9 Clinical Imaging Basics of the Thorax

Radiographs are always the initial choice for imaging of the tho-rax. The airfilled lungs are perfectly suited for x-rays, making it easy to identify air space abnormalities such as pneumonia, and provide high contrast to the soft tissues of the heart and medias-tinum. When more detail of the heart, mediastinum, or lung parenchyma is required (e.g., evaluation of interstitial lung dis-ease), computed tomography (CT) is used. The value of magnetic resonance imaging (MRI) in cardiac imaging is its ability to acquire dynamic images (heart in motion) without radiation. Ultrasound (echocardiography) also has the utility of dynamic imaging with-out radiation and without the long scan times and issues of claustrophobia associated with MRI. However, the anatomic detail of ultrasound and the ability to assess the coronary vessels is limited when compared with CT and MRI (Table 9.1).

The chest x-ray is the starting point of the vast majority of thoracic imaging. When evaluating a chest x-ray (Fig. 9.1), the examiner typically follows the airway from the upper trachea down into both lungs and then views each lung in its entirety, sweeping from side to side. The heart borders are evaluated for size and shape, and the smooth surfaces of each hemidiaphragm and mediastinal border are confirmed. Each rib and vertebra is examined (Fig. 9.2), and then attention is given to the chest wall and soft tissues. A similar procedure is used to examine the lateral view. The chest x-ray in Fig. 9.3 is from a patient with cough and fever. Compare the images to the normal radiographs in Fig. 9.1. Note the large area of white (opacity) on the right. The lateral view, in conjunction with the frontal view, confirms that this opacity is in the right lung and, more specifically, within the right middle lobe.

Table 9.1 Suitability of Imaging Modalities for the Thorax

Radiographs (X- The mainstay of thoracic imaging and the most rays) common radiologic study performed; excellent for

evaluation of the lungs, heart, pulmonary vessels,

Fig. 9.1 Chest radiograph anatomy

Rendered drawing of chest radiographic anatomy. Ao, ascending aorta; IVC, inferior vena cava; LA, left atrium; LPA, left pulmonary artery; LUL, left upper lobar bronchus; LV, left ventricle; MPA, main pulmonary artery; RA, right atium; RPA, right pulmonary artery; RUL, right upper lobar bronchus; RV, right ventricle; SVC, superior vena cava. (From Yoo S,

MacDonald C, Babyn P. Chest Radiographic Interpretation in Pediatric Cardiac Patients. 1st ed. New York: 2010.)

Computed tomography scans are excellent for showing details of the soft tissues of the thorax and can be examined in different windows to highlight specific organs (Fig. 9.4). CT can also reveal subtle abnormalities of the lungs that would be too small to be seen on a chest x-ray, such as inflammatory or neoplastic small lung nodules or interstitial lung diseases (Fig. 9.5). MRI, although not well suited for imaging the lungs, provides very good detail of the heart and allows imaging in specific planes (Fig. 9.6). An ultra-sound of the heart, or echocardiogram, provides a dynamic view of the heart and is best viewed in “real time.” However, standard static “snapshots” can provide important information, such as the four-chamber view (Fig. 9.7).

Fig 9.2 Radiograph of the thorax with the 4th ribs highlighted Frontal view.

The ribs extend horizontally from their articulation with the vertebrae and then curve laterally, anteriorly, and inferiorly. When examining a chest radiograph, each rib should be traced over its entire course. Note that the costochondral cartilage is not visible on an x-ray. (Courtesy of Joseph Makris, MD, Baystate Medical Center.)

chambers is white and the heart muscle is dark gray. This left ventricular outflow tract view positions the left ventricle and the ascending aorta in the same plane so the entire outflow tract is visible on a single image. A complete cardiac MRI would contain slices through the entire heart in this plane as well as several other planes. Additionally, MRI allows for dynamic imaging and can produce “cine” (movie) clips of several cardiac cycles showing chamber, wall, and valve motion. Note that dynamic MRIs cannot be seen in “real time” as with ultrasound. *, Superior vena cava (with termination of azygos vein); •, right pulmonary artery; Aoa, ascending aorta; Aos, descending aorta; LA, left atrium; RV, right ventricle; LV, left ventricle. (From Claussen C, Miller S, Riessen R et al. Direct Diagnosis in Radiology. Cardiac Imaging. 1st ed. New York: Thieme; 2007.)

Fig. 9.7 Echocardiogram (heart ultrasound)

Apical four-chamber view taken with the probe positioned at the cardiac apex. Both ventricles (RV, LV), both atria (RA, LA), and the mitral and tricuspid valves (MV, TV) are well seen. Although this is a single static image, the true power of echocardiography is the ability to see heart motion with real-time dynamic images. Ventricular wall motion, valve operation, and blood flow can all be seen and analyzed. The displayed electrocardiogram (ECG) allows the imager to synchronize the heart’s motion with its electrical activity. (From Flachskampf F. Kursbuch Echokardiografie, 4th ed. Stuttgart: Thieme Publishers; 2008.)

Unit III Review Questions: Thorax

1.Which of the following nerves contribute to the phrenic nerve?

A.Anterior rami of C3–C5 spinal nerves

B.Anterior rami of C5–T1 spinal nerves

C.Sympathetic fibers from C3–C5 spinal cord segments

D.Sympathetic fibers from T1–T4 spinal cord segments

E.Cardiac nerves from the cervical sympathetic trunk

2.Which of the following is true of bronchopulmonary segments?

A.Each is served by one terminal bronchiole.

B.There are three in the right lung and two in the left lung.

C.Each is supplied by one bronchial artery.

D.Each is an anatomically and functionally distinct respiratory unit of the lung.

E.They have single-celled walls designed for efficient gas exchange.

3.Which of the following structures is/are found in the right atrium?

A.Chordae tendineae

B.Oval fossa

C.Mitral valve

D.Papillary muscles

G.Trabeculae carneae

4.The sternal angle (of Louis) marks the location of the

A.second costal cartilage

B.T4–T5 intervertebral disk

C.origin of the aortic arch

D.bifurcation of the trachea

E.All of the above

B.Left 3rd intercostal space

C.Left 5th intercostal space

D.Right 5th intercostal space

E.Xiphoid process of the sternum

9.Dr. P. was performing a cardiac bypass on a 53-year-old man whose

anterior interventricular artery (also known as the left anterior descending artery, LAD) was narrowed near its origin. Although Dr. P. frequently used a saphenous vein graft for this procedure, he chose to use the left internal thoracic artery instead. Leaving its origin intact, he cut its distal connections and anastomosed it to the LAD beyond the narrowed segment. This successfully restored flow to the anterior part of the heart. What path does the blood take through this diverted route?

A.Aortic arch to left subclavian artery to internal thoracic artery

B.Aortic arch to brachiocephalic artery to internal thoracic artery

C.Aortic arch to internal thoracic artery

D.Aortic arch to left subclavian artery to pericardiaco-phrenic artery to internal thoracic artery

E.Aortic arch to axillary artery to internal thoracic artery

10.An elderly man who admits to some dizziness and minor chest

palpitations during the past week is finally admitted to the emergency department for chest pain and shortness of breath. Imaging reveals a major blockage of his right coronary artery near the crux of the heart just proximal to the origin of the posterior interventricular artery. Which part of the heart would be affected by the ischemia that results from this blockage?

A.Sinoatrial (SA) node

B.Atrioventricular (AV) node

C.Anterior two thirds of the interventricular septum

D.Left atrium

E.Right ventricle

11.A woman who had a recent history of a myocardial infarction (MI) complained to her cardiologist of a sharp, stabbing pain behind her sternum

that radiated to her shoulder and was accompanied by shortness of breath, particularly when she was lying down. Her physician noted a pericardial friction rub and treated her for pericarditis, an inflammation of her pericardium caused by the recent MI. Pain from her pericardium was transmitted by the

A.phrenic nerves

B.cardiac plexus

C.pulmonary plexus

D.intercostal nerves

E.None of the above

12.The right lymphatic duct drains the lymph from

A.the entire right side of the body

B.the right side of the thorax, right upper limb, and right side of the head and neck

C.only the right side of the thorax

D.only the right side of the head and neck and right upper limb

E.the right side of the thorax, the abdomen, and the right lower and the right upper limbs

13.Which of the following features are paired with the correct lung?

A.Lingula—right lung

B.Horizontal fissure—left lung

C.Cardiac notch—left lung

D.Two lobar bronchi—right lung

E.Shorter and wider than the contralateral lung—left lung

14.Several weeks after suffering a severe myocardial infarc-tion, a man

was rushed to the emergency department but died shortly afterward. It was discovered at autopsy that the muscle anchoring one leaflet of his mitral valve had ruptured, probably as a consequence of his earlier heart attack. Which was the affected muscle?

A.Papillary muscle

B.Trabeculae carneae

C.Pectinate muscle

D.Terminal crest

E.Septomarginal trabecula (moderator band)

15.What is the origin of the 3rd through 11th posterior intercostal arteries?

A.Descending aorta

B.Internal thoracic artery

C.Lateral thoracic artery

D.Subclavian artery

E.Superior epigastric artery

16.A woman with a history of asthma presents to the emergency

department with shortness of breath and wheezing. Drugs and oxygen are administered, but her condition worsens. She is transferred to the intensive care unit and put on a ventilator. Twenty-four hours after admission, she dies from complications of asthma. On autopsy it is found that she has severe inflammation, an increase in smooth muscle, and other pathologic changes around a part of the respiratory tree that does not contain cartilage. Which part of the airway was most likely affected in this patient?

A.Trachea

B.Main (primary) bronchi

C.Lobar (secondary) bronchi

D.Segmental (tertiary) bronchi

E.Bronchioles

17.During the physical examination of a 28-year-old construction worker,

you mention that his heart sounds strong and healthy. He asks you to explain what creates the heart sounds. You tell him that the first heart sound (the “lub”) is produced by the

A.closure of the tricuspid and pulmonary valves

B.closure of the atrioventricular valves

C.opening of the semilunar valves

D.contraction of the ventricles

E.turbulent flow through the valves

18.All of the following structures are in contact with thoracic vertebral

bodies except

A.Azygos vein

B.Trachea

C.Sympathetic trunk

D.Thoracic duct

E.Right posterior intercostal artery

19.What is/are the primary muscle(s) used in quiet respiration?

A.Intercostal muscles

B.Scalene muscles

C.Diaphragm

D.Pectoralis major

E.Anterior abdominal muscles

20.Which of the following valves is most audible at the right 2nd

intercostal space just lateral to the sternum?

A.Aortic valve

B.Left atrioventricular valve

C.Pulmonary valve

D.Right atrioventricular valve

E.Valve for the coronary sinus

21.During auscultation of the heart, which of the following relationships is

most likely to be correct in a normal adult?

A.The left 4th intercostal space at the midaxillary line is the site of auscultation of the mitral valve.

B.The left 2nd intercostal space at the sternal border is the site of auscultation of the aortic valve.

C.The right 3rd intercostal space at the sternal border is the site of auscultation of the pulmonary valve.

D.The right 2nd intercostal space at the sternal border is the site of

auscultation of the aortic valve.

E. The right 4th intercostal space at the midclavicular line is the site of auscultation of the tricuspid valve.

22.Which of the following events occurs during either quiet or forced

expiration?

A.Collapse of alveolar sacs

B.Increase in lung volume

C.Elevation of the ribs

D.Increase in intrapleural pressure

E.Temporary collapse of the segmental bronchi

23.During a routine physical exam of a young woman who is training to

compete in the Olympic trials, you scrutinize her cardiac rhythm for abnormalities. Which of the follow-ing events normally occur during ventricular diastole?

A.Contraction of the ventricles

B.Ejection of blood into the pulmonary trunk

C.Opening of the semilunar valves

D.Filling of the coronary arteries

E.Closure of the atrioventricular valves

24.You have been treating a 67-year-old woman for a mediastinal tumor for

three months. Following her latest CT scan, it’s clear that the tumor has increased in size, despite the chemotherapy, and is now large enough to compress her superior vena cava (superior vena cava syndrome). In spite of this obstruction, veins of her neck and upper limb appear only slightly distended. You know from the CT that the obstruction is located below the junction of the SVC and azygos, veins and you are confident that venous blood from the head and upper limb is flowing back to her heart via collateral channels. The backflow of blood through these collateral channels would cause some dilation in collateral vessels. Which of the following would not be affected by this backflow?

A. External jugular veins

B.Right pulmonary veins

C.Posterior intercostal veins

D.Hemiazygos vein

E.Internal thoracic veins

25.Your 64-year-old neighbor, a retired high school biology teacher, is

seemingly recovered from a serious heart attack from several months ago. However, during a recent checkup she was found to have an abnormally slow and irregular heartbeat, a diagnosis of atrioventricular heart block. In an effort to calm her distress and explain her condition, you try to explain how the heart is innervated. Which of the following statements is true of the cardiac plexus?

A.It contains postganglionic sympathetic fibers from the cervical and thoracic sympathetic trunk.

B.Visceral sensory fibers that innervate the barorecep-tors (which measure blood pressure) travel with sympathetic fibers.

C.It contains cardiac branches of the vagus nerve, which contain postganglionic sympathetic fibers.

D.It initiates the heartbeat but does not regulate the heart rate.

E.Sensations of pain carried on visceral sensory fibers travel with parasympathetic branches of the vagus nerve.

26.Your first patient as an Ob/Gyn intern is a 23-year-old woman who gave

birth to a premature 5-pound baby girl with Down syndrome. Within the first few days the child is diagnosed with an atrial septal defect (ASD), a common anomaly associated with her congenital defect. Atrial septal defects

A.cause a right-to-left shunting of blood in the atria

B.result in a decrease in blood volume in the pulmo-nary circulation

C.result from a failure of the ductus arteriosus to constrict

D.can result from a failure of the oval foramen to close at birth

E.can be compensated for by an effective collateral circulation that circumvents the defect

A.Right heart border

B.Right hemidiaphragm

C.Left hemidiaphragm

D.Right upper mediastinum

E.Right breast shadow

30.What would be the best way to detect a cardiac wall motion abnormality

in an unstable patient with a recent myocardial infarction (MI)?

A.Chest x-ray

B.Chest CT

C.Ultrasound (echocardiogram)

D.ECG

E.MRI

Answers and Explanations

1.A. The phrenic nerve is a somatic nerve containing C3–C5 anterior

rami (Section 5.2).

B.The anterior rami of C5–T1 form the brachial plexus.

C.There are no autonomic nerves that arise from the C3–C5 spinal cord.

D.Sympathetic splanchnic nerves that arise from T1–T4 contribute to the cardiac and pulmonary plexuses.

E.Cardiac branches from the cervical sympathetic trunk contribute to the cardiac plexus and are not related to the phrenic nerve.

2.D. Bronchopulmonary segments function independently from other

segments and are separated from them by thin septa (Section 8.2).

A.One segmental bronchi enters each bronchopulmo-nary segment and ramifies into many conducting bronchi-oles, which in turn divide into many terminal bronchioles.

B.The right lung has 10 bronchopulmonary segments, and the left lung has 8 to 10 segments.

C.Bronchial arteries supply the bronchi and connective tissue of the

lungs, including the visceral pleura. Branches of the pulmonary arteries supply the bronchopulmonary segments.

E. Alveoli, the smallest unit of the respiratory tree, have single-celled walls that facilitate gas exchange.

3.B. The oval fossa on the interatrial septum is the remnant of the

opening between the atria that allows right-to-left shunting in the fetal circulation (Section 7.4).

A. Chordae tendineae are found in the ventricles.

C.The mitral valve separates the left atrium and ventricle.

D.Papillary muscles are found only in the ventricles.

E.Trabeculae carneae are muscular ridges in the walls of the ventricles.

4.E. The sternal angle is a palpable bony prominence created at the

junction of the body and manubrium of the sternum. It marks the transverse plane that passes through the 2nd costal cartilage, T4–T5 intervertebral disk, origin of the aortic arch, and bifurcation of the trachea (Section 6.2).

5.C. The carina, at the bifurcation of the trachea, lies approximately at

the T4–T5 vertebral level, which is also the level of the sternal angle (Section 6.2).

A.The left atrium lies approximately at the level of T6–T7, below the carina at the bifurcation of the trachea.

B.The brachiocephalic artery, the first branch of the aortic arch, lies approximately at the level of T3. The carina lies at the level of the sternal angle at T4–T5.

D.The tricuspid valve lies at the level of the 5th costal cartilage. The carina lies at the level of the 2nd costal cartilage and the sternal angle.

E.Pulmonary veins on both sides enter the left atrium, approximately at the level of T6–T7, well below the carina at T4–T5.

6.B. Obstruction of the pulmonary artery impedes blood flow into the

lung and causes pooling of blood in the right side of the heart. This causes acute dilation of the right atrium and right ventricle (Section 8.5).

A. Collapse of the lung is a symptom of a pneumothorax in which air enters the pleural cavity.

C.The pressure of a tension pneumothorax can cause the heart to shift to the opposite side.

D.Hypertrophy of the left ventricle is the result of a chronic condition that causes the myocardium to work harder in response to a fluid overload or an obstruction in the aortic outflow tract. A pulmonary embolism is usually an acute event that causes a fluid overload in the right ventricle but decreases venous return to the left ventricle.

E.A pulmonary embolism reduces the volume of blood entering the lung from the right side of the heart and therefore results in a diminished venous return to the left side of the heart. The right atria and ventricle may be acutely dilated, but the left atria and ventricle are not.

7.D. A malignancy involving the lateral breast would most likely

metastasize via the axillary nodes and then on to nodes around the clavicle and the ipsilateral lymphatic duct (Section 6.1).

A.Medial portions of the breast may drain to the parasternal nodes. These nodes also receive lymph from the anterior abdominal wall above the umbilicus, the deeper parts of the anterior portion of the thoracic wall, and the superior surface of the liver.

B.Nodes of the anterior abdominal wall receive lymph from the medial and inferior parts of the breast.

C.Although some lymph from the breast may drain to deep pectoral nodes posterior to the pectoralis muscle, most lymph from the breast drains to axillary nodes.

E.Lymphatic drainage from the medial breast may drain to the contralateral breast, but lymphatic drainage from the lateral breast most abundantly passes to the axillary nodes.

8.C. The apex lies at the level of the 5th intercostal space (Section 7.4).

A.The sternal angle is at the level of the 2nd costal cartilages.

B.The 3rd intercostal space is above the level of the heart.

heart.

C.The pulmonary plexus, an extension of the cardiac plexus, regulates the constriction and dilation of the pulmonary vessels and bronchial passages.

D.Intercostal nerves innervate structures of the thoracic and abdominal

walls.

E.Not applicable

12.B. The right lymphatic duct drains the lymph from the right side of the

thorax, right upper limb, and right side of the head and neck (Section 5.2). A. Lymph from all structures below the diaphragm drains to the left

lymphatic duct (thoracic duct).

C.The right side of the head and neck and right upper limb also drain to the right lymphatic duct.

D.The right side of the thorax also drains to the right lymphatic duct.

E.Lymph from the abdomen and both lower limbs drains to the thoracic duct (left lymphatic duct).

13.C. The cardiac notch is a deep indentation along the anterior border of

the superior lobe of the left lung (Section 8.2).

A.The lingula is a thin tongue of tissue that forms the lower border of the cardiac notch of the superior lobe of the left lung.

B.The left lung has only an oblique fissure that separates the superior and inferior lobes.

D.The right lung has three lobes supplied by three lobar bronchi.

E.The right lung is shorter and wider than the left lung due to the presence of the liver below the right side of the diaphragm.

14.A. The papillary muscles of the left ventricle attach to the tendinous

cords of the mitral valve leaflets and prevent them from prolapsing during ventricular systole (Section 7.4).

B.Trabeculae carneae are the thick muscular ridges of the ventricular

walls.

C.Pectinate muscles are found in the right and left auricles.

A.The ventricles contract during ventricular systole.

B.Blood from the right ventricle is ejected into the pulmonary trunk during ventricular systole.

C.The semilunar valves open during ventricular systole to allow blood to flow into the aorta and pulmonary trunk.

E.During the initial phase of ventricular systole, as ventricular pressure increases, the atrioventricular valves close.

24.B. Backflow through collateral channels would affect veins that are part

of the azygos and caval systems. Blood would eventually drain from the inferior vena cava to the right side of the heart, so the pulmonary and cardiac circulations would remain unaffected (Section 5.1).

A. External jugular veins drain into the azygos system via the internal jugular and brachiocephalic veins.

C.Reverse flow through the azygos vein into the posterior intercostal veins would cause dilation of these vessels.

D.As in all parts of the azygos system, the hemiazygos veins would dilate with increased flow.

E.The reverse flow in the subclavian vein into their tributaries, including the internal thoracic vein, would result in dilation of these vessels.

25.A. Postganglionic sympathetic nerves arise from the cervical and

thoracic sympathetic trunk as the superior, middle, and inferior cervical cardiac nerves (Sections 7.4 and 7.5).

B.Visceral sensory fibers that innervate both the baroreceptors and chemoreceptors of the heart travel with the parasympathetic fibers of the vagus nerve.

C.The cardiac branches of the vagus nerve contain only parasympathetic fibers.

D.The cardiac plexus regulates the heart rate, but the SA node initiates and coordinates the timing of the contraction of the heart’s chambers.

E.Pain sensation from the heart is carried by visceral sensory fibers that travel with sympathetic fibers to the T1–T5 spinal cord.

26.D. At birth, the oval foramen, a normal opening between the right and

left atria during fetal growth, closes, thus forcing blood into the pulmonary circulation. Failure to do so results in an opening known as an atrial septa defect (Section 7.6).

A.Because of the reduced pressure in the right atrium compared to that in the left atrium, an ASD results in a left-to right-shunt.

B.The increased flow into the right atrium results in an increased flow through the pulmonary trunk and pulmonary circulation.

C.Failure of the ductus arteriosus to constrict is known as a patent ductus arteriosus, a condition unrelated to an ASD.

E.There is no collateral circulation that compensates for the defect in the atrial septum.

27.E. Superiorly, the esophagus lies posterior to the trachea, inferiorly it

passes posterior to the left atrium (Section 7.7).

A.The esophageal plexus receives parasympathetic fibers from the vagus nerves as well as sympathetic innervation from thoracic splanchnic nerves.

B.The lower esophageal veins anastomose inferiorly with inferior phrenic veins, which are tributaries of the portal system that drains the gastrointestinal system. This is an important anastomosis between the caval and the portal venous systems.

A.The upper esophageal sphincter is created by the cricopharyngeus muscle in the neck.

A.The esophageal hiatus is formed by the crura of the diaphragm at the T10 vertebral level.

28.C. The costodiaphragmatic recess is a lower recess of the pleural cavity,

where the fluid is likely to accumulate (Section 8.1).

A.The pleural cavity is surrounded by a continuous single layer of pleura. Parietal pleura lines the outer wall of the cavity, where it is adjacent to the ribs, the diaphragm, and the mediastinum. It is continuous with the visceral pleura that covers the surface of the lung.

B.Each pleural cavity is a separate space. There is no communication

between the right and the left cavities.

D. A chest tube is always inserted above the rib to avoid damage to the intercostal neurovascular bundle that runs in the groove along the lower edge of the rib.

D. A “mediastinal shift” is a symptom of a tension pneumothorax but not of a pleural effusion.

29.B. Lobar consolidations such as from pneumonia, often cause the

“silhouette sign,” which results in a normal anatomic border being rendered invisible because the normally air-filled adjacent lung is filled with fluid. The right lower lobe abuts the right hemidiaphragm, thus obscuring it (Chapter 9).

A. The majority of the right heart border abuts the right middle lobe.

C.The left hemidiaphragm would still be outlined by air in the left lower lobe.

D.The right upper mediastinum is not contiguous with the right lower

lobe.

E.The right breast shadow would not be affected by an intrapulmonary process.

30.C. Ultrasound (echocardiogram) provides real-time evaluation of

cardiac anatomy and is excellent for assess-ment of function including wall motion, contractility, and cardiac output. Ultrasound can be done at the bedside, is relatively fast and inexpensive, and uses no ionizing radiation (Chapter 9).

A.Chest x-ray may show evidence of congestive heart failure but would not identify cardiac abnormalities directly.

B.Cardiac anatomy is well delineated on CT, but function is not.

D.ECG does not show motion abnormalities.

E.Dynamic cardiac MRI is an excellent tool for cardiac anatomic and functional assessment but would not be suitable for an unstable patient. Long scan times with the patient placed in the MRI machine are prohibitive in this setting.

Unit IV Abdomen

10The Abdominal Wall and Inguinal Region

10.1Regions and Planes of the Abdominal Wall

10.2Structure of the Abdominal Wall

10.1Muscles of the Anterolateral and Posterior Abdominal Walls

10.3Neurovasculature of the Abdominal Wall

10.4The Inguinal Region

10.2Structures and Relations of the Inguinal Canal

10.3Coverings of the Testis

10.1Clinical Correlation: Inguinal Hernia

10.2Clinical Correlation: Hydrocele

10.3Clinical Correlation: Varicocele

10.4Clinical Correlation: Testicular Torsion

10.5Clinical Correlation: Testicular Cancer

11The Peritoneal Cavity and Neurovasculature of the Abdomen

11.1 The Peritoneum and Peritoneal Cavity

11.1Organs of the Abdomen

11.2Boundaries of the Omental Bursa (Lesser Sac)

11.3Boundaries of the Omental Foramen

11.1Clinical Correlation: Peritoneal Infections and Abscesses

11.2Clinical Correlation: Peritonitis and Ascites

11.2Neurovasculature of the Abdomen

11.4Branches of the Abdominal Aorta

11.5Tributaries of the Inferior Vena Cava

11.6Tributaries of the Portal Vein

11.7Lymph Node Groups and Tributary Regions

11.8Autonomic Plexuses in the Abdomen and Pelvis

11.9Effects of the Autonomic Nervous System in the Abdomen and Pelvis

11.3Clinical Correlation: Abdominal Aortic Aneurysm

11.4Clinical Correlation: Mesenteric Ischemia

11.5Clinical Correlation: Anatomoses Between Arteries of the Large Intestine

11.6Clinical Correlation: Esophageal Varices

11.7Clinical Correlation: Portal Hypertension and Surgical Portocaval Shunts

12Abdominal Viscera

12.1 Organs of the Peritoneal Cavity— Gastrointestinal

Tract

12.1Developmental Correlation: Rotation of the Midgut Tube

12.2Developmental Correlation: Localization of Pain from Foregut, Midgut, and Hindgut Derivatives

12.3Clinical Correlation: Gastric Ulcers

12.4Clinical Correlation: Duodenal (Peptic) Ulcers

12.5Developmental Correlation: Ileal Diverticulum

12.6Clinical Correlation: Inflammatory Bowel Disease

12.7Clinical Correlation: Appendicitis and Variable Position of the Vermiform Appendix

12.8Clinical Correlation: Colon Carcinoma

12.2Organs of the Peritoneal Cavity—Accessory Organs of the Gastrointestinal Tract

12.1Hepatic Segments

12.9Clinical Correlation: Cirrhosis of the Liver

12.10Clinical Correlation: Gallstones

12.11Clinical Correlation: Cholecystectomy and the Cystohepatic Triangle (of Calot)

12.12Clinical Correlation: Implications of the Shared Emptying of the Bile Duct and Pancreatic Duct

12.13Clinical Correlation: Carcinoma of the Pancreas

12.14Clinical Correlation: Splenic Trauma and Splenectomy

12.15Developmental Correlation: Accessory Spleens

12.3Organs of the Retroperitoneum

12.16Clinical Correlation: Renal Vein Entrapment

12.17Developmental Correlation: Common Renal Anomalies

12.18Clinical Correlation: Calculi of the Kidney and Ureter

13 Clinical Imaging Basics of the Abdomen

13.1Suitability of Imaging Modalities for the Abdomen

Review Questions: Abdomen