Clinical Director, University of Tennessee College of Medicine
Most of the root vessels to the rete degenerate mood disorder medications for children purchase amitriptyline 50 mg, leaving the kidney vascularized by a single enlarged branch great depression test answers purchase amitriptyline 50mg amex, the renal artery depression symptoms after miscarriage cheap amitriptyline 50 mg online. Because arterial degeneration begins at the cephalad end of the metanephros mood disorder organizations buy generic amitriptyline line, the segmental branch to the lower pole is the one most likely to persist as an accessory vessel. Although within the kidney the renal segmental arteries have a constant relationship with the renal segments. The apical and lower segmental arteries may originate independently directly from the aorta, in which case the renal segmental artery may supply a larger segment of the kidney than it would if it were a branch of the main renal artery. Multiple Renal Arteries Although they are anomalous, accessory renal arteries are evidence of the persistence of one or more of the segmental mesonephric roots extending from the 6th cervical to the 3rd lumbar segments, the more caudal of which once supplied the renal arterial rete. Magnetic resonance angiogram transverse section, showing right and left renal arteries arising from the aorta and supplying their respective kidneys. A persistent segmental artery to the lower pole may provide the origin of the gonadal artery, and one to the upper pole may also provide an adrenal artery. In addition to segmental arteries, smaller accessory arteries, usually multiple, may come from the inferior phrenic or from an adrenal artery. Venous Anomalies the renal veins develop from venous plexuses and pass through a complicated evolution by formation and absorption of the postcardinal, supracardinal, and subcardinal veins, which are involved in the formation of the inferior vena cava. Venous maldevelopment provides a continuum from almost normal to frankly abnormal configurations. Should the renal vein or vena cava become occluded, these persistent embryonic transitional pathways can provide alternative routes of drainage. In fact, those vessels that make up the venous complex develop at a deeper level than that occupied by the arteries, although near the vena cava, the renal veins come to lie anterior to the arteries. Three-dimensional magnetic resonance angiogram, showing the divisions of the renal arteries. On the right side, persistent arteries may lie anterior or posterior to the vena cava, and on the left, they may actually enclose the renal vein. Dilated renal pelvis due to congenital ureteropelvic junction obstruction residua of the intersubcardinal anastomosis. Also, as the renal vein crosses the midline it picks up the veins draining adjacent organs and the lumbar veins. This complex origin explains the greater length and larger number of veins draining into the left renal vein compared with the veins on the right, where these tributaries drain directly into the vena cava. The anomalies of the venous supply to the kidney that result from retention of embryologic pathways are described in Figures 2-9 and 2-10. Most apparent clinically are the persistence of the left caval vein, the circumaortic venous ring, and the formation of retroaortic renal veins. Thus, renal agenesis in the male is often associated with defects of the other derivatives of the duct. In 12% of males with a single kidney, a genital abnormality is found, including absence, hypoplasia, or cyst formation of the seminal vesicle, vas deferens, and ejaculatory ducts. Important surgically is that the remaining kidney may be abnormal in formation or position. The vagina may fail to form, or it may be septate or even obstructed, resulting in unilateral hematocolpos. A syndrome is recognized secondary to interruption of growth of the wolffian duct consisting of unilateral renal agenesis, absence of the fallopian tube, and absence of half of the uterus. Patient also has dilatation of the right renal pelvis from congenital ureteropelvic junction obstruction. The reasons for this difference may be found in the development of the inferior vena cava. To understand renal and ureteral venous anomalies, it is necessary to review the development part of Chapter 2. Autopsy study of a stillborn infant demonstrating that neither kidney is present in the retroperitoneum. The white arrows indicate the adrenal glands, which are typically large at birth, but diminish by almost 50% by the 9th to 14th week after birth. These kidneys have normal vasculature because the arterial distribution is not influenced significantly by abnormalities of the pelviocaliceal system. In contrast, the rare supernumerary kidney that results from a split of the nephrogenic blastema often has abnormal vessels. The anomalies of renal fusion and ectopia may be placed in five categories: crossed with and without fusion, not crossed with and without fusion, and fused caudally, the horseshoe kidney. Ectopia occurs when ascent is prevented at the time that the kidney lies at a level between the 3rd sacral and the 2nd lumbar vertebra. Because arrest occurs at a relatively early stage of embryologic development, ectopia is usually associated with incomplete rotation, a short ureter, and a blood supply that arises from local lateral segmental vessels, connections that account for the fixation of the kidney found at operation. In addition, anomalies of the external and internal genitalia and of structures associated with the cloaca are common. The typical pelvic kidney is usually smaller, lobulated, and of an abnormal (pancakelike) shape. The kidney may be malpositioned from any one of the factors responsible for its arrest; including malformation of the ureteric bud or of the metanephric tissue, or persistence of the primitive segmental structure of the arterial system, although this condition is usually secondary.
The right and left distal arterial arcades depression definition finance amitriptyline 25 mg mastercard, which together form the lower arterial arcade anxiety 34 weeks pregnant generic amitriptyline 25 mg mastercard, are formed by junction of the right and left epiploic arteries in the posterior reflection toward the inferior margin of the omentum depression definition dsm iv tr purchase amitriptyline once a day. These arcades are inconstant depression definition dictionary purchase amitriptyline australia, being composed of smaller vessels that cannot be depended on to supply the omentum if the gastroepiploic arcade is divided. The omental veins are valved, are larger than the arteries, and usually run in pairs with them. The left gastroepiploic vein carries venous drainage from the posterior layer of the omentum into the portal system; the right gastroepiploic vein empties blood from the anterior layer into the superior mesenteric vein and then into the portal vein. Anterior and posterior vagal trunks carry parasympathetic stimuli from the esophageal plexus on the esophagus via the anterior branch of the left vagus nerve to supply the anterior surface of the stomach. Blood Supply to the Posterior Aspect of the Stomach the pancreas and the vessels beneath it are exposed as the stomach and omentum are elevated. On the right, the gastroduodenal artery takes off from the common hepatic artery. The left gastroepiploic artery arises from the splenic artery before that vessel branches to enter the spleen. The superior mesenteric vein and the splenic vein drain into the portal vein behind the pancreas. The right vagus nerve through the posterior trunk joins the celiac plexus and supplies the posterior surface of the stomach. Lesser and Greater Omenta and Omental Bursa, Sagittal Sections Developmental Stage Both the lesser omentum and the greater omentum are formed from double layers of peritoneum that contain fatty tissue from the inner stratum of retroperitoneal connective tissue between them. The embryologic ventral mesentery that will form the lesser omentum is composed of two layers of peritoneum. It runs from the liver to the lesser curvature of the stomach and contains the left and right gastric vessels. This peritoneal sandwich splits to enclose the stomach, then the layers fuse caudally again to form the embryonic dorsal mesentery that will become the anterior and posterior layers of the greater omentum. The more posterior layer turns caudally at this level to form the anterior leaf of the transverse mesocolon. After enclosing the transverse colon, it runs cephalad as a posterior leaf that is fused to the anterior leaf before it continues as the parietal peritoneum of the body wall. At this stage, the deep omental bursa, or lesser sac, lies behind the lesser omentum and the stomach and continues caudally between the layers of the greater omentum. The dorsal mesentery overlies the transverse mesocolon, but at this stage both hang free in the peritoneal cavity. Adult State the anterior layer of the lesser omentum lies over the anterior aspects of the hepatic artery, the common bile duct, the portal vein, and the hepatic nerve plexus. The margin on the right side where the two layers fuse forms an opening into the omental bursa, the epiploic foramen, which lies immediately above the first part of the duodenum. The lesser omentum provides a hepatogastric ligament, connecting the left lobe of the liver to the stomach, and continues as a hepatoduodenal ligament, attaching the liver to the duodenum. The space between the two folds becomes fused (dashed line) but contains the blood supply. The space between the dorsal mesentery and the transverse mesocolon is also obliterated (dashed line) as the greater omentum becomes partially fused to the transverse mesocolon. The greater omentum is attached to the lower portion of the greater curvature of the stomach and to the first part of the duodenum. It descends a variable distance anterior to the intestines before folding back and fusing to itself. It adheres loosely to the upper surface of the transverse colon and the upper layer of the transverse mesocolon. One layer from the posterior leaf of the greater omentum continues cephalad to cover the pancreas; the other continues caudally to form the anterior leaf of the mesocolon and subsequently the coat of the transverse colon before becoming the parietal peritoneum inferiorly. The omental bursa (or lesser sac) communicates with the peritoneal cavity (greater sac) through the epiploic foramen. It lies behind the stomach and the greater omentum and is bounded posteriorly by the parietal peritoneum. The bursa extends caudally from behind the lesser omentum, now the hepatogastric ligament, and the anterior fold of the greater omentum to the level of the fusion of the posterior fold with the mesentery of the transverse colon. An understanding of the layers related to the omentum and transverse colon is aided by following the course of the peritoneum. Starting over the anterior surface of the lesser omentum, the peritoneum continues caudally over the anterior leaf of the greater omentum. At its lower end, the peritoneum turns under and partially fuses, thereby closing the caudal end of the omental bursa. The peritoneal surface ascends to cover the posterior leaf of the greater omentum, then descends to fuse with the anterior leaf of the transverse mesocolon. After enclosing part of the duodenum, the peritoneum turns again caudally to become the parietal peritoneum. The greater omentum usually lies folded about the upper abdominal organs, but its free edge may migrate to areas of inflammation. Not only is this tissue highly vascularized, but it has a well-developed system of lymphatic drainage; both are qualities that make it ideal for protective duties. It has a plentiful supply of fixed macrophages, seen as "milky spots" on the surface, for delivery as free macrophages to sites of inflammation. The omental bursa is bounded anteriorly by the stomach and the lesser omentum and posteriorly by the parietal peritoneum. The entrance to the bursa from the greater sac is the epiploic foramen at the right edge of the lesser omentum behind the common bile duct, hepatic artery, and portal vein. At the left margin of the omental bursa is the gastrosplenic ligament, which lies adjacent to the lienorenal ligament. Peritoneal Attachment of the Gastrointestinal Organs the parietal peritoneum leaves the posterior body wall as the visceral peritoneum at mesenteric roots.
Articulation of Lower Three Ribs the last three thoracic vertebrae represent a transition between the thoracic and lumbar regions anxiety mayo clinic discount 50mg amitriptyline with mastercard. The 10th thoracic vertebra has only one set of facets on the body; it does not connect with the rib below symptoms depression versus bipolar buy 50 mg amitriptyline with visa. Moreover depression symptoms dementia buy amitriptyline cheap, it may or may not have a facet on the transverse process for connection with the tenth rib status anxiety order discount amitriptyline online. On the 12th vertebra, the facets on the body are lower and the transverse processes smaller. The angle of the 11th rib is less pronounced than that of the ribs above, and the 12th rib is short and has no angle. The lumbar vertebrae are larger than their thoracic counterparts and have no facets for ribs; their transverse processes are thinner and longer. The spinous processes run horizontally rather than sloping obliquely as they do above. The superior costotransverse ligaments (the so-called costovertebral ligaments) have two layers, corresponding to the external and internal intercostal muscles. The posterior layer is more superficial and runs upward and medially at a right angle to the anterior layer; it joins the posterior surface of the neck of the rib to the transverse process above. It is continuous laterally with the external intercostal membrane and the external intercostal muscles. The anterior layer connects the upper edge of the neck with the lower edge of the transverse process lying just above it. It joins the internal intercostal membrane in the plane of the internal intercostal muscles. Rib 12 lacks a superior costotransverse ligament, having instead a lumbocostal ligament that attaches its shaft to the transverse process of the L1 vertebra. Less important surgically are the shorter ligaments, the costotransverse ligaments that lie between the neck of the rib and the transverse process. The parietal peritoneum covers the musculature and those organs related to the posterior body wall. Folds from it form the mesenteries of the small intestine, arising from the root of the mesentery, and form the mesocolons of the ascending, transverse, descending, and sigmoid colon. The attachment of the transverse mesocolon to the parietal peritoneum is somewhat narrower, and the mesocolon is more developed as it crosses the body wall above the duodenum. The root of the transverse mesocolon is shown, fused to the posterior layer of the greater omentum. The layer immediately beneath the peritoneum is the inner stratum that covers the gastrointestinal viscera and their blood supply. The intermediate stratum encloses the adrenals, kidneys, and ureters as well as the larger vessels and nerves. The inner stratum is a thin layer of areolar tissue that lies directly beneath the basement membrane of the peritoneum. It encases the intestinal tract within the abdomen and pelvis, constituting its adventitia. This stratum is continuous from the emergence of the esophagus from the diaphragm above to the pelvic diaphragm, where it fuses with the outer stratum. The intermediate stratum has a varied composition, ranging from fibrous in areas where the organs are fixed, to fatty about more mobile organs and in subjects with generous body fat. Across the posterior body wall, this stratum encloses the great vessels; the blood vessels to the intestines and to the body wall are covered as they pass through it. The anterior layer is split to form the anterior and posterior lamina of the renal fascia of Gerota enclosing the perirenal space (see Chapter 12). They also fuse with the outer stratum on the ventral surface of the diaphragm, although the fusion is not complete because gas infused into the perirenal space can spread to the mediastinum. The two layers enclose the ureters as they extend caudally and portions of the layers are continuous with the vesical connective tissue. The outer stratum forms the transversalis fascia that covers the investing fascia (epimysium) of the transversus abdominis muscle as a layer of dense, collagenous-elastic connective tissue. It also fuses with the psoas fascia at its lateral border and with the fascia of the quadratus lumborum that forms the anterior lamella of the lumbodorsal fascia. It is attached to the lateral and ventral surfaces of the vertebral bodies and is continuous with the iliac fascia and the fascia of the pelvic diaphragm. Fascial collars are formed from the transversalis fascia at the sites of exit of the urinary and digestive tracts, and of the reproductive tract in the female. The term endopelvic fascia is appropriate for these special arrangements of the transversalis fascia, although the term has also been used to denote all of the transversalis fascia in the pelvis. Fascial and Peritoneal Layers the transversalis fascia, from the outer stratum of retroperitoneal connective tissue, lines the inner aspect of the muscles of the abdominal wall. The fusion-fascia, derived from adherence of the peritoneum of the colonic mesentery with the primary posterior peritoneum, lies anterior to the anterior lamella of the renal fascia. The aorta enters beneath the median arcuate ligament and gives off the celiac trunk and the superior mesenteric artery. The pancreas and duodenum overlie the aorta and inferior vena cava and the kidneys and adrenals laterally. The junction of the diaphragm with the posterior abdominal wall is marked by the lateral and medial arcuate ligaments over the quadratus lumborum and psoas major, respectively. Anterior Aspect of the Innermost Layer and Diaphragm Removal of the peritoneum and transversalis fascia that overlie the diaphragm and the muscles of the posterior body wall exposes the internal surface of the posterior body wall. The posterior portion of the diaphragm arises from part of the lower six ribs and from the 2nd and 3rd lumbar vertebrae by two crura, which pass on either side to provide an opening for the aorta and esophagus (with the vagal trunks) as well as for the thoracic splanchnic nerves that go to the celiac plexus. The diaphragm is attached to the body of the 1st and 2nd lumbar vertebrae and to the transverse process of the 1st lumbar vertebra by thickened bands of fascia, the medial arcuate ligament over the psoas major. It is also attached to the midpoint of the 12th rib and the transverse process of the 1st lumbar vertebra by the lateral arcuate ligament spanning the quadratus lumborum.
Common Iliac Veins Each common iliac vein arises from where the external and internal iliac veins merge and ends on the right side of the fifth lumbar vertebra depression vs major depression buy cheap amitriptyline 25 mg on line, where it joins the inferior vena cava that runs on the right side of the aorta depression test calgary buy amitriptyline. An additional vein depression kid buy 50 mg amitriptyline, the middle sacral vein depression and definition buy amitriptyline 25 mg fast delivery, usually joins the left common iliac vein. External Iliac Vein the external iliac vein, a continuation of the femoral vein at the inguinal ligament, joins the common iliac vein over the sacroiliac joint. It drains three systems: the (1) inferior epigastric, (2) deep circumflex iliac, and (3) pubic. The inferior epigastric vein enters about 1 cm from the inguinal ligament and collects from the area supplied by the corresponding artery. The pubic vein forms a connection with the obturator vein and then ascends behind the pubis in company with the pubic branch of the inferior epigastric artery. The contributing veins match the arteries that come from the internal iliac artery. These veins enter the internal iliac veins: the superior and inferior gluteal veins drain from the buttock and the back of the thigh. The internal pudendal vein receives blood from the areas supplied by the internal pudendal artery and drains into the internal iliac vein as a single vessel. The obturator vein runs in front of the sacroiliac joint from the adductor compartment of the thigh via the obturator fossa and continues beneath the obturator artery and the ureter to join the internal iliac vein. Other branches contributing to the internal iliac vein are the lateral sacral veins, the middle rectal vein, and the rectal venous plexus. Venous Plexuses the plexuses are subject to stasis in conditions of high pressure and low flow when the subject is standing, factors that contribute to the frequency of thrombosis. The uterine and vaginal plexuses intercommunicate and also have connections with the other plexuses. The blood from the external genitalia and rectum returns through bulbar veins, vulvar and inferior rectal veins, and the deep dorsal vein of the clitoris by way of a retropubic plexus. The dorsal veins of the clitoris as well as smaller veins from the vesical plexus also drain into the internal pudendal vein. The vesical plexus lies over the lower anterior part of the bladder and is in continuity with the uterine plexus and also drains into the internal iliac vein, as does the rectal plexus. A retropubic plexus drains the clitoris, its small size contrasting with the large prostatic plexus (Santorini) that lies in front of and to the sides of the prostate and receives the deep dorsal vein of the penis. The retropubic plexus drains through the vesical plexus into the internal iliac vein. Male Venous Drainage Pelvic veins in the male are described and illustrated in. The blood drains from the bulbar, scrotal, and inferior rectal veins, and the deep dorsal vein of the penis by way of the prostatic plexus. The veins follow the path of the internal pudendal artery, finally draining into the internal iliac vein as a single vessel. The prostatic venous plexus overlies the prostate and the part of the bladder that lies behind the lower part of the symphysis pubis. The dorsal veins of the penis as well as smaller veins from the prostate and bladder drain into it. It has connections with the vesical plexus and with the internal pudendal vein, and empties into the internal iliac veins. Pelvic Lymphatics In general, the lymphatics from pelvic organs surround the arteries and the groups of nodes are named for the accompanying arteries: internal iliac, external iliac, and common iliac. In the male, the internal iliac nodes receive lymph from the prostate, seminal vesicles and membranous urethra, the bladder, and rectum as well as from part of the perineum and penile urethra. In the female, these nodes drain the bladder, vagina, uterus and rectum, and parts of the perineum. These nodes drain into the middle chain of the common iliac nodes that lie under the vessels in the fossa of the lumbosacral nerve. External Iliac Nodes these nodes can be viewed as composed of three chains: (1) external, (2) middle, and (3) internal. Lymph drains into the external chain from the superficial and deep inguinal nodes, from the glans penis or clitoris, and from the lower abdominal wall but not from organs within the pelvis. The external chain has three or four nodes between the external iliac artery and the internal border of the psoas muscle. The lowest node, into which most of the afferent vessels terminate, lies over the takeoff of the deep circumflex iliac arteries, adjacent to the division of the genitofemoral nerve into its two branches. Lymph from the bladder and prostate or parts of the uterus and vagina drains into the middle chain, made up of two or three nodes overlying the external iliac artery. The internal chain drains the superficial and deep inguinal nodes, the glans penis or clitoris by way of the deep drainage system, portions of the lower abdominal wall, and the bladder neck, prostate, and membranous urethra. This chain consists of three or four nodes that lie on the pelvic wall below the external iliac vein and above the obturator nerve. The efferents join with those of the internal iliac system to empty into the middle chain of the common iliac nodes. The external chain, usually composed of two nodes, lies on the surface of the common iliac artery and is continuous with the external chain of external iliac nodes distally (afferents) and the para-aortic nodes proximally (efferents). The internal chain, situated over the sacral promontory, is more important because it receives drainage from the prostate and bladder neck or the uterus and vagina. All these systems drain into the lateral aortic system of para-aortic nodes on their respective sides. The sacral plexus lies on the piriformis muscle and is formed from the ventral rami of the spinal nerves L4, L5, S1, S2, and S3. The nerve supply to the pelvic floor muscles is from the 2nd, 3rd, and 4th sacral nerves. The levator ani is innervated by branches from the 4th sacral nerve and from the pudendal nerve.
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