Anatomy Tutorial Renal Module (Answers) 2023 PDF

Anatomy Renal Module Tutorial (Answers) By: Dr. Essam Elbadawy Ismail, MD & Dr. Khulood Al-Khater, PhD Tuesday, December 3, 2024 ...

Anatomy Renal Module Tutorial (Answers) By: Dr. Essam Elbadawy Ismail, MD & Dr. Khulood Al-Khater, PhD Tuesday, December 3, 2024  Learning Objectives By the end of this tutorial, students will be able to understand and discuss the following: 1. What parts of the kidneys are most vulnerable to a penetrating injury? 2. The clinical significance of urinary calculi and where they are most likely to lodge in the ureter. 3. Referred renal /ureteric pain. 4. How entry of ureter into bladder prevents reflux. 5. The possible consequences of a ruptured abdominal aortic aneurysm. 6. Venous spread of cancer from gut (e.g. colon) compared to that of paired viscera (e.g. kidney). 7. The lymph drainage of the kidneys. Tuesday, December 3, 2024  Activity 1: Renal Trauma Q1. What parts of the kidneys are most vulnerable to a penetrating injury? Tuesday, December 3, 2024  Kidney Trauma ▪ The kidneys are well protected by the lower ribs, the lumbar muscles, and the vertebral column. However, a severe blunt injury applied to the abdomen may crush the kidney against the last rib and the vertebral column. Depending on the severity of the blow, the injury varies from a mild bruising to a complete laceration of the organ. ▪ Penetrating injuries are usually caused by stab wounds or gunshot wounds and often involve other viscera. Because 25% of the cardiac outflow passes through the kidneys, renal injury can result in rapid blood loss. ▪ A stab wound in the anterior abdomen may injure vital renal structures like the renal pelvis and the vascular pedicle, while a stab wound posterior to the anterior axillary line will injure the parenchyma but less likely the vital renal parts. ▪ Parenchyma of the kidney has a segmental arterial supply. Penetrating injuries cross the segmental vessels, while blunt injuries tend to fracture along the planes between the segmental vessels. This anatomic arrangement becomes important in the management of renal lacerations. Presentation title Tuesday, December 3, 2024  Activity 2: Course and constrictions of the ureter Q1: Describe the course of the ureter in radiograms. Q2: Name sites of ureteric constrictions with the help of the opposite IVP and diagram. Tuesday, December 3, 2024 Q1: Describe the course of the ureter in radiograms. ▪ The ureter runs down in front of the tips of the transverse processes of the lumbar vertebrae, crosses the region of the sacroiliac joint, swings out to the ischial spine, and then turns medially to the bladder. Q2: Name sites of ureteric constrictions with the help of the opposite IVP and diagram. ▪ Each ureter measures about 10 in. (25 cm) long and resembles the esophagus (also 10 in. long) in having three constrictions along its course: where the renal pelvis joins the ureter, where it is kinked as it crosses the pelvic brim, and where it pierces the bladder wall. ▪ Most stones, although radiopaque, are small and cannot be seen along the course of the ureter on plain radiographic examination. An intravenous pyelogram is usually necessary. Tuesday, December 3, 2024  Q3. Describe the relations of abdominal parts of the ureters with the help of the following diagrams: Tuesday, December 3, 2024  Right ureter Left ureter The duodenum, the terminal part of the The sigmoid colon and sigmoid ileum, the root of the mesentery of the mesocolon, the left colic vessels, and small intestine, the right colic and the left testicular or ovarian vessels. Anteriorly ileocolic vessels, and the right testicular or ovarian vessels. The right psoas muscle, which separates The left psoas muscle, which separates it from the lumbar transverse it from the lumbar transverse processes, and the bifurcation of the processes, and the bifurcation of the Posteriorly right common iliac artery. left common iliac artery The inferior mesenteric vein ascends along the medial side of the left ureter Medially Tuesday, December 3, 2024  Anterior relations of the abdominal parts of the ureters 9 Tuesday, December 3, 2024  Activity 3: Nerve supply of kidneys and ureters Q1: With the help of the opposite diagrams, describe the nerve supply of the kidney & ureter. Nerve supply Nerve supply of of ureter kidney Tuesday, December 3, 2024  Nerve supply of kidney The nerve supply to the kidney is derived from the renal sympathetic plexus. The afferent (pain) fibers that travel through the renal plexus enter the spinal cord in the 10th-12th thoracic nerves. Nerve supply of ureter The nerve supply to the ureter is derived from the renal, testicular (or ovarian), and hypogastric plexuses (in the pelvis) because of its long course in abdomen and pelvis. Visceral efferent fibers come from both sympathetic and parasympathetic sources, whereas visceral afferent fibers return to T11 to L2 spinal cord levels. Tuesday, December 3, 2024  Q2. A 50-year-old woman was found rolling on her kitchen floor, crying out from agonizing pain in her abdomen. The pain came in waves and extended from the right loin to the groin and to the front of the thigh. An anteroposterior radiograph of abdomen revealed a calculus in the right ureter. a. Where along the ureter is a calculus most likely to lodge? b. What causes the pain when a ureteral calculus is present? c. Why is the pain felt in such an extensive area? Tuesday, December 3, 2024  a. Ureteric stones There are three sites of anatomic narrowing of the ureter where stones may be arrested, namely, the pelvi-ureteral junction, the pelvic brim, and where the ureter enters the bladder. b. Cause of renal colic Strong peristaltic waves of contraction pass down the ureter to propel the stone. The spasm of the smooth muscle causes an agonizing colicky pain. c. Area of referred pain from ureter As the renal pelvis and the ureter send their afferent nerves into the spinal cord at segments T11 - L2, the referred pain is felt in the skin areas that are supplied by the same segments. These areas would include the posterior and lateral abdominal wall below the ribs and above the iliac crest, the pubic region, the scrotum in males, the labia majora in females, and the proximal anterior aspect of the thigh. Tuesday, December 3, 2024  Q3. Describe the region of referred pain originating from the kidney and ureter (with the help of the following diagrams). Tuesday, December 3, 2024  Renal Pain – Renal pain varies from a dull ache to a severe pain in the flank that may radiate downward into the lower abdomen. – Renal pain can result from stretching of the kidney capsule or spasm of the smooth muscle in the renal pelvis. – The afferent nerve fibers pass through the renal plexus around the renal artery and ascend to the spinal cord through the lowest splanchnic nerve. – They enter the spinal cord at the level of T12. Pain is commonly referred along the distribution of the subcostal nerve (T12) to the flank and the anterior abdominal wall. – Kidney's pain may refer to back or sides – Ureteric pain referred to lower abdomen or flank – The pain is often so severe that afferent pain impulses spread within the central nervous system, giving rise to nausea. Tuesday, December 3, 2024  Activity 4: Mechanism of prevention of urine reflux into ureters Q1. Explain how entry of ureters into bladder prevents reflux of urine into the ureters. Tuesday, December 3, 2024  ▪ The ureters pass obliquely through the muscular wall of the urinary bladder in an infero-medial direction, entering on the outer surface of the bladder approximately 5 cm apart, but their internal openings into the lumen of the empty bladder are separated by only half that distance. ▪ This oblique passage through the bladder wall forms a one-way “flap valve,” the internal pressure of the filling bladder causing the intramural passage to collapse. ▪ In addition, during micturition when the bladder contracts, this acts as a sphincter preventing the reflux of urine into the ureters. Tuesday, December 3, 2024  Activity 5: Abdominal aorta & aortic aneurysm Q1. Describe the location, important anterior relations, and surface anatomy of abdominal aorta (with the help of the following diagrams). Tuesday, December 3, 2024  Location of Abdominal Aorta The aorta enters the abdomen through the aortic opening of the diaphragm in front of the 12th thoracic vertebra. It descends behind the peritoneum on the anterior surface of the bodies of the lumbar vertebrae. At the level of the 4th lumbar vertebra, it divides into the two common iliac arteries. Relations of the Abdominal Aorta – On its right side lie the inferior vena cava, the cisterna chyli, and the beginning of the azygos vein. – On its left side lies the left sympathetic trunk. – Anteriorly, stomach, celiac plexus, pancreas, splenic vein, third part of duodenum, coils of small intestine, and peritoneum. – Posteriorly, upper 4 lumbar vertebrae. Tuesday, December 3, 2024  Surface anatomy of abdominal aorta It extends from a median point 2.5 cm above the transpyloric plane (L1) to a point 2.5 cm below and to the left of the umbilicus at the level of supracrestal plane (L4) (plane of highest points of iliac crest) Tuesday, December 3, 2024  Q2. What is abdominal aortic aneurysm? Discuss the possible consequences of a ruptured abdominal aortic aneurysm (with the help of the following diagrams). Tuesday, December 3, 2024 Aortic Aneurysms: Aneurism is a localized or diffuse dilatation of abdominal aorta, usually occurs below the origin of renal artery. Most aneurysms occur following atherosclerosis, which causes weakening of the arterial wall, and most commonly occurs in elderly males. Acute rupture of an abdominal aortic aneurysm is associated with severe pain in the abdomen or back, and in a leaking aortic aneurysm, the blood may first be confined to the retroperitoneal space before rupturing into the peritoneal cavity. Large aneurysms should be surgically excised and replaced with a prosthetic graft/or by endovascular surgery – the graft is inserted into a blood vessel and sewing the wall of the aneurismal aorta over the graft to protect it. Tuesday, December 3, 2024  ▪ Deep palpation of the mid abdomen can detect an aneurysm. ▪ Pulsations of a large aneurysm can be detected to the left of the midline; the pulsatile mass can be moved easily from side to side. Medical imaging can confirm the diagnosis in doubtful cases. Tuesday, December 3, 2024  Activity 6: Spread of cancer by venous route Q1. Contrast venous spread of cancer from gut (e.g., colon) with that from paired viscera (e.g., kidney) (with the help of the following diagram). Tuesday, December 3, 2024  Unpaired viscera like colon: cancer cells spread via portal vein and metastasize to the liver. Paired viscera like kidneys: cancer cells spread via IVC and metastasize to the lungs. Tuesday, December 3, 2024  Activity 7: Clinical Significance of lymphatic drainage of kidney Q1. A 50-year-old man is found to have carcinoma of the kidney. What is the lymphatic drainage of the kidney? (explain with the help of the opposite diagram) The renal lymphatics drain directly to para- aortic lymph nodes, then to the lumbar lymph trunks (which then drain to the cisterna chyli and then to thoracic duct). Tuesday, December 3, 2024  THANK YOU Tuesday, December 3, 2024