervation arises from the posterior vagal trunks
the first part of the duodenum. Perforation causes the (parasympathetic) and the greater and lesser splanchnic
duodenal contents to enter the abdominal cavity nerves (sympathetic).
causing peritonitis. An ulcer may also erode the
gastroduodenal artery causing major haemorrhage. An
Large intestine
anterior ulcer may be sealed off by the greater This consists of the caecum and appendix, colon, rec-
omentum. tum and upper part of the anal canal.

Caecum and appendix

The caecum and the vermiform appendix lie in the right
Jejunum and ileum iliac fossa. The caecum is a blind ending pouch invested
The jejunum and ileum are intraperitoneal. They are at- by peritoneum. It is the first part of the large intestine,
tached to the posterior abdominal wall by the mesen- continuous with the ascending colon. The ileum enters
tery of the small intestine. The root of the mesentery the caecum at the ileocaecal valve (not a true valve).
extends along the posterior abdominal wall from the The appendix is a blind-ending tube, 6–9 cm long,
left of the L2 vertebra to the right sacroiliac joint and and rich in lymphoid tissue. It opens into the posterome-
contains blood vessels, fat, lymph nodes and nerves. dial wall of the caecum, 2 cm inferior to the ileocaecal
Figure 5.16 outlines the differences between the jeju- junction. It is suspended by a mesentery (the mesoappen-
num and ileum. Of note are lymphoid nodules known as dix). The taeniae coli (bands of smooth muscle which
Peyers patches, found mostly, but not exclusively, in the correspond to the outer, longitudinal layer of muscle else-
ileum. They play a role in generating the immune response, where in the gastrointestinal tract) of the caecum merge at
containing many of the cells of the immune system. the base of the appendix – this is a useful landmark dur-
ing surgery. The position of the body of the appendix var-
ies – the majority are retrocaecal (65%) or pelvic (30%),
Fig. 5.16 Distinguishing characteristics of the jejunum and with the remainder (5%) occupying a variety of positions.
ileum. Swelling of the appendix may obstruct the artery, result-
Characteristic Jejunum Ileum ing in necrosis and perforation. The arterial supply, ve-
nous and lymphatic drainage, and nerve supply of the
Colour Deep red Paler pink
caecum and appendix are detailed in Figure 5.17A and B.
Wall Thick and heavy Thin and light
Vascularity Greater Less CLINICAL NOTE

Vasa recta Long Short Appendicitis

Arcades A few large Many short Appendicitis occurs when the appendix is obstructed by
loops loops faecoliths or by swelling of lymphoid tissue (often after a
Peyer’s patches No Yes viral infection). As the appendix becomes inflamed it
(aggregated produces periumbilical pain (the appendix is part of the
lymphoid follicles) midgut and visceral pain from this region is felt around
Plicae circulares More and larger Less and the umbilicus). Pain subsequently becomes sharper
(mucosal folds smaller/ and localized to the right iliac fossa, due to irritation of
increasing surface absent the parietal peritoneum. Treatment is appendicectomy.
area)
Untreated appendicitis can result in rupture,
Fat Less – stops at More – peritonitis (with increased pain, nausea/vomiting and
the mesenteric encroaches abdominal rigidity), the formation of an appendix
border with the onto the
jejunum ileum
abscess and sepsis.

100
 Fig. 5.17A Colon and its blood
A supply.
aorta
superior transverse
right colic mesenteric artery colon left colic
(hepatic) (splenic)
flexure flexure

middle
colic inferior
artery mesenteric
artery
right
colic jejunal and
artery ileal arteries

ileocolic
left colic
artery
artery
anterior
caecal
artery
ileal artery sigmoid
arteries
posterior
ileum
caecal artery
appendicular
artery appendix

sigmoid
colon
rectum superior
rectal artery

Fig. 5.17B Arterial supply, venous and lymphatic drainage and innervation of the colon.

Arterial supply Venous drainage Nerve supply Lymphatic

drainage
Caecum SMA ! ileocolic Ileocolic veins !
artery ! anterior and SMV ! portal vein
posterior caecal
arteries
Appendix SMA ! ileocolic Superior
Appendicular vein Parasympathetic fibres from the
artery ! mesenteric
! SMV ! portal vagus nerves and sympathetic fibres
appendicular artery nodes
vein from the superior mesenteric plexus
Ascending SMA ! ileocolic and Ileocolic and right
colon right colic arteries colic veins ! SMV !
portal vein
Transverse Proximal two-thirds: Proximal two-thirds: Proximal two-thirds: sympathetic
colon SMA ! middle colic middle colic vein ! and vagus nerves in the superior
artery SMV ! portal vein mesenteric plexus
Distal one-third: Distal one-third: left Distal one-third: sympathetic via
SMA! left colic colic vein ! IMV ! inferior mesenteric ganglion,
artery portal vein parasympathetic via pelvic
splanchnic nerves
Descending IMA ! left colic and Superior rectal veins
colon sigmoid arteries ! IMV ! portal Inferior
vein Sympathetic via inferior mesenteric mesenteric
ganglion, and parasympathetic nodes
Sigmoid IMA ! sigmoid Superior rectal veins pelvic splanchnic nerves
colon arteries and superior ! IMV ! portal vein
rectal arteries
IMA, inferior mesenteric artery; IMV, inferior mesenteric vein, SMA; superior mesenteric artery; SMV superior mesenteric vein; ! branches of,
with regard to arterial supply and tributary of, with regard to venous drainage

101
 The abdomen

CLINICAL NOTE CLINICAL NOTE

Meckel’s diverticulum Diverticulae

This is a remnant of the vitelline duct (a connection Outpouchings of mucous membrane may herniate
between the gut tube and the embryonic yolk sac). It through the perforations in the muscle layer of the
projects from the ileum, approximately 2ft from the colon made by the blood vessels between the taeniae
ileocaecal junction in roughly 2% of people. It is twice coli. The outpouchings are known as diverticulae
as common in males compared with females. It may and are most common in the sigmoid colon. The
contain ectopic mucosa (gastric, pancreatic or colonic). presence of diverticulae is known as diverticulosis.
It may cause ulceration with pain, bleeding or Inflammation of the diverticulae, resulting in pyrexia,
diverticulitis, producing symptoms similar to those of and pain in the left iliac fossa, is known as diverticular
appendicitis. disease.

Colon CLINICAL NOTE

The colon has several characteristic features:
Ischaemic bowel and Hirschprung’s disease
• Three bands of smooth muscle which run longitudi-
nally along the wall of the colon – the taeniae coli. The terminal branches of the superior mesenteric artery
They correspond to the outer longitudinal layer of (SMA) and inferior mesenteric artery (IMA) form an
the muscularis externa in other regions of the gastro- anastomotic network (important in the event of arterial
intestinal tract occlusion), known as the marginal artery. Vasa recta
• Haustra – pouches along the length of the colon, arise from the marginal artery to supply the colon.
formed by the taeniae coli, which ‘bunch together’ The splenic flexure is the watershed area between
the colonic wall the arterial supply of the SMA and IMA. Anastomoses
• Appendices epiploicae – pouches of peritoneum filled
here are often weak or absent, and so this region
with fat project from the external surface of the colon.
is an area particularly prone to ischaemia and infarction.
The colon is composed of the following regions:
Hirschsprung’s disease generally presents in infancy
• Ascending colon: this occupies a retroperitoneal po- or childhood. It arises due to an absence of nerve
sition, and extends from the ileocolic junction to the plexuses within the wall of the gut, most commonly
right colic (hepatic) flexure. The right paracolic gut-
in the rectosigmoid region. This results in
ter lies on its lateral side.
constipation, bowel obstruction and vomiting. It is
• Transverse colon: this extends from the right colic
(hepatic) flexure to the left colic (splenic) flexure, normally confirmed by biopsy. Treatment consists of
the former being lower due to the right lobe of the surgical removal (resection) of the affected area of the
liver. It is intraperitoneal suspended by the trans- colon.
verse mesocolon.
• Descending colon: this extends from the left colic
(splenic) flexure to the sigmoid colon. It lies retroper-
itoneally. The left paracolic gutter lies on its lateral side. Spleen
• Sigmoid colon: this extends from the descending co- The spleen is a large lymphoid organ, located in the
lon and becomes continuous with the rectum inferi- left hypochondrium, inferior to the diaphragm. It is
orly. It hangs free from the sigmoid mesocolon. The only palpable when enlarged. It removes damaged or
mesocolon is an inverted V-shape (Fig. 5.13B), the antibody-coated cells from the blood and assists in
base of which lies over the sacroiliac joint. From mounting immunological responses against blood-
here, one part runs to the midinguinal point along borne pathogens. It is a site of haematopoeisis in the
the external iliac vessels and the other runs to the fetus and a potential site of haematopoeisis in the adult.
level of the S3 where the rectum begins. It has a convex diaphragmatic surface and on its concave
The arterial supply, venous and lymphatic drainage, visceral surface lies the hilum – the site of entry and exit
and nerve supply of the colon is illustrated and detailed of the splenic vessels. The visceral surface is also related
in Figure 5.17 A and B. to the stomach, kidney, colon and the tail of the

102
 The abdominal organs 5

pancreas. Its anterior and superior borders are notched subdivisions (Fig. 5.18). Anteriorly, the falciform liga-
and sharp, but its posterior and inferior borders are ment (visible on the anterior surface of the liver) at-
rounded. taches the liver to the anterior abdominal wall and
It is connected to the greater curvature of the stomach also divides the liver into right and left lobes. Posteri-
by the gastrosplenic ligament, and to the posterior orly, the caudate lobe lies superiorly, between the fissure
abdominal wall at the left kidney, by the splenorenal for the inferior vena cava and the fissure for the ligamen-
(lienorenal) ligament. It is completely enclosed by tum venosum. Inferior to this lies the quadrate lobe, be-
peritoneum except at the hilum. tween the gallbladder fossa and the ligamentum teres.
Its arterial supply arises from the splenic artery (a The transverse fissure separates the caudate lobe from
branch of the coeliac trunk), a tortuous vessel which the quadrate lobe. Functionally, the quadrate and cau-
passes along the superior border of the pancreas and an- date lobes are part of the left lobe as they are supplied
terior to the left kidney. As it does so the splenic artery
gives off short gastric and left gastroepiploic arteries to
the stomach and branches to the pancreas. Between
the layers of the splenorenal ligament, the splenic artery
divides into terminal branches which enter the hilum of Anterior view
the spleen. anterior layer of
lesser omentum
Venous drainage occurs via the splenic vein, which inferior greater
runs along the posterosuperior aspect of the pancreas, vena cava posterior layer of omentum
lesser omentum oesophagus
and is joined by the inferior mesenteric vein posterior upper layer
to the body of the pancreas. Posterior to the neck of of coronary
ligament
the pancreas, the vein unites with the SMV to form
the hepatic portal vein.
Lymphatic drainage is to the splenic nodes and, sub-
sequently, the coeliac trunk. Its nerve supply arises from
the coeliac plexus.
left lobe
left triangular
CLINICAL NOTE ligament
ligamentum teres in
Ruptured spleen and splenectomy falciform ligament
The spleen can be damaged by blunt trauma or right lobe gall bladder
rib fractures (particularly of the 9th to 11th ribs).
Posterior view
Splenic rupture can lead to massive blood loss and
inferior
hypovolaemic shock. Emergency splenectomy is falciform vena cava
required. Patients who have undergone a ligament
upper layer of
splenectomy are vulnerable to infection (due to the left triangular caudate coronary ligament
role of the spleen in immunity) and so they must ligament lobe
bare area
ensure that they are vaccinated against appropriate right lobe
diseases. They may also be advised to take lifelong
antibiotics.

gastric surface
Liver (left lobe)
lesser omentum
The liver is a wedge-shaped organ, surrounded by a fi- ligamentum teres
brous capsule, which lies inferior to the right hemi- quadrate lobe
diaphragm. It spans the right hypochondrium, the porta hepatis gall
bladder
epigastrium and the left hypochondrium. It lies largely renal
caudate process surface
under the cover of the ribs and it is invested by perito-
neum except for the ‘bare area’, on the diaphragmatic lower layer of right triangular
coronary ligament ligament
surface of the liver.
The liver has four lobes, although this is a purely an-
atomical description and does not reflect functional Fig. 5.18 Anterior and posterior views of the liver.

103
 The abdomen

by the left hepatic artery, left branch of the portal vein • Destruction of erythrocytes
and deliver bile to the left bile duct. • Production of heat
The falciform ligament is the remnant of the embry-
onic ventral mesentery. On the superior surface of the
liver the falciform ligament forms the left and right tri- Gallbladder and biliary tract
angular ligaments. The right layer forms the upper layer
The gallbladder lies in a fossa on the visceral surface of
of the coronary ligament, the right triangular ligament
the liver. It has a fundus, a body and a neck (Fig. 5.19).
and the lower layer of the coronary ligament (Fig. 5.18).
Bile secreted by the liver is concentrated and stored in
The area between the upper and lower parts of the
the gall bladder (its capacity is approximately 50 ml).
coronary ligament is the bare area of the liver that lies
After fat- or protein-rich food, cells of the duodenum re-
in contact with the diaphragm. The right and left layers
lease cholecystokinin (CCK), which stimulates the
of peritoneum meet on the visceral surface of the liver to
smooth muscle of the gallbladder wall and relaxes the
form the hepatogastric and hepatoduodenal ligaments,
hepatopancreatic sphincter (sphincter of Oddi – a layer
part of the lesser omentum. Between the caudate and
of circular muscle surrounding the ampulla, controlling
quadrate lobes, the two layers surround the porta hepa-
the flow of bile and pancreatic secretions), releasing bile
tis. The porta hepatis, the inferior vena cava, the gall
into the duodenum.
bladder and the fissures of the ligamentum venosum
The cystic duct drains the gallbladder and joins the
and ligamentum teres form an H-shaped pattern. The
common hepatic duct to form the common bile duct
ligamentum venosum is the remnant of the fetal ductus
(CBD). The CBD passes through the free margin of
venosus, which transported blood from the portal and
the lesser omentum, posterior to the first part of the
umbilical veins to the hepatic veins.
duodenum. It then enters the second part of the duo-
The porta hepatis contains the following structures
denum with the pancreatic duct at the hepatopan-
(Fig. 5.18):
creatic ampulla (of Vater). The ampulla opens at the
• The hepatic artery proper (a branch of the coeliac major duodenal papilla.
trunk) splits into right and left hepatic arteries and Blood supply to the gallbladder is via the cystic ar-
supplies oxygenated blood to the liver. The right he- tery, a branch of the right hepatic artery. Venous drain-
patic artery gives off the cystic artery, which supplies age occurs via the cystic veins, which drain into the right
the gallbladder.
• The hepatic portal vein carries the products of diges-
tion from the gut to the liver. This blood is also par-
tially oxygenated.
right and left
• The right and left hepatic ducts drain bile into the hepatic ducts
common hepatic duct, which joins the cystic duct
to form the bile duct. neck
• These three structures form the portal triad that lies
portal vein
in the right free margin of the lesser omentum. The
porta hepatis also contains lymph nodes and nerves. spiral folds
common
hepatic duct
Venous drainage of the liver occurs via the hepatic
veins which pass directly from the posterior surface of cystic duct

the liver into the inferior vena cava, draining the liver. body of hepatic
Lymphatic drainage of the liver is to the hepatic nodes gall bladder artery
around the porta hepatis and on into the coeliac nodes.
free margin bile duct
Lymphatics of the bare area drain into the posterior me- of lesser passing behind
diastinal nodes. Innervation is provided via sympathetic omentum superior part
and parasympathetic nerve fibres (via the vagus nerves) of duodenum
in the hepatic plexus, a branch of the coeliac plexus. fundus
pancreatic duct
The functions of the liver include :
duodenal bile duct
• Production of bile, cholesterol, albumin and clotting papilla
factors
• Detoxification of drugs and chemicals
• Homeostasis of blood glucose levels
• Metabolism of carbohydrates, proteins and fats
• Storage of vitamins, cholesterol, fats, proteins, cop-
per and iron Fig. 5.19 Gall bladder and biliary tract.

104
 The abdominal organs 5

hepatic vein. The majority of lymph drains to the he- the common bile duct to form the ampulla of Vater.
patic nodes and ultimately into the coeliac nodes. The This then opens into the duodenum at the major duode-
nerve supply arises from the coeliac plexus, the vagus nal papilla. Approximately 2 cm proximal to this, the
nerve and the right phrenic nerve. accessory pancreatic duct opens into the duodenum at
the minor duodenal papilla. It drains the head of the
pancreas.
The splenic artery (a branch of the coeliac trunk) sup-
CLINICAL NOTE plies the neck, body and tail of the pancreas. The supe-
rior and inferior pancreaticoduodenal arteries supply
Jaundice
the head. The splenic and SMV drain the pancreas. Lym-
Jaundice results from an increased level of bilirubin in phatics drain into superior and inferior pancreatic
the blood. It accumulates in the skin, and mucous nodes then to coeliac and superior mesenteric nodes.
membranes, including the conjunctiva of the eye. The Nerve supply to the pancreas arises from the vagus
causes of jaundice may be classified as pre-hepatic, nerves (parasympathetic) and the splanchnic nerves
usually related to increased breakdown of bilirubin; (sympathetic) arising from the coeliac and superior
hepatic, disease within the liver; and post-hepatic, mesenteric plexuses.
disruption to the flow of bile. Obstruction of the biliary
tree is most commonly due to gallstones, but may occur
secondary to carcinoma of the head of the pancreas. If Arterial supply of the gut
the biliary tree is obstructed, causing post-hepatic
The foregut, midgut and hindgut (Fig. 5.1) are supplied
jaundice, bilirubin cannot enter the intestine (bile
by the branches of the coeliac trunk, the SMA and the
pigments give stools their brown colour) therefore it is
IMA, respectively.
reabsorbed into the blood, filtered by the kidney and The coeliac trunk arises from the abdominal aorta at
excreted in the urine. This produces the characteristic the level of T12. It gives off the left gastric, common
features of obstructive jaundice; dark urine and pale hepatic and splenic arteries (Fig. 5.14).
stools. The SMA arises from the abdominal aorta at the
level of L1 (transpyloric plane). It gives off the inferior
pancreaticoduodenal, jejunal and ileal, ileocolic, right
colic and middle colic arteries. The IMA arises from
the abdominal aorta, opposite L3. It gives off the
Pancreas left colic, sigmoid and superior rectal arteries
The pancreas has both exocrine and endocrine func- (Fig. 5.17A).
tions. It is a retroperitoneal organ, lying posterior
to the stomach (Fig. 5.15). It spans the epigastrium
and left hypochondrium. It has a head, neck, body
and tail: Venous drainage of the gut
• The head lies in the concavity of the duodenum, an- Venous drainage of the intestine occurs via the hepatic
terior to the inferior vena cava and left renal vein. portal system (Fig. 5.20). The hepatic portal vein is
The bile duct travels through it. formed by the union of the SMV and the splenic vein,
• The uncinate process is an extension of the head; posterior to the neck of the pancreas. The IMV drains
the SMA and SMV pass anterior to the uncinate into the splenic vein.
process. The hepatic portal vein passes posterior to the first
• The neck lies anterior to the point at which the part of the duodenum, in the free edge of the lesser
SMV and splenic vein join to form the portal omentum. At the porta hepatis, the vein divides into left
vein. and right branches, supplying left and right lobes of the
• The body is related to the stomach anteriorly, and to liver. Within the sinusoids of the liver, hepatic portal
the aorta, splenic vein, left kidney and renal vessels, blood and oxygenated blood from the hepatic artery
and left suprarenal gland posteriorly. mix together and come into contact with hepatocytes,
• The tail passes into the splenorenal ligament, reach- where metabolites, such as the products of digestion,
ing the hilum of the spleen, accompanied by the are exchanged. Blood from the sinusoids empties into
splenic vessels and lymphatics. hepatic veins draining the liver, they in turn drain
The main pancreatic duct begins in the tail of the into the inferior vena cava and blood is returned to
pancreas. In the head of the pancreas it joins with the heart.

105
 The abdomen

right atrium • Anal canal – between the superior and middle/inferior

hepatic veins rectal veins – enlargement results in rectal varices
right ventricle • Peri-umbilical region of the abdominal wall –
between the para-umbilical veins and the superficial
and inferior epigastric veins – enlargement causes
oesophageal vein
caput medusae: visible, enlarged, systemic veins
left gastric vein radiating outwards from the umbilicus
• Retroperitoneal anastomoses and anatomoses of the
right gastric vein bare area of the liver – these are not clinically
significant.
splenic vein
inferior
vena cava
portal vein inferior
mesenteric
Nerve supply of the gut
middle colic vein vein The gut tube receives sympathetic and parasympathetic
superior
mesenteric vein nerves that travel with the gut arteries. See the section on
right
right colic vein gastroepiploic nerves of the posterior abdominal wall for more detail.
vein

ileocolic vein jejunal and

ileal veins Lymphatic drainage of the gut
The majority of lymph from the gastrointestinal tract
drains to nodes close to the viscera in question (usually
of the same name), then into either the para-aortic
nodes (coeliac nodes, superior or inferior mesenteric
Fig. 5.20 Hepatic portal venous system. nodes) if the viscera is intraperitoneal, or to the lumbar
nodes if the viscera is retroperitoneal. In the case of or-
gans which are secondarily retroperitoneal (the pan-
creas, the ascending and descending colon) drainage
CLINICAL NOTE
is to the pre-aortic nodes. Lymph from the pre-aortic
Portal hypertension and areas of portosystemic nodes drains to intestinal trunks, lymph from lumbar
nodes drains to lumbar trunks. Lymph from the intesti-
anastomosis
nal and lumbar trunks then drains into the cisterna chyli
In portal hypertension, the pressure within the portal vein and into the thoracic duct.
is elevated. This is usually due to either increased blood
flow or increased resistance to blood flow through the
liver (e.g. in cirrhosis, where the liver becomes fibrosed
destroying the blood vessels within the liver). The THE POSTERIOR ABDOMINAL
consequence is that a large amount of the blood which WALL
would normally pass through the portal vein into the
liver, is shunted into the systemic circulation, via collateral The posterior abdominal wall offers protection to the
vessels, which provide an alternative route for the blood abdominal contents, houses components of the ab-
to return to the inferior vena cava. Dilatation of these dominal cavity and serves as a passageway for structures
travelling to other regions of the body (Fig. 5.21). It is
vessels increases the risk of rupture and bleeding. There
composed of:
are several sites at which the portal circulation meets the
systemic circulation (i.e. where shunting occurs). These • Bony structures: the bodies of the five lumbar verte-
brae (and their intervertebral discs), which project
are known as portosystemic anastomoses:
forwards into the abdominal cavity, the medial
• Lower end of the oesophagus – between the
region of the ilia, and ribs XI and XII.
oesophageal tributary of the left gastric vein and the • Muscular structures: the psoas major, iliacus and
oesophageal tributaries of the azygos vein – quadratus lumborum muscles (Fig. 5.22). The ilio-
enlargement results in oesophageal varices, which lumbar ligament is a ligament passing from the
may rupture, causing massive haematemesis transverse process of L5 vertebra to the posterior part
of the iliac crest.

106
 The posterior abdominal wall 5

Fig. 5.21 Structures of the posterior

abdominal wall.
right and left suprarenal glands
oesophagus

diaphragm

inferior
vena cava left kidney

right kidney
abdominal aorta
subcostal nerve
quadratus
iliohypogastric lumborum
nerve muscle
ilioinguinal psoas major
nerve muscle
lateral femoral iliacus muscle
cutaneous nerve

genitofemoral
nerve

right and left ureters

Fig. 5.22 Muscles of the posterior abdominal wall.

Name of muscle Origin Insertion Action

(nerve supply)
Psoas major Bodies, transverse processes and intervertebral Lesser trochanter Flexes thigh on trunk
(L1–L3) discs of T12 and L1–L5 vertebrae of femur
Quadratus Iliolumbar ligament, iliac crest, transverse 12th rib Depresses 12th rib during
lumborum processes of lower lumbar vertebrae respiration; laterally flexes
(T12–L3) vertebral column
Iliacus (femoral Iliac fossa Lesser trochanter Flexes thigh on trunk
nerve) of femur
(Adapted from Snell RS (1996) Clinical Anatomy. An Illustrated Review with Questions and Explanations, 2nd edn. Little
Brown & Co.)

Fascia of the posterior Tendinous fibres of the diaphragm pass in front of the
aorta in the midline to form the median arcuate ligament.
abdominal wall
Fascia covers the muscles of the posterior abdominal
wall: psoas fascia covering psoas major and thoraco-
Vessels of the posterior
lumbar fascia already mentioned. abdominal wall
The superior edge of the thoracolumbar fascia forms
the lateral arcuate ligament slung between the middle Abdominal aorta
of the 12th rib and the transverse process of L1 vertebra. The abdominal aorta passes through the diaphragm at
From here, the medial arcuate ligament (the superior edge the level of T12. It passes inferiorly on the bodies of
of psoas fascia) extends to the side of L1 or L2 vertebra. the lumbar vertebrae. Anterior to the L4 vertebrae it

107
 The abdomen

(EVAR), to place a graft within the weakened area.

inferior phrenic Management of patients with aneurysms between 5
artery and 5.5 cm depends upon the presence of risk factors
suprarenal artery coeliac trunk (T12) and symptoms.
suprarenal artery
superior Aneurysm rupture results in back or abdominal pain,
mesenteric lumbar artery
hypotension and shock. The degree of blood loss is
artery (L1) left renal artery (L2)
usually fatal.
right renal artery
(L2)

gonadal artery Inferior vena cava

inferior lumbar arteries The inferior vena cava (IVC) is formed by the joining of
mesenteric
the left and right common iliac veins (Fig. 4.22) at the
artery (L3)
level of the L5 vertebrae. The IVC ascends to the right of
the aorta, passes posterior to the liver and pierces the
diaphragm at the level of T8 with the right phrenic
median common nerve. It then almost immediately enters the heart.
sacral iliac artery
artery
Nerves of the posterior
external
iliac artery
internal
iliac artery
abdominal wall
Somatic nerves
Fig. 5.23 Branches of the abdominal aorta. The L1–L4 spinal nerves emerge from their intervertebral
foramina and enter psoas major, which they supply. The
ventral (anterior) rami of the nerves form the lumbar
divides into the right and left common iliac arteries. The plexus (Fig. 5.24), which is mostly concerned with sen-
branches of the abdominal aorta are illustrated in sory and motor innervation to the lower limb. However,
Figure 5.23. some branches are motor and sensory to the anterior ab-
dominal wall, e.g. iliohypogastric nerve, and sensory to
CLINICAL NOTE the parietal peritoneum, e.g. obturator nerve. The
lumbosacral trunk joins the first three sacral nerves to
Abdominal aortic aneurysm contribute to the sacral plexus.
An abdominal aortic aneurysm most commonly occurs
infrarenally (distal to the branching of the renal Autonomic nerves
arteries). Aneurysms are most common in males. They
The autonomic nerve supply of the abdomen is com-
may be detected as an incidental finding, felt as an
posed of the following:
expansile mass on the left of the midline. Symptoms
include pain in the abdomen or back, and a pulsing • Parasympathetic supply from the vagal trunks and
pelvic splanchnic nerves (S2,3,4)
sensation in the abdomen.
• Sympathetic supply from the lumbar sympathetic
Patients suspected to have an aneurysm undergo
trunks and the thoracic and lumbar splanchnic nerves
assessment, to confirm the diagnosis, and to assess risk. • Prevertebral autonomic plexuses surrounding the
Assessment is based upon the age of the patient, the aorta (coeliac, aortic and superior hypogastric),
size of the aneurysm (assessed via ultrasound or CT which distribute the nerve fibres.
scanning), the rate of enlargement of the aneurysm,
family history of aneurysm rupture and the level of a Sympathetic nerves
chemical known as MMP-9 in the blood (associated The lumbar sympathetic trunk comprises preganglionic
fibres from the lower thoracic trunk and from L1 and L2
with weakening of the wall of the aorta).
nerves (via white rami). This trunk enters the abdomen
Aneurysms less than 5 cm in diameter are generally
posterior to the medial arcuate ligament of the dia-
monitored by means of regular ultrasound scans. phragm. It lies on the bodies of the lumbar vertebral
Aneurysms over 5.5 cm normally require surgery – bodies, along the medial border of psoas major.
either open surgery or endovascular aortic repair There are usually four lumbar ganglia. These give so-
matic branches (grey rami communicantes) to all five

108
 The posterior abdominal wall 5

Fig. 5.24 Lumbar plexus and the

relationship of the branches to the psoas
T12 muscle. Note that the sciatic nerve is not
quadratus part of the lumbar plexus and is shown
lumborum L1 only for completeness.
iliohypogastric
muscle nerve
L2
ilioinguinal nerve
psoas major
(L1)
muscle L3
lateral
cutaneous L4
nerve of genitofemoral nerve
the thigh (L1, L2)
(L2, L3) L5

iliacus muscle

inguinal
ligament femoral nerve
(L2, L3, L4)
femoral
branch of
genitofemoral
sciatic nerve
nerve
(L4, L5, S1−3)

genital branch of obturator nerve

genitofemoral (L2, L3, L4)
nerve

lumbar nerves, supplying the body wall and lower limb, Parasympathetic nerves
and visceral branches (lumbar splanchnic nerves) that The vagal trunks supply foregut, midgut and hindgut:
join the prevertebral plexuses. Fibres from the third they enter the abdomen on the surface of the oesopha-
and fourth lumbar ganglia join with fibres from the aor- gus, directly supplying the stomach. Branches to the
tic plexus in front of L5 vertebra to form the superior coeliac plexus then supply the remainder of the gut as
hypogastric plexus. The superior hypogastric plexus di- far as the distal two-thirds of the transverse colon.
vides into the right and left hypogastric nerves, which Branches to the renal plexus pass to the kidneys.
run into the pelvis to join the inferior hypogastric plexus. The pelvic splanchnic nerves (from S2 to S4) join
The sympathetic trunks in the abdomen do not give the inferior hypogastric plexus. Some fibres pass up
branches to the abdominal viscera, which are supplied into prevertebral plexuses to be distributed to the distal
by the greater, lesser and least splanchnic nerves. part of the transverse colon and descending and
The greater and lesser splanchnic nerves are sigmoid colons (hindgut). Parasympathetic activa-
preganglionic – they pierce the crura of the diaphragm tion of the gut causes stimulation of peristalsis and
to synapse in the coeliac ganglion. The least splanchnic secretomotor activity of glands (remember ‘rest and
nerves relay in a small renal ganglion close to the renal digest’).
artery.
From the coeliac ganglion, postganglionic fibres
form the coeliac plexus around the origin of the coeliac
trunk. Fibres either pass directly or via superior and in-
Kidneys
ferior mesenteric plexuses along branches of the aorta to The kidneys are involved in removal of toxins, control
supply all abdominal viscera. of blood pressure, stimulation of red blood cell produc-
The suprarenal gland also receives preganglionic tion, maintenance of fluid and electrolyte balance and
fibres directly from the lesser splanchnic nerve – maintenance of calcium and phosphate levels. They
stimulation of which causes the release of adrenaline. are retroperitoneal organs lying mostly under cover of
Functions of the sympathetic nerves include vaso- the costal margin in the paravertebral gutters of the pos-
motor, motor to the sphincters and inhibition of peri- terior abdominal wall. They extend from approximately
stalsis, and carrying sensory fibres from all of the the T12 vertebrae to the L3 vertebrae. The right kidney
abdominal viscera. lies slightly lower than the left kidney due to the

109
 The abdomen

kidney. These are further subdivided into segmental,

Right kidney Left kidney
arcuate and interlobular arteries (end arteries). Venous
left renal suprarenal drainage is via interlobular, arcuate and segmental
duodenum vein gland veins, which join together to form the renal vein – this
stomach
liver suprarenal pancreas joins the inferior vena cava at the level of L2. The left
gland spleen renal vein is longer because it passes in front of the
aorta to reach the inferior vena cava. The sympathetic
nerve supply to the kidneys arises from the coeliac, re-
nal and superior hypogastric plexuses. The parasympa-
thetic nerve supply is from the vagus. Lymphatic
drainage is to renal nodes then lumbar nodes.

HINTS AND TIPS

colon

colon small intestine

In the hilum of the kidney, the structures from anterior
superior to posterior are vein, artery and ureter.
mesenteric
small intestine artery

Dark shading = structures directly related

Light shading = structures indirectly related
Ureters
Fig. 5.25 Kidneys and their main anterior relations. The ureters are muscular tubes which connect the renal
pelvis (at the ureteropelvic junction) to the bladder.
They descend retroperitoneally on the medial aspect
presence of the liver (Fig. 5.25). Their structure is illus-
of the psoas major muscle and cross the pelvic brim
trated in Figure 5.26.
at the bifurcation of the common iliac artery. At the
Each kidney is surrounded by three layers. From
level of the ischial spine, the ureters pass anteriorly
superficial to deep they are: the renal fascia (encloses
and medially towards the bladder, where they pass
both the kidney and the suprarenal gland, and is at-
through the bladder wall at an oblique angle (this
tached to the renal vessels and the ureter at the hilum
prevents reflux of urine).
of the kidney), the perinephric fat and the renal capsule.
There are three points of narrowing within the
The renal arteries supply the kidneys (Fig. 5.26). They
ureters – these are the sites at which renal calculi are
arise from the aorta, inferior to the SMA and divide into
most likely to become impacted:
anterior and posterior branches at the hilum of the
• At the ureteropelvic junction
• Where the ureter crosses the pelvic brim
• As the ureter passes through the bladder wall.
cortex
Blood supply is segmental and arises from the renal
renal column artery, abdominal aorta, gonadal and vesical arteries,
common and internal iliac arteries, and the middle rec-
renal papilla capsule
tal artery. Venous drainage is to the renal, testicular and
ovarian veins. Lymphatic drainage occurs via the para-
minor calyx aortic and common iliac nodes. The ureters receive a
medulla sympathetic nerve supply from the coeliac, mesenteric
major calyces
anterior branch
and hypogastric plexuses. Parasympathetic fibres come
renal artery from the pelvic splanchnic nerves. The pain afferents
pyramid posterior accompany the sympathetic nerves.
branch
renal pelvis
CLINICAL NOTE
medullary ureter
rays Renal colic
Renal calculi are most commonly formed from calcium
or struvite, and less commonly uric acid or cystine. They
Fig. 5.26 Macroscopic structure and arterial supply of the may produce renal colic, as the stone makes its way from
kidney.

110
 Radiological anatomy 5

X-rays
the kidney to the bladder. This normally presents as
Abdominal X-rays (AXRs) are most commonly
colicky flank pain, which radiates to the groin, often requested for patients who present with an ‘acute abdo-
accompanied by vomiting. Patients with renal colic are men’. AXRs are normally anteroposterior (AP) films,
restless, moving around frequently (in contrast to patients taken with the patient in a supine position. They are
with peritonitis for whom any movement is very painful). not generally used to diagnose a perforated viscus; this
The most effective analgesics are NSAIDs and opiates. is normally diagnosed by an erect chest X-ray, where air
Diagnosis is made by X-ray or CT scan. Treatment ranges will be visible under the diaphragm (usually more easily
from allowing the stone to pass spontaneously to seen on the right side).
extracorporeal shock wave lithotripsy (ESWL) or surgery.
An important differential diagnosis of suspected Normal radiographic anatomy
left-sided renal colic, particulary in older males, is a
ruptured or leaking abdominal aortic aneurysm.
of an AP abdominal X-ray
A normal abdominal X-ray is illustrated in Figure 5.27.

How to examine an AP abdominal

Suprarenal gland X-ray methodically
The suprarenal gland lies on the medial aspect of the The initial assessment of an AXR is the same as for a
superior pole of each kidney, separated from it by a chest X-ray, confirming the identity of the patient, date
thin layer of fibrous tissue. The left suprarenal gland and time of X-ray, and projection, as well as looking for
lies posterior to the stomach (lesser sac intervening) and any obvious abnormalities. As with any X-ray it is then
the right lies posterior to the inferior vena cava, liver important to examine the film in a systematic way.
and hepatorenal pouch. The glands consist of a central Below is one example:
medulla which secretes adrenaline, and a peripheral cor-
• Gas: this appears black. Normal sites for gas are the
tex which secretes aldosterone, cortisol and sex hormones.
stomach (seen as a ‘gastric bubble’, particularly if
Each suprarenal gland is supplied by three main
the film is an erect AXR), the large bowel and
vessels:
rectum
• The superior suprarenal artery – a branch of the in- • Bowel: the small bowel lies centrally in the film, with
ferior phrenic artery large bowel around the periphery. Small bowel has a
• The middle suprarenal – a branch of the abdominal maximum diameter of 3 cm with valvulae conni-
aorta ventes visible across the width of the bowel wall.
• The inferior suprarenal – a direct branch of the renal Large bowel has a maximum diameter of 6 cm
artery. (9 cm for the caecum) and features folds known
The gland is drained by the medullary veins, which as haustra, which do not extend across the full dia-
merge to form the suprarenal vein. On the right the su- meter of the bowel wall. The large bowel may also
prarenal vein drains directly into the inferior vena cava contain faeces, giving it a mottled appearance. Gas
directly. On the left the suprarenal vein drains into the outwith the bowel or within the bowel wall is not
left renal vein. Lymphatic drainage is to the para-aortic normal.
lymph nodes. The nerve supply of the suprarenal gland • Viscera and muscles:
is from the coeliac plexus and splanchnic nerves. • Liver: in the right upper quadrant; enlargement
pushes the intestines inferiorly
• Spleen: in the upper left quadrant; enlargement
pushes the splenic flexure inferiorly
RADIOLOGICAL ANATOMY • Kidneys: have a smooth outline. Their position
varies with inspiration
Imaging of the abdomen • Bladder (and uterus): looking for any calcification
• Psoas major muscle: its outline can be traced infe-
Ultrasound riorly into the pelvis to its insertion into the lesser
Ultrasound examination is quick and simple to per- trochanter of the femur. If this outline is lost or
form, therefore it is often a first-line investigation in not visible it may indicate that fluid, e.g. blood,
the diagnosis of abdominal diseases, e.g. testicular is present within the abdomen.
swellings, inflammation of the gallbladder, gallstones • Bones: look at the lower ribs, lumbar vertebrae
and abdominal aortic aneurysm. and pelvis for continuity of the cortex areas of

111
 The abdomen

1
4

3 6
5

1. L1 vertebra
7 2. Gas in the descending colon
3. Faeces in the ascending colon
4. Hepatic flexure
5. Left psoas muscle
6. Right psoas muscle
7. Bladder

Fig. 5.27 Abdominal radiograph – supine projection.

darkness (i.e. fracture) or white lesions (i.e. meta- Abdominal contrast studies
static deposits). Costal cartilages may be calcified.
Examine the hip joint for narrowing of the joint The use of contrast medium (barium sulphate) en-
space, loss of the smooth joint surface, formation hances images produced by plain abdominal X-ray.
of bone (osteophytes) and loose bodies. Depending upon the area of the gut to be assessed,
• Calcification: there are areas of the body in which one of the following may be performed:
calcification is normal, such as the costal cartilages • Barium swallow: barium is swallowed in order to de-
(above), the mesenteric lymph nodes and the pros- tect problems in the oesophagus
tate (however, calcification may also occur in carci- • Barium meal: barium is swallowed in order to detect
noma of the prostate). Calcification is not normal in problems in the stomach and duodenum
the pancreas, kidneys, blood vessels, gallbladder and • Barium follow through: barium is swallowed in
bladder. Calculi (particularly renal) may also appear order to detect problems in the small intestine
as calcified masses on X-ray. (Fig. 5.28)

112
 Radiological anatomy 5

2a

2a
3
2c
3
2b

4
4 4

5 1. Stomach
2. a. Descending (second) part duodenum
5
2. b. Horizontal (third) part of duodenum
2. c. Ascending (fourth) part of duodenum
3. Proximal jejunum
4. Valvulae conniventes
(plicae circulares) of jejunum
5. Proximal ileum

Fig. 5.28 Abdomen barium follow-through showing duodenum and small intestine.

• Barium enema – barium is introduced via the rec- and trauma. CT is also used to guide biopsies (e.g. a liver
tum in order to detect problems in the colon biopsy) or drainage of abscesses. A transverse CT
(Fig. 5.29). scan of the abdomen at the level of L1 is shown in
Both a barium meal and a barium enema can be Figure 5.30.
further enhanced by the introduction of air into the
gastrointestinal tract (a double contrast barium meal/
enema).
Angiography of the abdominal
CT/MRI scanning of the abdomen aortic branches
CT or MRI scans of the abdomen are performed to diag- Figures 5.31, 5.32 and 5.33 show the branches of the ab-
nose or provide more detail of diseases within the dominal aorta and their subsequent divisions, forming
abdomen, such as tumours, inflammatory bowel dis- the arterial supply of the foregut (coeliac trunk) and
eases, vessel disease (e.g. abdominal aortic aneurysm) midgut (superior mesenteric artery).

113
 The abdomen

6
6
4
4 7

3 8

7
8
2
8
1
1
9 8 1. Terminal ileum
9
2 2. Caecum
3. Ascending portion
4. Right colic (hepatic) flexure
5. Transverse portion
6. Left colic (splenic) portion
10 7. Descending portion
8. Sacculations (haustrations)
9
9. Sigmoid colon
10 10. Rectum

Fig. 5.29 Abdomen double-contrast barium enema of colon.

114
 Radiological anatomy 5

5
10 4
1
3
8
2
7

6
1. Inferior vena cava
2. Right kidney
3. Descending aorta
4. Coeliac trunk
5. Portal vein
6. Right crura of diaphragm
7. Left kidney
8. Spleen
9. Gallbladder
10. Liver

Fig. 5.30 CT scan (transverse section) of the abdomen at the level of L1.

12

8 12 2

10 1. Tip of catheter in coeliac trunk

4 3
7 2. Splenic artery
2
11 5 1 3. Left gastric artery
4. Hepatic artery
9 5. Gastroduodenal artery
6. Superior pancreaticoduodenal
6 artery
7. Right hepatic artery
8. Left hepatic artery
9. Dorsal pancreatic artery
10. Left gastro-epiploic artery
11. Right gastro-epiploic artery
12. Phrenic artery

Fig. 5.31 Digital subtraction angiogram of the coeliac trunk and its branches.

115
 The abdomen

9
2

3
4

4
8
4
4

7 6
5

5
9
9

6 12

1. Tip of catheter in superior

5 mesenteric artery
11 2. Superior mesenteric artery
10 5
3. Inferior pancreaticoduodenal
artery
11 4. Jejunal branches of superior
mesenteric artery
5. Ileal branches of superior
5
mesenteric artery
6. Ileocolic artery
7. Right colic artery
8. Middle colic artery
9. Lumbar arteries arising
from abdominal aorta
10. Appendicular artery
11. Common iliac artery
12. Aorta

Fig 5.32 Digital subtraction angiogram of the superior mesenteric artery and its branches

116
 Radiological anatomy 5

7
8 L1
9

10 11
3

1. L1 vertebra
13 2. 12th rib
4 3. Transverse process of L5 vertebra
12 4. Sacroiliac joint
5. Thoracic aorta
6. Abdominal aorta
7. Coeliac trunk
8. Superior mesenteric artery
9. Inferior mesenteric artery
14 10. Right common iliac artery
11. Left common iliac artery
12. Right external iliac artery
13. Right internal iliac artery
14. Left external iliac artery
Fig. 5.33 3D CT angiogram of the abdominal aorta and its major branches.

117