Dynamic Radiology of the Abdomen Normal and Pathologic Anatomy

MORTON A. MEYERS

Dynamic Radiology of the Abdomen Normal and Pathologie Anatomy

with a contribution in ultrasonography by

Elias Kazam

638 figures including 14 color plates

Springer Science+Business Media, LLC

1976

Morton A. Meyers, M.D. Professor of Radiology Cornell University Medieal College New York, New York

Elias Kazam, M.D. Assistant Professor of Radiology Cornell University Medieal College New York, New York

Library of Congress Cataloging in Publieation Data

Meyers, Morlon A. Dynamie radiology of the abdomen.

Ineludes bibliographieal referenees and index. 1. Abdomen-Radiography. I. Kazam, Elias. 11. Title.

RC944.M48 617' .55'07572 76-18722

All rights reserved.

No part of this book may be translated or reprodueed in any form without written permission from Springer-Verlag.

© 1976 by Springer Science+Business Media New York

Originally published by Springer-Verlag New York Inc. in 1976.

Softcover reprint of the hardcover 1st edition 1976

ISBN 978-1-4757-3957-2 ISBN 978-1-4757-3955-8 (eBook)DOI 10.1007/978-1-4757-3955-8

To my wife, Bea, and my children, Richard and Amy

There are some things which cannot be learned quickly, and time, which is all we have, must be paid heavily for their acquiring. They are the very simplest things; and, because it takes a man's life to know them, the little new that each man gets from life is very costly and the only heritage he has to leave.

Ernest Hemingway (1898-1961), Oeath in the Afternoon

Preface

This book provides a systematie applieation of anatomie and dynamie prineiples to the praetieal understanding and diagnosis of intraabdominal diseases. Anatomie sections and injeetion studies form a basis for understanding the eharaeteristie features of many eommon and uncommon diseases and their spread and loealization in the abdomen. These relationships and speeifie eriteria provide a rational system for accurate radiologie analysis in plain films, eonventional eontrast studies, ultrasonography, and computerized transaxial tomography (CTT). This informa­tion leads to the uncovering of clinieally deeeptive diseases, the evaluation of the effeets of disease, the antieipation of eompliea­tions, and the determination of the appropriate diagnostie and therapeutie approaches.

The introductory atlas presents full color anatomie cross seetions of the abdomen and pelvis, eomplemented by labeled traeings, and detailed CTT seans at eorresponding levels. The seetions, whieh are approximately 3.8 em (1.5 in.) thiek, were obtained from fresh eadavers frozen in dry iee for 48 hours, in order to maintain the true intimate anatomie relationships. The aeeompanying text of the atlas stresses normal gross rela­tionships, eommon variants, and the basis of their radiologie identifieation, partieularly in plain films. The subsequent ehap­ters deal with the diagnosis and the pathways of spread of infeetion, malignaneies, and traumatie and inflammatory effu­sions within the intra- and extraperitoneal spaees. Emphasis is plaeed on the specifie loealizing features based on the anatomie planes and reeesses and the dynamies of extension of disease. Sagittal and coronal as weIl as horizontal anatomie seetions support the findings in eonventional radiologie proeedures, ultrasonography, and eomputerized transaxial tomography throughout. Correlation with the clinieal findings and manage­ment underscores the value of the radiologie observations. Diagnostie eriteria whieh are easily applied are established for the eharaeteristie features of speeifie disease processes ranging from loealized abseesses to dis semina ted metastases.

Many of the insights detailed in this book have been made only in the past few years. The applieation of peritoneography as a clinieal diagnostie study, for example, first indieated the dy­namie cireulation of fluid states within the peritoneal reeesses and permitted an insight into the spread of infeetion and malignaneies. Similarly, the signifieanee of the anatomie and radiologie definition of the extraperitoneal spaees, the small

vii

viii

bowel mesentery and other peritoneal refleetions, the haustral eontours of the large intestine, and the eontiguity of eertain organ relationships has only reeently been appreciated.

Acknowledgments

I first learned my basie gross anatomy as a medieal student at The State University of New York Upstate Medieal Center in Syraeuse. It is a partieular pleasure to thank Dr. Donald Good­man, Chairman of the Department of Anatomy, for permission to reproduee many of the anatomie seetions skillfully prepared by Mr. Lou Rimmler. Alfred S. Berne, M.D., an intelleetually demanding radiologist who has always stressed anatomie and pathologie eorrelation, has provided eontinued support and en­eouragement.

Many of the illustrations have been reprodueed, with permis­sion of the publishers, from articles of mine whieh have first appeared in Radiology and The American Journal 0/ Roentgenology, Radium Therapy and Nuclear Medicine. David H. Stephens, M.D., Robert R. Hattery, M.D. and Patriek F. Sheedy 11, M.D., Mayo Clinie, Roehester, Minnesota, and Stuart S. Sagel, M.D. and Robert J. Stanley, M.D., Washington University Sehool of Medicine, St. Louis, Missouri, have graciously allowed me the use of some of their material of eomputerized transaxial tomogra­phy of the abdomen.

A grant from E. R. Squibb and Sons made possible mueh of the art work neeessary for the graphie exposition of the ana­tomie relationships.

Last, I would like to thank the editorial staff of Springer­Verlag, New York, for their helpful suggestions and eonsistent cooperation through the preparation of this work.

Morton A. Meyers, M.D.

Foreword by Richard H. Marshak, M.D.

Few books present so fresh an approach and so clear an exposition as does Dynamie Radiology 0/ the Abdomen: Normal and Pathologie Anatomy.

This well-doeumented, clearly written, and beautifully illus­trated book details the answers not only to "what is it?" but also "how?" and "why?" Such fundamental information regarding the pathogenesis of disease within the abdomen reinforces and simplifies accurate radiologie analysis. The eharaeteristie radio­logie features of intraabdominal diseases are shown to be easily identified, expanding the praetieal applieation of the term "pat­tern recognition." It eertainly is of praetieal value in daily clini­eal experienee and will be of considerable help for furt her ad­vanees.

The traditional dissectional method of learning anatomy dis­turbs the intimate relationships of struetures. The sectional anat­omy presented in this book is the framework for understanding the findings in eonventional radiology-in plain films and rou­tine eontrast studies-as weIl as in ultrasonography and com­puterized tomography of the abdomen.

This is not just a review of others' experienees, but a erystal­lization of the author's contributions over the past several years. Dr. Meyers' coneept of dynamie cireulation within the peritoneal eavity is a breakthrough in our understanding of the spread of intraabdominal disease, partieularly abseesses and malignaneies. Peritoneography, the opaeifieation of the largest lumen in the body, offers a potential yield of vast diagnostie information. The precise definition of the three extraperitoneal spaees represents a eharting of previously unexplored territory. Awareness of the renointestinal and duodenoeolie relationships, the spread of pancreatitis along mesenterie planes, and the pathways of extra­pelvie spread of disease again underscores the praetieal impor­tanee of anatomie features. The approach to the mesenterie and antimesenterie borders of the small bowel and to the haustral pattern of the colon adds a new dimension to the interpretation of abdominal radiology.

This book eonfirms Dr. Meyers' reputation as one of the au­thorities in normal and pathologie radiologie anatomy of the abdomen.

Riehard H. Marshak, M.D. Clinieal Professor of Radiology Mount Sinai Sehool of Medieine New York City

ix

Foreword by Lloyd M. Nyhus, M.D., F.A.C.S.

Dr. Morton A. Meyers indeed has developed adynamie text relating to radiologie aspeets of abdominal disease. But this statement, with its emphasis on radiology, is misleading. This book is an important reading souree for surgeons. Dr. Meyers' observations have not been confined to those arising from a purely radiologie study of the abdomen. The inclusion of obser­vations based on injeetion studies both in the eadaver and in vivo has given this work a noteworthy eomprehensiveness.

The insights provided by both the atlas of full-page color anatomie cross seetions of the abdomen and pelvis and the exeellent anatomie-radiologie eorrelations found in the text make the book indispensable. The atlas establishes the basis for intimate anatomie relationships which are then applied to the practieal areas of clinieal diagnosis and treatment of intraabdomi­nal pathology. Presentations of these diagnostic and therapeutie eonsiderations are enhanced by illustrated discussions relative to the new techniques of ultrasonography and eomputerized trans­axial tomography.

Dr. Meyers' presentation of this timely information is valua­ble, but what makes this book invaluable is the vast personal experienee he is able to bring to it. This is not "just another" book purporting to give us something new in this important field. I believe the special approach given to this subjeet by Dr. Meyers is truly innovative. The radiologist and surgeon looking for the latest techniques in angiography for the diagnosis and treatment of massive bleeding from the gastrointestinal tract will not find it here. What they will find is major help in the understanding of, and indeed, therapeutie approach to a number of common intraabdominal problems, including infeetion and malignancy.

Lloyd M. Nyhus, M.D., F.A.C.S. Warren H. Cole Professor and The Abraham Lineoln School of Medieine University of Illinois at the Medical Center Chieago, Illinois

xi

Contents

Prefaee vii

Foreword by Riehard H. Marshak, M.D. ix

Foreword by Lloyd M. Nyhus, M.D. xi

Normal Anatomie Relationships and Variants xvii

Chapter 1 Intraperitoneal Spread of Infeetions

General Introduetion 1

Anatomie Considerations 2 The Posterior Peritoneal Attaehments 2 Detailed Anatomy of the Right Upper Quadrant 3

The Right Subhepatie Spaee 3 The Right Subphrenie Spaee 6

The Left Subphrenie Spaee 7 The Lesser Sae 8

Radiologie Features 10 The Spread and Loealization of Intraperitoneal

Abseesses 1 0 Pelvie Abseesses 11 Right Subhepatie and Subphrenie Abseesses 12 Lesser Sae Abseesses 21 Left'Subphrenie Abseesses 23 Summary 33

Management 33

Referenees 34

Chapter 2 Intraperitoneal Spread of Malignaneies

General Introduetion 37

Direet Invasion from Noneontiguous Primary Tumors 38 Invasion along Mesenterie Refleetions 38

Careinoma of the Stomaeh 39 Careinoma of the Panereas 43 Careinoma of the Colon 44

Invasion by Lymphatie Permeation and Extension 47

Direet Invasion from Contiguous Primary Tumors 48

Intraperitoneal Seeding 54 Anatomie Features 55 Pathways of Aseitie Flow 56 Seeded Sites 57

Poueh of Douglas (Reetosigmoid Junetion): Radiologie Features 58

Lower Small Bowel Mesentery (Terminal Ileum and Ceeum): Radiologie Features 59

Sigmoid Colon: Radiologie Features 69 Right Paraeolie Gutter (Ceeum and Aseending

Colon): Radiologie Features 71

Embolie Metastases 71 Metastatic Melanoma 71 Breast Metastases 75 Bronehogenie Careinoma 79 Renal Carcinoma 80

Referenees 80

Chapter 3 Peritoneography: Normal and Pathologie Anatomy

General Introduetion 83

Safety of Intraperitoneal Water-Soluble Contrast Media 84 Investigational Evidenee 84 Clinieal Evidence 85

Historical Development of Peritoneography 85

Indieations and Contraindications 86

Teehnique of Peritoneography 87 Adjunet to Peritoneoscopy 89

Findings on Peritoneography 90 Right Upper Quadrant 91

Liver: Right Lobe 91 Liver: Left Lobe 95 Gallbladder 97

Stomaeh and Supporting Mesenteries 97 Left Upper Quadrant 101

Spleen 101 Tail of Pancreas 101

Colon 103 Pelvie Area 104

Urinary Bladder 104 Female Pelvic Organs 109

References 110

xiii

Chapter 4 The Extraperitoneal Spaees: Normal and Pathologie Anatomy

General Introduetion 113

Anatomie Considerations 115 The Three Extraperitoneal Compartments 116 The Psoas Museie 121 The Hepatic and Splenic Angles 122

Anterior Pararenal Spaee 123 Roentgen Anatomy of Distribution and Localization of

Collections 123 Sources of Effusions 125

Extraperitoneal Perforations of the Colon and Appendix 126

Perforations of the Duodenum 129 Retroduodenal Hematoma 131 Pancreatitis 133 Bleeding from Hepatic or Splenic Artery 135

Perirenal Spaee 139 Roentgen Anatomy of Distribution and Localization of

Collections 139 Sources of Effusions 141

Perirenal Gas-Producing Infection 142 Perirenal Abscess 145 Uriniferous Perirenal Pseudocyst (Urinoma) 151 Distinction between Perirenal and Subcapsular

Collections 157

Posterior Pararenal Spaee 172 Roentgen Anatomy of Distribution and Localization of

Collections 172 Clinical Sources of Effusions 174

Spontaneous Bleeding 174 Abscess 174 Lymphatic Extravasation 174 Posterior Spread of Pancreatitis 179 Diffuse Extraperitoneal Gas 181

Rectal Perforation 185 Sigmoid Perforation 185 Extraperitoneal Gas of Subdiaphragmatic

Origin 187 Differential Diagnosis of Small Amounts of

Subdiaphragmatic Gas 187

Psoas Abseess 189

Referenees 192

Contents

xiv

Chapter 5 The Renointestinal Relationship_s: Normal and Pathologie Anatomy

General Introduetion 195

Anatomie Considerations 195 The Right Kidney 195 The Left Kidney 197

Radiologie Observations 199 Characteristic Mass Displacements 199

The Right Kidney 199 The Left Kidney 206

Ptosis and Rotation 213 Invasive Hypernephroma 214 Perinephritis and Renointestinal Fistulas 214 Renal Agenesis and Ectopia 220

The Right Side 224 The Left Side 228

Direct Intestinal Effects Unique to Renal Ectopia 231

Referenees 234

Chapter 6 The Duodenoeolie Relationships: Normal and Pathologie Anatomy

General Introduetion 237

Anatomie and Normal Radiologie Features 237

Abnormal Radiologie Features 243 Masses within the Mesocolic Leaves 243 Effect on the Descending Duodenum by Carcinoma of

the Hepatic Flexure 243 Duodenocolic Fistulas 247 Effect of Gallbladder Disease on the Duodenocolic

Relationships 247 Duodenocolic Displacements from Right Renal

Masses 249 Effect on Colon of Mass Arising in Descending

Duodenum 249 Inframesocolic Extension of Neoplasm of Third

Duodenum 253 Acute Pancreatitis 253 Abscess of Morison's Pouch versus Inframesocolic

Abscess 253 Duodenojejunal Junction: Relation to Colon 256

Referenees 260

Chapler 7 Intestinal Effeets of Panereatitis: Spread along Mesenterie Planes

General Introduetion 261

Anatomie Considerations 261

Effeets of Panereatitis on Colon: Spread along the Transverse Mesoeolon 265 Hepatic Flexure 265 Transverse Colon and Splenie Flexure 269

Effeets of Panereatitis on the Duodenum, Small Bowel, and Ceeum: Spread along Small Bowel Mesentery 273 Duodenum 273 Small Bowel and Cecum 273

Referenees 277

Chapler 8 The Small Bowel: Normal and Pathologie Anatomy

General Introduetion 279

Anatomie Considerations 279

Normal Radiologie Observations 283 Axis of Root of the Small Bowel Mesentery 283 Undulating Changeable Nature of Coils of Bowel

Loops 283 Identification of Mesenteric and Antimesenteric Borders

of Sm all Bowel Loops 286

Abnormal Radiologie Features 288 Diverticulosis of the Small Intestine 289 Meckel's Diverticulum 292 Intestinal Duplication 293 Seeded Metastases 295 Hematogenous Metastases 295 Regional Enteritis 296 Lymphoma 301 Intramural and Mesenteric Bleeding 303

Referenees 303

Chapler 9 The Colon: Normal and Pathologie Haustral Anatomy

General Introduetion 305

Anatomie Considerations 306 Classification of Organization of Haustral Rows 309

Normal Radiologie Observations 309

Abnormal Radiologie Features 315 Lesions within the Gastrocolic Ligament 315 Lesions within the Transverse Mesocolon 318 Distinction between Intra- and Extraperitoneal

Processes 325 Diverticulosis and Diverticulitis 328

Summary 330

Referenees 332

Chapler 10 Pathways of Extrapelvie Spread of Disease

General Introduetion 333

Anatomie Considerations 335

Radiologie Findings 337

Referenees 345

Index 347

Contents

XV

Normal Anatomie Relationships and Variants

General Introduction

Abasie knowledge of normal anatomie relationships and variants is essential to understanding the effeets of pathologie processes. Fundamental eonsiderations include constant ana­tomie landmarks, variations in positions of struetures, rela­tionships maintained and bounded by peritoneal and faseial attaehments, distribution of intra- and extraperitoneal fat pro­viding the eontrasting interfaces of organ and viseus eontours, and governanee of the configuration of the hollow viscera by specifie anatomie eharaeteristies and general physieal laws.

Figure 1 illustrates that the image one first sees is determined by the relationship established between individual features (7). In a similar manner, clinieal and radiologie diagnosis is based on the extraetion of a set of features eharaeteristie of a partieular proeess. Deviation from the normal, however, must be reeog­nized before alesion ean be suspeeted.

This atlas provides a detailed overview of the eomplex ana­tomie relationships within the abdomen. Its aeeompanying text stresses normal radiographie features. Cadavers, frozen in dry iee for 48 hours, were seetioned into horizontal slices approximately 3.8 em (1.5 in.) thiek with a band saw (Seetions 1 through 12). Tracings of the anatomie seetions, appropriately labeled, are included to faeilitate identifieation. The clarity of the features demonstrated in the anatomie seetions readily provide eorrela­tion with the struetures now identifiable by computerized trans­verse tomography (CTT 1 through 9).

The Liver

The RIGHT LOBE is mueh larger than the left and extends from its domed surfaee near the diaphragm to its inferior viseeral surfaee whieh faees posteriorly and has complex relationships to

xvii

FIG. 1. W. E. Hill's "My Wife and My Mother-in-Iaw." 80th images are present in the drawing. The viewer first sees either an old woman or a young lady. The old woman's prominent nose in profile is the young woman's chin. This drawing illustrates that perception is determined by the relationships.

several intraperitoneal and extraperitoneal structures. The ante­rior third of the inferior surface of the right lobe is inden ted by the hepatic flexure of the colon. A fossa for the right kidney lies posterior to the colonic impression. The gallbladder lies just under the anterior-inferior edge of the liver. Medial to the gallbladder lie the first and second portions of the duodenum. The gallbladder cannot be seen on plain films because it is not invested by or adjacent to any significant adipose tissue, but its position may be inferred from the gas-containing hepatic flexure or duodenal bulb. The segment between the gallbladder fossa and the ligamentum teres is known as the quadrate lobe which is in relation to the pyloric end of the stomaeh, the superior portion of the duodenum and the transverse colon. Posteriorly, the caudate lobe lodges the inferior vena cava against the bare area of the liver. A process of the caudate lobe forms the upper border of the epiploic foramen of Winslow and thus faces the superior recess of the lesser sac. A common variant in females is a Riedel's lobe, a conspicuous inferior tonguelike extension of the right lobe of the liver. Normally, the lower edge of the right lobe of the liver does not cross the right psoas margin or extend below the iliac crest.

The nature of plain film visualization of the shadow of the liver's lower edge appears to be dependent on body habitus and the interfaces presented to the roentgen beam (1), but the

Normal Anatomie Relationships and Variants

xviii

(a)

FIG. 2. Plain film visualization 01 the liver as determined by anatomie relationships.

anatomie relationships of the right lobe of the liver in the main determine the image. These are illustrated in Fig. 2. The ante­rior-inferior edge of the liver, which can be clinically palpated, is generally not directly visualized radiographically but only indi­rectly by its known relationship to the hepatic flexure of the colon. Occasionally, suflicient omental and pericolic fat may exist to outline it only along its lateral margin (1). The posterior aspect of the right lobe, in relationship to the kidney, and the hepatic angle abut the extraperitoneal adipose tissue, accounting for visualization of their contours which present as a soft tis­sue-fat interface (10). The peritoneal cavity extends between the right kidney and the visceral surface of the right lobe of the liver as the hepatorenal fossa (right posterior subhepatic space, or Morison's pouch). The posterior parietal peritoneum reflects to form the right coronary ligament which suspends the liver intraperitoneally (Fig. 3).

It is important to recognize that the pleural cavity posteriorly extends down ward to come into relationship to the bare area of the liver, the upper portion of the right kidney, and the posterior subhepatic space (Fig. 4). Althoughthe pleura extends in front as low as the seventh costal cartilage, posteriorly the costo­phrenic sulcus reaches as low as the twelfth rib and at times even to the transverse process of LI.

The porta hepatis separates the quadrate lobe in front from the caudate lobe and process behind. It transmits the portal vein, the hepatic artery, and the hepatic duct. The vascular and ductal structures of the liver course within the free edge of the lesser omentum. As shown in Fig. 5, the precise level of the porta may occasionally be determined on plain films. Extraperitoneal fat extends into the liver hilus, enveloping the common bile duct and its ramifications in a sleevelike fashion. This periductal fat

Posterior surface of right lobe outlined by extra­peritoneal lat

Lateral surface of right lobe outlined by properitoneal lat

Under surface of anterior edge of right lobe outlined by perico lic fat

--.... ---~ Anterolnler ior edge of nght

lobe (not directly visualizedl

The Liver

xix

(b )

(a)

Normal Anatomie Relationships and Variants

XX

FIG. 3. The rellections 01 the right coronary ligament (arrows) suspending the right lobe of the liver are outlined by free intraperitoneal air in the lateral view. The inferior leaf is at the level of the 12th rib. The nonperitonealized bare area of the posterior surface of the right lobe lies between the reflections of the ligament.

FIG. 4. The inlerior extent 01 the right pleural space in relationship to the abdominal viscera is shown by the presence of a surgical clip (arrow) which has gravitated to the posterior costophrenic sulcus following an intrathoracic operation. (a) Intravenous urogram, oblique view. (b) Upper gastrointestinal series, prone view.

I

(b)

(a)

FIG. 5. Location of porta hepatis indicated by periductal fat. (a) Plain film. A curved tubular radiolucent band (arrows) projects with the liver shadow over the upper renal pole. (b) Intravenous cholangiography with tomography confirms sleevelike lucent periductal fat paralleling the contours of the common hepatic and common bile ducts. Extraperitoneal fat outlining the visceral border of the liver is continuous with the periductal hilar fat.

may produce a striking tubular radiolucent shadow which char­acteristically projects within the liver anterior to the upper pole of the right kidney and superior to the duodenal bulb, with a gentle lateral convexity and branching in its upper segment (2). Likewise, the approximate location of the porta hepatis may be recognized by a radiolucent li ne of variable diameter represent­ing fat around the round ligament (ligamentum teres hepatis) in the free edge of the falciform ligament (3) (Fig. 6).

The LEFT LOBE is smaller and more ßattened than the right. It comes into its fullest dimensions superiorly in the epigastrium. Above, it is molded by the diaphragm. A tuberosity from its under surface fits into the concavity of the lesser curvature of the stornach, and the lobe may then extend anterior to the stornach for a variable distance into the left upper quadrant. Inferiorly, it typically becomes abruptly attenuated. The area of the left lobe of the liver has been best evaluated radiologically as the space anterior to the stornach on lateral views during an upper gastro­intestinal series. Plain film identification is generally impossible, although occasionally an apicallordotic projection may permit it to be viewed tangentially (Fig. 7).

The Liver

xxi

(b)

(a)

FIG. 6. Location of porta hepatis indicated by fat around the ligamentum teres. (a) Plain film. Fatty radiolucent streaks (arrows) project within the liver shadow. (b) Intravenous cholangiogram. The lucent shadows are distinct from the common hepatic and common bile ducts. The medial one outlines a portion of the left lobe (LL) of the liver.

FIG. 7. The leH lobe of the liver (LL) is seen in an apical lordotic projection. S = stomaeh, Sp = spleen.

FIG. 8. Positions of the spleen and axes of insertion of the tail of the pancreas. Schematic frontal view. The spleen is usually obliquely oriented (1) but may be vertical (2), or, rarely, horizontal (3). The tail of the pancreas inserts within the splenie hilus.

Normal Anatomie Relationships and Variants

xxii

(b)

FIG. 9. The anterior notched border of the spleen (Sp) (arrows) is seen because of intraperitoneal fat. The posteromedial border of the spleen is in intimate relationship to the lateral border of the left kidney (LK), both of wh ich are seen because of extraperitoneal fat.

FIG. 10. The anterior notched border of the spleen produces scalloped indentations upon the distal transverse colon.

The Spleen

The spleen lies deep in the left upper quadrant between the fundus of the stomach and the diaphragm. Although it is an intraperitoneal organ, its extremely posterior position explains why only considerable enlargement allows it to become clinically palpable through the anterior abdominal wall. Generally, the main axis of the spleen is obliquely oriented between the lateral cusp of the diaphragm and the posterolateral abdominal wall (Fig. 8). Some variability exists, however. At times, the spleen is vertical, extending inferiorly in the flank. Rarely, it is horizontal between the gastric fundus and the diaphragm, radiologically simulating a mass widening the gastrophrenic interval.

The anterior notched border of the spleen separates its diaphragmatic and visceral surfaces. On plain films, this border can be visualized by virtue of the fatty contrast provided by the greater omentum (Fig. 9). At times, as the distal portion of the mesenteric transverse colon insinuates itself between the greater curvature of the stomach and the medial aspect of the spleen, the anterior notched border is indicated by a characteristic scalloping of the colonic surface (Fig. 10). The medial visceral surface of the spleen faces the posterior wall of the stomach anteriorly and the upper part of the left kidney posteriorly. The hilum of the spleen receives the reflections of its supporting mesenteries, the gastrosplenic and splenorenal ligaments. On plain films, the posteromedial border of the spleen can be visualized by virtue of

The Spleen

xxiii

FIG. 11. Plain film. The phrenicocolic ligament (arrows) is seen as a striplike density subtending the splenie angle at the level of the anatomie splenie flexure of the colon.

the contrast provided by extraperitoneal fat, against which this intraperitoneal organ abuts (10). The inferior tip, referred to as the splenie angle, extends down ward to the level of the anatomie splenic flexure of the colon where it tends to be supported by the phrenicocolic ligament. OccasionaHy, this peritoneal reflec­tion can be seen on pl~in films of the abdomen (5) (Fig. 11).

The Pancreas

The head of the pancreas is cradled by the descending duode­num, its body lies in the bed of the stomaeh, and the tail near the spleen, creating complex anatomie relationships as the pan­creas crosses the upper abdomen. The head in particular and the body of the pancreas are situated weH in front of the midcoronal plane of the body. This relatively anterior position of the pan­creas is often surprising if one assurnes that extraperitoneal organs are necessarily posterior in the abdomen. An insufficient amount of adjacent extraperitoneal fat prevents plain film visual­ization of the pancreas. The duodenojejunal junction serves as a useful demarcation between the body and the tail of the pan­creas. The tail curves posteriorly to cross the left kidney, usuaHy in its upper part (Fig. 12). It then enters the splenie hilus, being ensheathed within the splenorenal ligament. It is important to recognize that since it is here incorporated within a mesenteric reflection, the extreme tip of the pancreatic tail is, by definition, an intraperitoneal structure.

Postmortem and in vivo studies have documented considera­ble variation in the size, shape, and position of the pancreas. Its course across the abdomen may be oblique, sigmoid, transverse, or horseshoe-shaped (4,9). Much of this variation appears to be related not only to the descent of some organs with age because of the laxity of supporting structures, but to the axis of insertion of the tail of the pancreas as dictated by the position of the spleen (Fig. 8). As a gross landmark, however, the longitudinal axis of the pancreas can be projected along a line from the middescending duodenum to the central area between the spleen's posteromedial contour and anterior notched border.

The Gastrointestinal Tract

The stomach should be considered three-dimensionally. Rather than lying in one plane of the body, this organ is normally rotated about both the vertical and horizontal axes of the abdo­men. In this way, the greater curvature of the stornach represents

Normal Anatomie Relationships and Variants

xxiv

(a)

Splenie vessels

Adrenal gland

Transverse mesocolon

Lelt paracolic groove

FIG. 12. (a and b) Retroperitoneal pneumography with tomography in the left posterior oblique position illustrates the tail of the pancreas (P) ventral to the upper half of the left kidney (K) as it inserts within the splenic hilus. The splenic flexure of the colon (C) is outlined by some residual barium.

a portion of its anterior wall and the lesser curvature a portion of its posterior wall. The fundus lies quite posteriorly in the left upper quadrant, whereas the distal body and antrum course anteriorly. The first and seeond portions of the duodenum are then redireeted posteriorly.

The jejunum and ileum are supported by the small bowel mesentery. The root of this mesentery extends for a distanee of only about lS em from the region of the duodenojejunal june­tion to the eecocolie junetion. Jejunalloops, therefore, are most eommonly seen in the left upper quadrant and ilealloops in the lower midabdomen and right lower quadrant. A eommon vari­ant is nonrotation of the small bowel, wherein jejunalloops are suspended from the mesentery in the right midabdomen.

The large intestine has eomp1ex anatomie relationships as it courses through the abdomen. The eeeum may be eompletely extraperitoneal, but is often suspended intraperitoneally. This is particularly common in females, the extreme of whieh is seen as the "mobile" eecum. The ascending colon is extraperitonea1 up to the anterior hepatic ßexure, wh ich marks the beginning of the transverse mesocolon. This peritoneal reßection permits the transverse colon to be suspended anteriorly in the abdomen. At the level of the anatomie splenie ßexure, the large intestine penetrates the posterior parietal peritoneum to eontinue as the

The Gastrointestinal Tract

XXV

(b)

extraperitoneal descending colon. The sigmoid mesocolon re­fleets obliquely off the level of the left sacroiliac joint to suspend the redundant sigmoid loops anteriorly. The large intestine then penetrates the peritoneum at S2-S4 to continue as the subperi­toneal rectum.

Gas in the intestinal tract provides a natural contrast of the luminal contours. Its normal distribution and localization is a consequence primarily of the effects of gravity and its relation­ship ro hydrostatic pressure. In the supine position, gas rises and fills the distal pars media and antrum of the stomaeh, the cecum and proximal ascending colon, the transverse colon and often the splenie flexure, and the distal descending and sigmoid colon. In the pro ne position, gas enters the gastric fundus, the duode­nal bulb and often the descending duodenum, the distal ascend­ing colon, hepatic flexure, the proximal descending colon, and the rectum. At times, advantage may be taken of such localiza­tion by intentionally positioning a patient to demonstrate opti­mally a particular area or lesion on plain films.

Normal variability in the position of portions of the bowel and their relationship to each other are determined largely by body habitus and differences in mesenteric attachments. In a tall, thin female the stornach may be J-shaped and the transverse colon may curve into the lower abdomen or pelvis. In contrast, a short, stocky male typically has a stornach horizontally oriented in the upper abdomen with the duodenal bulb directed posteri­orly, accompanied by a straight and high transverse colon. Indi­vidual differences in length of their major peritoneal reflections -the greater (gastrocolic ligament) and lesser (gastrohepatic ligament) omenta and the transverse mesocolon-which are somewhat related to body habitus, and their increased laxity with age result in variability. Nevertheless, the greater curvature of the stornach maintains a generally parallel, if not dose, rela­tionship to the superior aspect of the transverse colon. Any localized increase should be viewed with suspicion.

The Extraperitoneal Structures The extraperitoneal region is anatomically divided by well­

defined fascial extensions into three compartments (6, 8). These are discussed in detail in Chapter 4. The anterior para renal space contains litde fat, explaining why the oudines of the major extraperitoneal portions of the alimentary tract within it (as­cending and descending colon, the entire duodenalloop, and the pancreas) are not direcdy seen on plain films. The central perire­nal space contains abundant fat and permits visualization of the kidneys and, occasionally, the adrenal glands. The most dorsal

Normal Anatomie Relationships and Variants

xxvi

extraperitoneal compartment, the posterior pararenal space! con­tains no major organs, but its properitoneal fat continues laterally around the flanks, where it is visualized radiographically as the "flank stripe."

The lateral borders of the psoas muscles are normally seen because of extraperitoneal fat, but different portions of it con­tribute to visualization of specific segments (6, 8). In its upper portion at the level of the kidneys, the psoas muscles are seen because of the contrast provided by perirenal fat. The lower portions, however, are visualized because they are outlined by posterior pararenal fat.

Extraperitoneal fat also outlines the inferior contours of the diaphragms. At times, it may appear radiologically as a strikingly lucent, thin subdiaphragmatic crescent and should not be mis­taken for free intraperitoneal air or other abnormalities. The same fat can be traced medially where it permits plain film visualization of the medial crura of the diaphragms.

In the pelvis, subperitoneal fat frequently outlines the dome of the urinary bladder. Its identification on plain films may be very helpful in distinguishing atme supravesical soft tissue mass from a distended urinary bladder. Visualization of the levator ani and obturator internus muscles bordering the bony pelvis is common.

REFERENCES

1. Gelfand D: The liver: Plain film diagnosis. Semin Roentgenol 10:177-185, 1975

2. Govoni AF, Meyers MA: Pseudopneumobilia. Radiology 118:526, 1976 3. Haswell DM, Berne AS, Schneider B: Plain film recognition of the

ligamentum teres hepatis. Radiology 114:263-267, 1975 4. Kreel L, Sandin B, Slavin G: Pancreatic morphology: A combined

radiological and pathological study. Clin Radiol 24:154-161, 1973 5. Meyers MA: Roentgen significance of the phrenicocolic ligament. Radi­

ology 95:539-545, 1970 6. Meyers MA: Acute extraperitoneal infection. Semin Roentgenol 8:445-

464, 1973 7. Meyers MA, Oliphant M: Pitfalls and Pickups in Plain-film Diagnosis of

the Abdomen. Current Problems in Radiology. Year Book Medical Publ., Chicago, Vol. IV, No. 2, pp. 1-37, March-April 1974

8. Meyers MA, Whalen JP, Peele K, Berne AS: Radiologie features of extraperitoneal effusions: An anatomie approach. Radiology 104:249-257, 1972

9. Varley PF, Rohrmann CA Jr, Silvis SE, Vennes JA: The normal endo­scopic pancreatogram. Radiology 118:295-300, 1976

10. Whalen JP, Berne AS, Riemenschneider PA: The extraperitoneal peri­visceral fat pad. 1. Its role in the roentgenologic visualization of abdomi­nal organs. Radiology 92:466-472, 1969

References

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Ouodenojejunal junction

Jejunal loops

Pancreas

cn 1. At the level 01 the 11th thoraeie vertebra. The left lobe of the liver extends anterior to the stomach. The posterolateral margin of the left kidney is in intimate relationship to the posteromedial border of the spleen. The anterior border of the spleen is normally notched.

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Caudate lobe

Right lobe 01 liver

Aorta

1i~~~ti'~~g--Ri9ht kidney

Falcilorm ligament

Leh lobe 01 ---liver

Right lobe ~--of liver

Aorta

cn 2. At the level 01 the 1 st lumbar vertebra. The neck of the pancreas bridges the superior mesenteric artery near its origin from the aorta. The duodenojejunal junction provides a land mark to separate the body from the tail of the pancreas. In this patient. the latter is at a higher level.

Proximal superior mesenteric artery

Aorta

Leh renal artery-~I:II""""

Left kidney

Colon

Jejunum

Left renal artery --1'-....-r

Lelt kidney

Psoas muscle -~ ... _~

lumborum museie

CTT 3. At the level of the upper bord er of the 2nd lumbar vertebra. The tail of the pancreas extends behind the body of the stomach. The colon descends anterolateral to the left kidney.

Falciform L-~'k----ligament

Gallbladder

R ight lobe 01 liver

~~~~~j-:€.~--~L1l- Head 01 pancreas

t:-;;--;=;-!:.:o..;.;==-;:::~-tiL_ I nlerior vena cava

Medial Crura of diaphragms

Right kidney

Falciform ligament

Gallbladder

;7,:-~;::?,~~t.:-a- Pa ncreas

Right lobe olliver

~~-;:;~;j~h_lnferior vena cava

Right renal vein

Aorta

CTT 4. At the level of the midportion of the 2nd lumbar vertebra. The left lobe of the liver has become attenuated but still extends anterior to the stomach. The head and body of the pancreas remain anterior to the midcoronal plane of the abdomen. The left renal artery lies behind the left renal vein, body of the pancreas, and the splenic vein.

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Jejunum

Superior mesenteric

artery

Stomach

Colon --1 .... +--:;~

Jejunum -.~rh~ Aorta

Spleen

Left lobe of liver Jej unal artery

Caudate lobe

~!:;~':"';=~:-7~,=--lnferior vena cava

Right lobe of liver

Quadratus lumborum museie Left renal ve in

CTT 5. At the level 01 the midportion 01 the 2nd lumbar vertebra. The vertical spleen in this patient is seen to extend inferiorly. The left renal vein passes in front of the aorta just below the origin of the superior mesenteric artery which crosses it anteriorly.

This study, performed after intravenous contrast injection, also demonstrates dilated intrahepatic bile ducts indicative of obstructive jaundice. A cyst projects posteriorly from the right kidney and a dromedary hump is present on the lateral margin of the left kidney. Calcification in the abdominal aorta is evident.

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CTT 6. At the level 01 the lower border 01 the 2nd lumbar vertebra. Virtually the full length of the pancreas is shown. The tail projects beyond the duodenojejunal junction anterior to the left kidney to insert within the splenic hilus. The caudate lobe of the liver extends behind the first portion of the duodenum near the inferior vena cava. The right renal artery passes behind the inferior vena cava and right renal vein.

CTT 7. At the level 01 the 3rd lumbar vertebra. The right lobe of the liver extends inferiorly in the flank. The third portion of the duodenum passes in front of the great vessels and is crossed by the superior mesenteric vessels and the mesentery.

Duodenojejunal junction

Aorta

Spleen

Left kidney

Pancreas

Medial crura of the diaphragms

CTT 6

Stomach

Duodenal bulb

__ ~~-;;:':;';::::i~~r-T- Caudate lobe

;':;;';;;':~~~~~§~J;fl_ Inferior vena cava

Right renal artery

Right lobe of liver

Superior mesenteric artery Superior mesenteric vein

Aorta

Quadratus lumborum muscle

CTT 7

Psoas muscle Inferior vena cava

Third (horizontal) duodenum

Right lobe of liver

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Pyramid mU5cle

Obturator

mU5cle

Femoral _-'IC=-__ :!Do:.-­head

Urinary bladder

Femoral head

Levator ani muscle

Rectum

Coccyx

Obturator internus muscie

pyramid muscle

Gluteus maximus museie

Femoral vein

Obturator foramen

Seminal vesicles

Femoral artery

Symphysis pubis

Obturator foramen

Ischial tuberosity

Coccyx Gluteus maxi mus muscie

CTT 8. At the level lust above the symphysis pu bis. This male pelvis shows the seminal vesicles and the upper pole of the prostate gland. Air is present in the urinary bladder from a previous cystoscopy. The obturator internus and iliopsoas muscles as they insert on the lesser trochanter of the femur are clearly shown.

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CTT 9. At the level of the symphysis pu bis. The site of the enlarged prostate gland in this male pelvis would be occupied by the uterus in a eTT of a female pelvis.