The Kidneys

1
The Kidneys

• Function
  1-excretion of urine.
  2-control water electrolyte balance.
  3-maintain the acid base balance of blood.
• They are retro-peritoneal , lie behind parietal
  peritoneum on the post.abd.wall.
• Right kidney is lower than the left one , due to
  large size of right lobe of liver.
• The hilum of the kidney ( slit on the concave
  medial border) transmits VAP from front
  backward renal vein, renal artery , pelvis of
  ureter.. Or VAUA renal vein,_ 2 branches of
  renal artery, ureter, _ 3rd branch of renal
  artery. Some lymph vessels symp.Fs.also
  present.

• The hilum lies at level of transpyloric plane ,
  (L1 vertebra).

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The Kidneys

• The kidneys extend from T12V to L3 vertebra.
  They recive some protection from lower part of
  rib cage.
• Left kidney is slightly higher than right one ,
  it reaches 11th rib , while the right kidney
  reaches only 11th intercostal space (due to
  presence of liver).

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Coverings of the Kidney

• Fibrous capsule it is closely attached to its
  outer surface.
• Peri-renal fat it covers the fibrous capsule.
• Renal fascia it is a condensation of C.T.
  surrounding the peri-renal fat and encloses the
  kidneys suprarenal glands.
• Para-renal fat lies external to renal fascia.
• Peri-renal fat , renal fascia ,and para-renal fat
  support the kidneys and held them in position on
  post.abd.wal.

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Renal Structure

• Each kidney has a light brown outer cortex , and
  a dark brown inner medulla.
• The medulla is composed of about a
  dozen renal pyramids, with base toward the cortex
  and apex ( renal papilla) projecting medially.
• The pyramids are separated by extensions of
  cortex called renal columns. Extending Fs.from
  the bases of renal pyramids into cortex are
  striations called medullary rays.
• Renal pelvis or (pelvis of ureter) is a
  funnel-shaped dilatation, which is formed in the
  sinus of kidney by union of 2-3 major calyces,
  Each major calyx divides into 2 or 3 minor
  calyces. It passes through hilum.
• Each minor calyx is indented by tha apex of the
  renal pyramid ,(renal papilla).

A.ant.surface of Rt.kidney. B. coronal section
showing cortex, medulla, pyramids, renal papillae
and calyces. C .showing
the Nephrons blood vessels within the kidney.
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Anterior relation of the Kidneys
Right Kidney

• Suprarenal gland , liver , second part of
  duodenum , right colic flexure, coils of jejunum.

Left Kidney

• Suprarenal gland , spleen , stomach, pancreas ,
  left colic flexure descending colon , coils of
  jejunum.

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Peritoneal Covering of the Kidney

• The anterior surface only of right kidney is
  covered with peritoneum except
  1- supra-renal area. 2-
  duodenal area. 3- colic
  area.
• The anterior surface only of left kidney is
  covered with peritoneum except
  1- supra-renal area. 2-
  pancreatic area. 3- area of
  descending colon.

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Posterior Relations of the kidneys
Right Kidney

• Diaphragm ,, 12th rib , psoas
  ,quadratus lumborum transversus abdominis ms.
  Subcostal (T12), iliohypogastric, ilioinguinal
  nerves (L1), run downward and laterally.

Left Kidney

• Diaphragm, 11th 12th ribs. The other
  structures as the right kidney.

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Posterior Relations of Kidneys
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Blood Supply of the Kidney

• At level of L2 V.-renal artery arises from aorta.
  Each renal artery divides into 5 segmental
  arteries 4- in front 1- behind the renal
  pelvis.
• Lobar arteries arise from each segmental
  artery, one for each renal pyramid.
• 2 or 3 -Interlobar arteries arise from each lobar
  artery , running on each side of renal pyramid.
• At the junction of cortex medulla, interlobar
  arteries give off arcuate arteries arching over
  the bases of pyramids, at junction of cortex
  medulla.
• Several interlobular arteries arise from arcuate
  arteries that ascend in the cortex.
• Afferent glomerular arterioles arise as branches
  of interlobular arteries.

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Blood supply of Kidneys

• Afferent glomerular arterioles break into
  capillaries that collect into efferent glomerular
  arterioles.
• Efferent G.arterioles breaks into interlobular
  veins ending in arcuate veins that collect to
  interlobar, lobar, renal vein. Eff.G.arterioles
  also pass deeply into medulla and breaks into
  vasa recta which pass to apex of pyramid and
  breaks into capillaries which constitute the
  venous side and end in arcuate veins, at junction
  of cortex medulla.
• Arcuate veins collect into inter-lobar veins
  which collect into lobar then renal vein and
  finally I.V.C.

C-section of kidney, showing position of nephrons
arrangement of Bl.vs. in kidney
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Venous , lymphatic drainage N.Supply

• Veins Renal vein emerges from hilum in front
  of renal artery and drains into I.V.C.
• Lymph drainage lateral aortic L.Ns. around
  origin of renal artery.
• N.Supply
  -Sympathetic parasympathetic via renal
  plexus surrounding renal artery. afferent
  sympathetic Fs.in the renal plexus enter spinal
  cord segments at T10,11, 12

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Ureter (Abdominal part)

• It is a muscular tube that extends from hilum of
  kidney to post.surface of urinary bladder.
• It propels urine by peristaltic contractions.
• It has 3 constrictions where renal pelvis joins
  ureter, where it is kinked as it crosses pelvic
  brim (bifurcation of common iliac artery), where
  it pierces bladder wall.
• Renal pelvis is funnel-shaped upper part of
  ureter, lies in the hilum of kidney and receives
  major calyces.

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Ureter
Course of ureter

• It emerges from hilum of kidney to run
  vertically downward behind parietal peritoneum,
  on the psoas major ms., which separates it from
  lumbar transverse processes.
• It enters pelvis by crossing bifurcation of
  common iliac artery in front of sacroiliac
  joint, till it reaches level of ischial spine.
• It ends in U.B. by openning at supero-lateral
  angle of trigone.

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Anterior relations of Right Ureter

• Duodenum terminal part of ileum.
• Superior mesenteric artery mesentry of small
  intestine.
• Right gonadal vessels.
• Right colic Iliocolic vessels

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Posterior relations of Right Ureter

• Right psoas major which separates it from
  lumbar transverse processes.
• Right psoas minor.
• Genito-femoral N.
• Bifurcation of right common iliac artery.
  

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Anterior relations of Left Ureter

• Sigmoid colon mesocolon.
• Sigmoid vessels.
• Left gonadal vessels.
• Left colic vessels.

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Posterior relations of Left Ureter (as the Right
ureter)

• Left psoas major which separates it from lumbar
  transverse processes.
• Psoas minor.
• genito-femoral N.
• Bifurcation of left common iliac artery.

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Blood Supply ,Lymph drainage N. Supply

• Upper part renal artery (L2 V.).
• Middle part gonadal artery (testicular or
  ovarian).
• Pelvic part superior vesical artery.
• Lymph drains to lateral aortic iliac L.Ns.
• N.supply
  -Sympathetic parasympathetic Via Renal ,
  gonadal hypogastric plexuses (in the pelvis).
  -Afferent sympathetic
  Fs.enter spinal cord segments at T11,12 L1,2.
  

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Suprarenal glands

• 2 yellowish retro-peritoneal glands that lie on
  upper poles of kidneys.
  
• They are surrounded by renal fascia but
  separated from kidneys by perirenal fat.
• Yellow cortex secrets mineral corticoids
  glucocorticoids sex hormones.
• Medulla secrets catecholamines epinephrine
  norepinephrine.
• Rt,gland caps upper pole of Rt.kidney, lies
  behind Rt.lobe of liver, I.V.C., anterior to
  diaphragm.
• Left gland reaches hilum of kidney, lies
  behind pancreas, lesser sac stomach, anterior
  to diaphragm.

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Blood Supply, Lymph N. Supply of Suprarenal
glands

• Arterial supply inferior
  phrenic artery (upper part),
  aorta (middle part) renal
  artery (lower part).
• Vein of right gland ends in I.V.C., while vein of
  left gland ends in left renal vein.
• Lymph drains into lateral aortic nodes.
• N.Supply symp. Fibres from splanchnic nerves
  parasympathetic Fs.

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Clinical Notes 1- Renal pain

• Type of pain dull ache to severe pain in the
  flank that may radiate into lower abdomen.
• Causes 1-stretching of kidney capsule.
  2-spasm of smooth muscle in
  renal pelvis.
• Pain is referred along distribution of subbcostal
  N.(T12) . to the flank anterior abd. Wall.,
  because afferent N.Fs.ascends from renal plexus
  to spinal cord at level of T12, via lowest
  splanchnic N.in thorax symp.trunk.

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2- Renal colic

• In renal colic, strong peristaltic waves of
  contraction pass through ureter in attempt to
  pass the stone onward, so the spasm of smooth
  muscle causes an agonising colicy pain.
• Renal pelvis ureter send their afferent nerves
  into spinal cord segments T11,12 and L1,2
• Colicy pain is referred to areas supplied by
  these seg.of spinal cord, into flank, loin
  groin.
• When stone enters low part of ureter, pain is
  referred to testis or tip of penis or labium
  majus in female.
• Sometimes ureteric pain is referred to front of
  thigh along femoral branch of genitofemoral
  N.(L1,2).
• Pain is often so severe that spreads in C.N.S.
  giving nausea.

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3-Ureteric Stone

• Ureteric stones are arrested in the ureteric
  narrowing at these sites 1-at pelvi-ureteral
  junction. 2-at pelvic brim. 3-at its
  enterance to urinary bladder.
• Most of ureteric stones are not seen by plain
  radiographic examination, so I.V.pyelography is
  usually necessary by using of radiopaque compound
  (iodine-containing compound), by injection into
  subcut.arm vein, so the coarse of ureter is
  clearly seen in front of tips of transverse
  processes of lumbar vertebrae, crossing
  sacro-iliac joint then ends in bladder.

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Abdominal Aorta

• It is a continuation of descending thoracic aorta
  ,it enters abdomen through aortic opening of
  diaphragm at the level of T12 vertebra.
• It descends behind peritoneum on the bodies of
  lumbar vertebrae.
• it terminates at the level of L4 vertebra
  (inter-cristal plane) , into 2 common
  iliac arteries.
• On the right side I.V.C., azygos vein ,lymph
  trunk (cisterna chyli) Rt.crus of diaphragm.
• On the left side sympathetic trunk left crus
  of diaphragm.

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Branches of Abdominal Aorta

• 3 anterior visceral branches celiac, superior
  mesentric inferior mesenteric arteries.
• 3 lateral visceral branches suprarenal, renal
  gonadal arteries.
• 5lateral abdominal wall branches inferior
  phrenic 4 lumbar arteries.
• 3terminal branches 2 common iliac median
  sacral artery.

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Single Branches of Abdominal Aorta

• Coeliac artery from front of aorta at the level
  of T12 V. (or upper border of
  L1 V)
• Superior mesentric artery from front of aorta
  at the level of L1 V. (transpyloric plane).
• Inferior mesenteric artery from front of
  abdominal aorta at level of L3 V. (subcostal
  plane).
• Median sacral artery from back of
  abdominal aorta at the level of L4 V.

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Paired Branches of Abdominal Aorta

• Phrenic arteries at the sides of coeliac artery
  (at level of upper border of L1 V.,or T12V.)
• Middle suprarenal arteries (at lower
  border of L1 V.)
• Renal arteries (at L2)
• Testicular or ovarian arteries on the sides of
  inferior mesenteric artery (at level of L3V).
• Lumbar arteries 4 pairs of arteries, arising
  from back of aorta.
• Common iliac arteries at
  level of L4 V. (inter-cristal plane)

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Terminal Branches of Abdominal Aorta

• Common iliac arteries they arise at level of L4
  V ,descend downward and laterally along medial
  border of Psoas major.
• Each common iliac artery crossed anteriorly by
  the ureter ends in front of sacro-iliac
  joint into external internal branches.

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Branches of Common iliac artery

• 1-External iliac artery
  -runs along medial border of Psoas major.
• It enters thigh behind inguinal ligament to
  become femoral artery.
• It gives off 2 branches above inguinal ligament
  1-inferior epigastric artery.
  2-deep circumflex
  iliac artery.
• Inferior epigastric artery passes medially along
  medial margin of deep inguinal ring and enters
  rectus sheath behind rectus abdominis to
  anastomose with superior epigastric artery to
  supply anterior abd.wall.
• Deep circumflex iliac artery ascends laterally to
  iliac crest to supply Ms. of anterior Abd.wall

2-Internal iliac artery descends to pelvis in
front of sacro-iliac joint.
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Obliteration of abdominal aorta iliac
arteries

• Atherosclerosis leads to gradual occlusion of
  bifurcation of abdominal aorta iliac arteries,
  results in pain in leg during walking
  (claudication) due to lack of blood in external
  iliac artery impotance due to lack of blood in
  internal iliac arteries.
• Some collateral circulation is established, but
  it is physiologically inadequate, so skin ulcer
  tisssue death may occur.
• Surgical treatment by thrombo-end-arterectomy or
  a bypass graft should be done.

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Obliteration of abdominal aorta iliac
arteries

• Note the possible collateral circulation of
  abdominal aorta.
• Note great dilatation of mesenteric arteries
  their branches, which occurs if the aorta is
  slowly blocked just below level of renal arteries
  (L2).

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Course of I.V.C.

• It is formed by union of the 2 common iliac veins
  behind right common iliac artery at level of L5
  vertebra (intertubercular plane), 1 inch to right
  of median plane.
• It ascends on right side of aorta to pierce
  central tendon of diaphragm at level of T8
  vertebra to drain into right atrium of heart.

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Tributaries of I.V.C

• 2 anterior visceral tributaries the 2 hepatic
  veins.
• 3 lateral visceral tributaries
  -Rt.suprarenal V. (left drains into left renal
  vein). -renal veins.
  -Rt.gonadal V.
  (left drains into left renal vein).
  
• 5 lateral abdominal wall tributaries
  -inferior phrenic veins.
  -4 lumbar veins.
• 3 veins of origin 2 common iliac veins median
  sacral vein.
  

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Medial lateral Relations of I.V.C.

• Medially( on left side) abdominal aorta.
• Laterally (on right side) right ureter.

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Anterior relations of I.V.C.

• Right common iliac artery.
• Root of mesentry superior mesenteric vessels.
• 3rd part of duodenum.
• Right testicular or ovarian Ar.
• Head of pancreas.
• 1st part of duodenum.
• foramen to lesser sac separates I.V.C. from _
  portal vein, hepatic artery bile duct in free
  right margin of lesser omentum.

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Foramen to lesser sac

• Note that opening to lesser sac (epiploic foramen
  at level of transpyloric plane L1) separates
  I.V.C. from portal vein.
• Venous blood from abdominal part of G.I.T.drains
  to liver by portal vein,then from hepatic veins
  to I.V.C.

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Posterior relations of I.V.C.

• Bodies of lumbar vertebrae.
• Right sympathetic trunk.
• Right psoas major.
• Right lumbar arteries.
• Right renal, suprarenal phrenic arteries.
• Right crus of diaphragm.

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Inferior Mesenteric Vein

• It begins halfway down anal canal as a
  continuation of superior rectal vein.
• It is a tributary of portal circulation.
• It joins splenic vein behind body of pancreas.
• It receives tributaries related to branches to
  the artery (left colic,
  sigmoid, sup.rectal veins)

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Splenic Vein

• It is a tributary of portal vein.
• It begins at hilum of spleen by union of several
  splenic veins and is joined by short gastric
  left gastro-epiploic veins.
• It passes within splenicorenal ligament with
  splenic artery ( the artery lies
  along upper border of pancreas) ,then runs behind
  body of pancreas to join superior mesentric V
  behind neck of pancreas to form portal vein.
• It is joined by pancreatic veins inferior
  mesenteric vein.

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Superior Mesenteric Vein

• It is a tributary of portal vein.
• It begins at ileocecal junction lying within root
  of mesentry of small intestine on right side of
  the artery.
• It passes in front of 3rd part of duodenum ,
  behind neck of pancreas, where it joins splenic
  vein to form portal vein.
• It receives tributaries correspond to the artery
  (middle colic, right colic, iliocolic jejunal
  and ileal veins).

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• Note tributaries of the Portal vein.
• Portal vein drains blood from abdominal part of
  G.I.T. from lower 1/3 of esophagus to halfway
  down the anal canal, it also drains blood from
  spleen, pancreas, gallbladder.
• Portal vein enters liver and breaks into
  sinusoids, from which blood passes into hepatic
  veins that drain into I.V.C.

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External iliac vein

• It begins behind inguinal ligament as a
  continuation of femoral vein.
• It ends by joining internal iliac vein to form
  common iliac vein.
• It receives inferior epigastric deep circumflex
  iliac veins.

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Internal iliac vein

• It begins in the pelvis by joining all
  tributaries that correspond to branches of the
  artery.
• It ends in front of sacroiliac joint by joining
  external iliac vein to form common iliac vein.
• The 2 common iliac veins joined together to form
  I.V.C. (at L5V.)

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Collateral venous anastomoses between I.V.C.
S.V.C.

• Temporary varicose veins , result from
  compression of I.V.C. by enlarged uterus during
  later stages of pregnancy.
• Malignant retro-peritoneal tumors cause blockage
  of I.V.C., resulting in dilatation of extensive
  anastomoses of the tributaries of I.V.C. (as
  lumbar, Azygos hemiazygos veins).
• This alternative pathway for blood to return to
  right atrium is commonly referred to as
  caval-caval shunt.
• The same pathway results in case of
  Sup.mediastinal tumor, compressing S.V.C
  Clinically enlarged subcutaneous anastomosis is
  seen on thoracabdominal wall between lateral
  thoracic vein (tributary of axillaryvein)
  superficial epigastric vein. (tributary of
  femoral vein).

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Collateral venous anastomoses between I.V.C.
S.V.C.

• Note the alternative pathways for blood to
  return to right atrium if S.V.C. becomes blocked
  below enterance of Azygos vein, through azygos,
  internal or lateral thoracic veins into I.V.C.
• Similar pathways exist if I.V.C.becomes blocked
  below renal veins.
• So,a number of anastomotic channels connect both
  venae cavae indirectly in case of thrombosis of
  any vein.
• Note also anastomosis between portal systemic
  veins in anal canal.

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Sympathetic trunk (Abdominal part)

• It is continuous above with thoracic part below
  with pelvic part of symp.trunk.
• It enters abdomen behind medial arcuate ligament.
• It descends along medial border of psoas major,
  lying on the bodies of lumbar vertebrae.
• it enters pelvis behind common iliac vessels.
• Right symp.trunk lies behind right border of
  I.V.C., but left symp.trunk lies close to left
  border of aorta.
• It has 4 or 5 ganglia, 1st 2nd ofen being
  fused together.

Aorta and related sympathetic plexuses.
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Sympathetic Trunk

• It enters abdomen behind medial arcuate ligament.
• It descends along medial border of psoas major.
• Note left symp.trunk lies close to left border of
  aorta..

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Sympathetic trunk (Abdominal part)
Branches

• White rami communicantes the upper 2 ganglia
  receive a white ramus communicantes from 1st
  2nd lumbar spinal nerves, they contain sensory
  N.Fs.
• Gray rami communicantes join each ganglion to a
  corresponding lumbar spinal nerve. These
  postganglionic Fs.are distributed through the
  branches of spinal nerves to 1-blood vessels
  (vasomotor) 2-sweat glands
  3-arrector pili muscles of skin.
• Vascular Fibres pass medially to form the symp.
  plexuses on abdominal aorta its branches.
  (these plexuses also receive Fs.from splanchnic
  nerves vagus).
• Vascular Fibres pass downward medially below
  bifurcation of abdominal aorta, between common
  iliac vessels to form Sup.hypogastric plexus

Aorta and related sympathetic plexuses.
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Aortic Plexuses

• The nerve plexus around the abdominal aorta
  (front sides) is formed of
  1-preganglionic
  postganglionic sympathetic fibres.
  2-preganglionic
  para-sympathetic fibres (from the vagus nerves).
  3- visceral
  afferent fibres.
• This plexus concentrates around origin of certain
  blood vessels to form
  1-celiac plexus. 2-renal plexus.
  3-Sup.mesenteric plexus.
  4-Inferior mesenteric plexus.
  

Aortic and related sympathetic plexuses.
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Aortic Plexuses

• Celiac plexus -it
  consists mainly of 2 celiac ganglia connected
  together by a large network of fibres which
  surround celiac trunk. - the ganglia
  receive greater lesser splanchnic nerves,
  which arise from symp. trunk in the thora
  (preganglionic symp.Fs).
  -
  Postganglionic symp.Fs. arise from ganglia and
  accompany the branches of celiac trunk to supply
  structures supplied by left gastric, hepatic
  splenic arteries.
  -
  Parasympathetic vagal Fs. From posterior gastric
  N. also accompany the branches of the artery.

Aortic and related sympathetic plexuses.
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Aortic Plexuses

• Renal Sup.mesenteric plexuses
  - they are smaller than
  celiac plexus.
  -they are distributed along the
  branches of the corresponding arteries.
  -it receives also parasymp. vagal Fs.
• Inferior mesenteric plexus -it is
  similar to the above plexuses but it receives
  parasymp.Fs. From sacral parasymp. Nerves.
  ( pelvic splanchnic Nerves).

Aortic and related sympathetic plexuses.
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Abdominal part of parasympathetic Trunk

• Anterior gastric Nerve -it arises
  from lower part of esophageal plexus.
  -it contains fibres mainly from left
  vagus nerve in thorax.
  -it descends in front of esophagus stomach to
  supply abdominal viscera.
  -A large hepatic branch
  passes up to liver, and from this a pyloric
  branch passes down to pylorus.

Distribution of anterior posterior gastric N.
Trunks.
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Abdominal part of parasympathetic Trunk

• Posterior gastric Nerve -it arises
  from lower part of esophageal plexus.
  -it contains Fs. mainly from right vagus
  nerve in thorax.
  -it descends behind esophagus stomach
  to supply abdominal viscera.
  -celiac branch of
  posterior gastric nerve is distributed to celiac
  superior mesenteric plexuses to supply
  intestine as far down as the left colic flexure.
  

Distribution of anterior posterior gastric
N.trunks.
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Abdominal part of parasympathetic Trunk

• The vagus nerves supply parasympathetic fibres to
  1-esophagus.
  2-stomach. 3-small intestine.
  4-large
  intestine up to junction of right 2/3 left 1/3
  of transverse colon. 5-liver, pancreas,
  kidneys.
• Left 1/3 of transverse colon ,descending colon
  ,pelvic colon rectum are supplied by
  parasymp.Fs.from pelvic splanchnic nerves,.which
  are formed of S2,3,4 spinal nerves.
• These parasympathetic fibres are viscero-motor,
  but symp. Fs. carries pain-transmiting N.Fs.

Visceromotor Secretomotor to glands. Motor
to walls of G.I.T. Relaxation to the
sphincters.
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Spinal cord segments supplying Sympathetic Nerves
to Abdominal organs

• Visceral stomach pain is reffered to epigastrium
  because afferent sensory Fs.from the stomach
  ascend in company with symp.nerves to enter
  spinal cord at segments T5-9, so pain is reffered
  to lower chest upper abdominal wall
• Visceral pain from appendix is reffered to
  umbilicus (T10 dermatome), because sensory
  N.Fs. in company with sympathetic nerves enter
  spinal cord at segment T10.
• Liver Gallbladder (choecystitis or gallstone
  colic), Symp.N.Fs. passing through celiac plexus
  greater splanchnic nerves enter spinal cord at
  T5-9 segments, which is reffered to lower chest
  upper abdominal wall.

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Spinal cord segments supplying Sympathetic Nerves
to Abdominal organs

• Central diaphragmatic peritonitis, which is
  innervated by phrenic N.( C3,4,5), can give rise
  to reffered pain over the shoulder because skin
  in this area is innervated by supraclavicular
  nerves (C3,4).
• Kidney T10,11,12
• Ureter T11,12 - L1,2
• Suprarenal T8 L1

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