RADIOLOGICAL

ANATOMY OF
THE GASTRO
INTESTINAL TRACT

prepared by Tizita A.
LEARNING OUTCOMES
 At the end of this chapter, the student will be able
to:-
 Identify anatomical structures seen on plain
abdominal radiograph.
 Describe the imaging techniques of GIT.
 Identify GI structures on barium examinations.
 Know the following structures on normal CT and
MRI of the abdomen.
o major organs and their accessories
o Abdominal blood vessels
o Bony structures and muscles of the
abdomen 2
3
INTRODUCTION
 Abdomen, in anatomy, the cavity of the
body between the chest and the pelvis in
humans and all other vertebrates.
 The abdominal cavity contains major
organs of the digestive, urinary, and
reproductive systems.
 Unlike the skull and the chest cavity, bones
do not surround the abdomen. This allows
the abdominal cavity to vary in size and
shape. 4
 CON’T …
 Three layers of muscles in front and on the sides
of the abdomen, together with the spine and back
muscles, form abdominal walls that support the
internal organs.
 Major organs of the abdomen include the
stomach, liver, small intestine and large intestine,
gallbladder, pancreas, spleen, kidneys, adrenal
glands, and bladder.
 In a female, the abdomen holds the uterus and
ovaries.
 In a male, it holds the prostate gland. A two-
layered membrane, the peritoneum, surrounds
the abdominal organs. 5
 Transversalis mu

Internal oblique

External oblique

Axial CT image at the level of the lower pole of the kidneys. Note the
rectus abdominis muscles joined in the midline, and laterally the three
layers
6
(external oblique, internal oblique and thin transversalis), whose
fascia can be
seen passing deep to the rectus muscle
7
DIVISIONS OF THE ABDOMINOPELVIC CAVITY

1. Quadrants of the abdomino pelvic cavity

 the intersection of the median sagittal plane
with the horizontal plane which passes
through the umbilicus divides the cavity into
its four quadrants:
a. Right upper quadrant
b. Left upper quadrant
c. Left lower quadrant
d. Right lower quadrant
8
9
REGIONS OF THE ABDOMINOPELVIC CAVITY
 boundaries separating the regions
1. The subcostal plane is a horizontal plane
which passes anteriorly through the lowest
points of the costal margins.
2. The transtubercular plane is a horizontal plane
which passes through the illiac tubercles of
the innominate bones.
3. The midclavicular planes are the vertical
planes which bisect the clavicles. 10
CON’T ….
 Themid clavicular planes divide the parts of
the abdominopelvic cavity above the
subcostal plane, b/n the subcostal and
transtubercular planes, and below the
transtubericular plane into 3 regions each.

1.The 3 regions above the subcostal plane are

a. the right hypochondriac region.
b. the epigastric region.
c. the left hypochondriac region. 11
CON’T ….
2. The 3 regions b/n the subcostal and
transtubericular planes are:
a. The right lumbar region
b. The paraumblical region
c. The left lumbar region
3.The 3 regions below the transtubericular
plane are:
a. the right illiac fossa (right inguinal region)
b. the hypogatric region
c. the left iliac fossa (left inguinal region)
12
13
CONVENTIONAL ABDOMINAL RADIOGRAPHS
A. General feature
1. The abdominal radiograph, or abdominal plain
film, is a composite of the image cast by the
lower thoracic vertebrae, lower ribs, lumbar
vertebrae, sacrum, coccyx, the upper parts of the
innominate bones, soft tissues of the abdominal
wall, and major viscera of the abdomen and
pelvis.
2. The radiograph may be taken with the patient
upright, lying supine or lying on the left or right14
side.
B. BONY STRUCTURES
The radiograph shows:-
 the two or three lowest thoracic vertebrae, the
entire of 11th & 12th ribs, portion of the next
one or two higher ribs.
 all the 5 Lumbar vertebrae and their structure
like the body, pedicle, spinus process,
transverse process and the superior and
inferior articular process.
 antro-posterior projection of the sacrum, the
coccyx, the upper parts of the innominate
bones, and part or all of the femoral heads. 15
16
SPECIAL PROCEDURES OF THE GIT
 What is GIT?
 The plain film can be very imformative in pts with
an acute abdomen, but for most other intestinal
disorders some form of contrast examination is
necessary.
 Barium sulphate is the best for the GIT.
 It produces excellent opacification, good coating of
the mucosa and completely inert.
 It is important to understand some basic terms
applicable to barium examinations of the GIT
which are often used in rather a loose way:
17
 CON’T . . .
 The wall of the bowel is never seen as such. What is
seen is the outline of the lumen and from this one
has to draw conclusions about the state of the wall.
 Usually the most reliable infn is obtained when the
bowel is fully distended.
 Mucosal folds are seen when the bowel is in a
contracted state so that the mucosa becomes
folded.
 When the bowel is distended these mucosal folds
disappear.
18
 CON’T . . .

 The normal mucosal pattern may be altered by

smoothing out or by abnormal irregularity.
 Filling defect is a term used to describe
something occupying space with in the bowel
there by preventing the normal filling of the
lumen with in the barium column.

19
BARIUM SWALLOW
The Oesophagus
 The barium swallow is the contrast examination
employed to visualize the oesophagus.
 Plan film does not normally show the oesophagus
unless it is very dilated.(e.g. achalasia), but they
are of use in demonstrating an opaque foreign
body such as a bone lodged in the oesophagus.
 The pt drinks barium and its passage down the
oesophagus is observed on a television monitor.

20
 CON’T . . .
 Filmsare taken in an oblique position to
project the oesophagus clear of the spine with
the oesophagus both full of barium, to show
the outline and empty to show the mucosal
pattern.

Note: In normal barium swallow, the

oesophagus when full of barium should have a
smooth outline. When empty and contracted,
barium normally lie in b/n folds of mucosa
which appears as 3 or 4 long, straight parallel 21
lines.
 Lt atrium

 The aortic arch gives clearly visible impression on the left side of the
oesophagus, which is more pronounced in the elderly as the aorta 22
becomes tortuous and elongated.
 Lt main bronchus

oesophagus

aorta

Azygous vein

CT image to demonstrate the relations of the oesophagus in the

mediastinum. Note the left main bronchus anteriorly and the aorta and
azygous
23
vein posteriorly. The pleura and lungs are the lateral relations
BARIUM MEAL
 The barium meal is the standard contrast
examination to examine the stomach and
duodenum.
 For this the pt drinks about 2oo ml of barium.
 Each part of the stomach and duodenum is
shown distended by barium and also
distended with air but coated with barium to
show the mucosal pattern.

24
STOMACH

25
 CON’T . . .
 It has 2 openings and 3 parts

 Cardiac orifice

it is the region of GEJ that prevent reflux of

stomach content in to the esophagus
 Pyloric orifice

at the level of gastro-duodenal junction

formed by circular muscle of the stomach

26
 CON’T . . .
 Two curvatures
Lesser curvature
 forms the rt boarder of the stomach and extends
from the cardiac orifice to the pylorus (forms
posterior wall upper stomach)
 The greater curvature-

 lies lower anteriorly to the left

 Much longer than the lesser curvature
 Extends from the left of the cardiac orifice over
the dome of the fundus and sweeps around and
to the right to the inferior part of the pylorus 27
IMAGING THROUGH BARIUM MEAL
 To provide better mucosal detail, the stomach
is distended by giving a gas producing agent
and an IV injection of a short-acting smooth
muscle relaxant.
 In normal barium meal, each part of the
stomach and duodenum should be checked to
ensure that no abnormal narrowing is present.
 A transit contraction wave must not be
confused with a constant pathological
narrowing. 28
 CON’T . . .

 The outline of the lesser curvature of the

stomach is smooth with no filling defects or
projections visible but the greater curve is
nearly always irregular due to prominent
mucosal folds.
 In the stomach the mucosa is thrown up into a
no of smooth folds and barium collects in the
troughs b/n the folds.
 There should be no effacement of the folds or
rounded collection of barium. 29
Lesser curvature
Gastric fundus

First part of
duodenum

rugae

Greater curvature

Stomach on barium meal, in supine position. The stomach mucosa is 30

coated with barium and distended with air. The posteriorly-lying fundus
contains dense barium. The first part of the duodenum is distended with air,
while the descending second part contains barium.
Left lobe
Lt lobe of liver

Gastric rugae

spleen

Axial CT image through the upper abdomen. The gastric rugae are well
demonstrated (compare with the barium meal image). Note the position of the
stomach, passing anteriorly below the left lobe of the liver, and on the
anteromedial side of the spleen. Fat lying between these structures appears
31
black on CT.
DUODENUM
 shortest widest and least mobile part of small
intestine
 C- shaped tube of ≈ 25cm long which curves
around the head of the pancreas and situated
in the epigastria and umbilical regions
 It extends form pylorus to duodenojejunal
junction at lig. treiz
 Is studied as a continuation of barium meal

32
33
STUDIES OF DUODENUM THROUGH
BARIUM MEAL
 The duodenal cap or bulb should be
approximately triangular in shape.
 It arises just beyond the short pyloric canal and
may be difficult to recognize if deformed due to
chronic ulceration.
 The duodenum forms a loop around the head
of the pancreas to reach the duodeno-jejunal
flexure.
34
 First part of duodenum Pyloric canal

Second part
of duodenum
Gastric antrum
Third part
of
duodenum
DUODENUM ON BARIUM MEAL. BARIUM COATS THE MUCOSA WITH ITS
CHARACTERISTIC MUCOSAL FOLDS, AND IT IS PARTLY DISTENDED WITH GAS. THE
SHORT
PYLORIC CANAL ACCOUNTS FOR THE CONSTRICTION BETWEEN THE GASTRIC
ANTRUM AND THE 35
WELL-DISTENDED FIRST PART OF THE DUODENUM.
 liver Portal vein
Pancreatic head

duodenum
Ascending jejunum
colon

The second, third, and fourth part of the duodenum are seen here on a
coronal reconstruction from an axial CT scan. Lying on the inside of the curve
formed by the duodenum is the pancreatic head and the portal vein passes
obliquely towards the liver. 36
BARIUM FOLLOWS THROUGH
The small intestine
 The standard contrast examination for the
small intestine is the barium small bowel
follow-through
 The patient drinks about 200-300 ml of barium
and its passage through the small intestine is
absorbed by taking films at regular intervals
until the barium reaches the colon.
 this can be a time consuming procedure and
usually takes 2-3 hours but transit time is very37
variable.
CON’T . . .

 In normal barium follow through, the normal

small intestine occupies the central and lower
abdomen usually framed by the colon
 the terminal portion of the ileum enters the
medial aspect of the caecum through the ileo
caecal value
 As the terminal ileum may be the first site of
disease this region is often fluoroscoped and
observed on a television monitor so that
peristalisis can be seen and films can be taken
with the terminal ileum unobscured by the other
loop of small intenstine. 38
THE BARIUM FORMS A CONTINOUS COLUMN
DEFINING THE DIAMETER OF THE SMALL BOWEL
WHICH IS NORMALLY NOT MORE THAN 25 MM.

39
 SMALL INTESTINE ON A CORONAL CT REFORMAT. NOTE THE SIMILARITY
WITH THE
SMALL BOWEL BARIUM STUDY. SOME OF THE MESENTERIC VESSELS PASSING
IN THE
MESENTERY (FAT WITHIN MESENTERY HERE IS BLACK) ARE WELL SHOWN

Superior
mesentric vein

Part of
superior
mesentric
artery jejunum

ilium

40
 liver

stomach

Transverse colon

Small intestines
Coronal reformat CT showing the
transverse colon. Note the stomach
and liver superiorly and small bowel
loops inferiorly. 41
BARIUM ENEMA
Large intestine
 the standard radiological examination of the
large intestine is the barium enema
 Barium is run into the colon under gravity
through a tube inserted into the rectum.
 There are two types of techniques of Barium
enema
 single contrast method and

 double contrast method

42
CON’T . . .
 In the single contrast method, the whole colon is
distended with barium.
 when a double contrast technique is used only
part of the colon is filled with barium and air is
then blown in to push the barium around the
colon with the result that the colon is distended
with air and the mucosa coated with barium.
 Prior bowel preparation by means of aperients or
washouts is most important to rid the colon of
faecal material, which might otherwise mask
small lesions and cause confusion by simulating
polyps.
43
44
 bladder sacrum

Seminal vesicles rectum

Prostate gland

Sagittal MRI image to show the rectum surrounded by fat (white on

this sequence) and small vessels anteriorly to the sacrum and posterior to the
seminal vesicles, bladder and prostate in this male patient. Note also the angle 45
at the ano-rectal junction.
C. ABDOMINOPELVIC VISCERA
1. Liver:
 the liver casts a large water-density
shadow in the right upper quadrant .
 The liver’s Postero inferior border may
sometimes be directly outlined by a fat-
density line.
 Fat line represents the extra peritoneal fat
layer of the posterior abdominal wall into
which the sharp postero inferior border of46
the liver is embedded.
 The liver is the largest solid organ and has complex
anatomy. It is very commonly the subject of imaging
investigations as it is affected by spread of tumors, as
well as having its own range of diseases.
 Ultrasound is usually the initial investigation (Fig.
5.15) and is useful to categorize liver disease,
suspected on blood tests, into disease affecting the
drainage of bile from the liver via the bile ducts, or
disease affecting the liver parenchyma itself.

47
 Anatomy

 The liver has a smooth anterior and superior

surface, which has a relatively straight lower
border from deep to the lower left costal
margin across the midline running inferiorly
and to the right deep to the right costal
margin to the lateral abdominal wall.

48
 The posterior and inferior surface is irregular and
borders numerous other intra abdominal structures.
 The liver is sometimes described as containing four

lobes: right, left, quadrate, and caudate.

 The smooth anterior surface is related to the inner

aspect of ribs and costal margins, the inferior

posterior surface is related to the esophagus and
stomach on the left, and on the right to the gall
bladder, the second part of the duodenum, the
hepatic flexure of the colon and the right kidney, and
adrenal gland.
49
 Thesite where the artery and portal vein
enter the liver, and the common hepatic
duct (draining bile) exits the liver, is
referred to as the hepatic hilum. These
structures then run in the hepato
duodenal ligament towards the
duodenum and pancreatic head.

50
 liver

Hepatic
veins
diaphragm Inferior vena ca

Ultrasound image through the liver superiorly. The hepatic veins are
seen as black tubular structures converging on the inferior vena cava. The heart 51
lies to the right of the image.
 CON’T ……
2. Kidneys
The lower halves of the kidneys are commonly
outlined by fat. The fat-density line that defines
each kidney’s margin represents the envelope
of perirenal fat that surroundes the kidney.

 The hilla of the rt and lt kidneys closely

approximate or overlap, respectively, the tip of
the right transverse process of the 2nd lumbar
vertebra and the tip of the lt transverse
52
process of the 1 lumbar vertebra.
st
CON’T …..

 Mental reconstruction of the upper halves of

the kidneys shows that, with the pt supine,
I. the rt kidney shadow is superimposed
upon the 12th rib
II. The lt kidney shadow is superimposed
upon the 11th and 12th rib.

53
 Spleen
 The spleen is a vascular organ located under
the left hemidiaphragm.
 In normal adults it measures around 12 cm in
maximum length and, like the liver, it has a
curved superior and lateral surface lying
against the diaphragm and overlain by the
lower ribs, and an inferomedial surface bearing
impressions from its anatomical relations.
54
 These are the kidney posteroinferiorly, the
splenic flexure of the colon anteriorly, and the
gastric fundus posteromedially.Centrally in its
inferior surface, the tail of the pancreas lies in
contact with it. The anterior surface has a
notch between the gastric and colic areas,
which can be easily palpable when the spleen
enlarges significantly.

55
 The spleen is easily seen with ultrasound in
most individuals, but in some cases CT or MRI
are used to assess perfusion and the vessels,
especially following trauma to the lower chest
when rib fractures may also be present. Rarely,
arteriography is used if there is disease
affecting the blood supply, and an injection
into the artery allows a delayed image to show
the venous drainage and the portal vein.
56
 Pancreas

 The pancreas is a non-encapsulated

retroperitoneal organ with exocrine and
endocrine function. It lies in the upper
abdomen and contains a variable amount of fat
between lobules of tissue. It tapers in size from
the pancreatic head to the right of the midline,
into a thinner neck, body, and tail, which run
obliquely to the left, superiorly, and posteriorly.

57
 The pancreas is variably seen with ultrasound
due to the presence of overlying gas. When
well seen this is a good modality for assessing
it; however, CT and MRI are more reliably able
to demonstrate it, as well as allowing
assessment of its perfusion.

58
 Themost clinically important recesses of
peritoneum

o Subphrenic spaces
o These are where it reflects onto the spleen

and liver (although a small area of the liver is

in direct contact with the right
hemidiaphragm, known as the bare area)

59
 Lesser sac
 This lies between the posterior surface of the
stomach and the anterior surface of the
pancreas and is a blind-ended sac,
communicating with the main cavity behind
the vessels running towards the liver hilum
from the second part of the duodenum.

60
 Sub hepatic space
 This is in free communication with the main
peritoneal cavity, but may be a site of local fluid
accumulation in gall bladder disease.
 Pelvic recesses
 The utero vesical pouch is the pelvic recess
between bladder and uterus in the female, and
the recto uterine pouch (also known as the
pouch of Douglas) lies posteriorly

61
 CON’T . . .

o Bladder and fundus of the uterus

 the bladder in a normal male casts an ovoid

water-density shadow in the suprapubic

region of the radiograph.
 the superior border of the bladder in a

normal female is outlined by a fat line and is

broadly intended by the fundes of the uterus
if the uterus is anteverted and anteflexed; the
fundus of the uterus may cast an ovoid water-
density shadow above the bladder shadow.
62
 The most important ligaments and omenta
 Greater omentum
 An apron-like fold of several layers of
peritoneum extending inferiorly from the
greater curve of the stomach and the
transverse colon, often for a considerable
distance. This frequently contains much fat
and is the first structure seen once the
abdominal cavity is opened at surgery.
63
 Lesser omentum
 These are the two layers from the inferior
surface of the liver to the lesser curve of the
stomach.
 Falciform ligament
 This contains the obliterated umbilical vein and
therefore runs from the umbilicus and anterior
abdominal wall to a fissure on the anterior
surface of the liver.

64
 Coronary ligaments
 These are the reflections of peritoneum onto
the liver.
 Transverse meso colon and small bowel
mesentery
 These broad mesenteries fan out towards their
respective parts of the gut and contain vessels
and variable fat

65
 bladder

Utero vesical pouch

uterus

Rectouterine pouch

rectum
Axial CT with contrast in peritoneal cavity to show the paravesical 66
spaces, the uterovesical pouch, and the rectouterine pouch (pouch of
Douglas).
 stomach

Head of
pancreas
liver

spleen
Rt posterior
subhepatic space

kidneys

Axial CT with contrast in peritoneal cavity to show the anterior right

subhepatic space, the posterior right subhepatic space (Morison’s 67
pouch), and
the inferior recess of the lesser sac.
 Transverse mesoco
Greater omentum jejunum
Root of small bow
mesentry and
liver duodeno jejunal
Hepato flexure
duodenal Lt paracolic gutt
ligament
Root of pancreas
transverse
mesocolon
Lt kidney

dodenum

Rt posterior
subhepatic
space Axial CT with contrast in peritoneal cavity to show the root of the
transverse mesocolon, the root of the small bowel mesentery, the greater
omentum, and the duodenocolic ligament 68
 Second part of duodenum

Gall bladder Pancreatic hea

Hepatic flexure of colon

Splenic vein

Rt lobe of liver Inferior vena c

Axial CT image through the right lobe of the liver at the level of the gall
bladder. At this level also lies much of the head and body of the pancreas and
the spleen. The splenic vein is well seen posterior to the tail of pancreas.
69
 liver

Portal vein Gall bladder

Inferior vena cava Common bile duct

Ultrasound image of the gall

bladder. Note the thin wall. It lies
beneath 70
the liver.
 RADIOLOGIC ANATOMY OF THE
GENITO URINARY TRACT
71
LEARNING OUTCOMES
 -At the
end of this chapter, the student
will be able to:-
 Identify anatomical structures seen on
plain abdominal radiograph.
 Describe the imaging techniques of GUT.
 Identify GU structures on IVP
 Identify the female reproductive rtact on
HSG.
72
 Know the following structures on normal
ultrasound,CT and MRI of the abdomen.
o major organs and their accessories

o Abdominal blood vessels

o Bony structures and muscles of the

abdomen

73
THE URINARY SYSTEM IS A COMPRISES OF
STRUCTURES; 2 KIDNEYS, 2 URETERS, 1
BLADDER AND 1 URETHERA.

74
KIDNEY
 are described as bean-shaped organs and ~ 9-12 cm
long, 4-5 cm wide, 3-4 cm thick
 located between the levels of T12-L3.
 Each kidney consists of an outer renal cortex and an
inner renal medulla.
 The renal cortex is a continuous band of pale tissue
that completely surrounds the renal medulla.
 Extensions of the renal cortex (the renal columns)
project into the inner aspect of the kidney, dividing
the renal medulla into discontinuous aggregations of
triangular-shaped tissue , the renal pyramids.
 On the medial margin of each kidney is the hilum of
kidney, which is a deep vertical slit through which
renal vessels, lymphatics, and nerves enter and leave
the substance of the kidney 75
76
 aorta
Rt adrenal gland stomach

pyramid
spleen

Lt adrenal gland

Upper pole of lt kidney

cortex

Lower pole of lt kidney

Rt psoas muscle Renal hilum
Fig. Coronal T1W MRI through the kidneys. The upper poles lie medial in relation 77
to the lower poles. The renal cortex has an intermediate signal intensity
and the medullary pyramids have a low signal intensity. The renal sinus fat is of
high signal intensity.
 pancreas

duodenum Lt renal vein

Inferior vena
cava

Rt renal vein Unopacified lt renal pe

Renal sinus fat Retro aortic lt Lt renal

aorta renal vein artery
Fig. CT scan at the cortico-medullary phase.Note the left renal 78
vein passing posteriorly to the aorta (retro-aortic). The renal pelves are
unopacified at this early stage following contrast administration.
Fig. MR venogram in the coronal plane demonstrates the right renal
vein draining directly into the IVC. There are two right renal arteries,
an anatomical variant.

Rt lobe of liver

Intra hepatic IVC

aorta
Rt renal vein

Rt renal arteries
Rt renal hilum

IVC
79
 Upper pole of rt kidney

Major calyx Upper pole

Renal pelvis minor calyces

Upper pole
major calyces
Middle pole minor
calyces
Minor calyx
Pevi Lower pole
ureteric minor calyces
junction
Tip of L3 transverse process Upper ureter

Fig. Intravenous urogram (compression view) demonstrating bilateral

80
smooth nephrograms and opacification of the renal collecting systems. The
ureters
pass anteriorly to the transverse processes of the lumbar vertebrae.
 Fig Intravenous urogram, full-length view of the
renal tract.

Rt nephrogram

Upper ureter

Rt pelvi ureteric
junction Sacro iliac joint

Mid ureter
Lower ureter

Position of vesico-
Narrowing of right ureteric junction
ureter where it
Bladder, distended
crosses the common
with contrast 81
iliac vessels at
pelvic brim
THE URETER
 The ureter is a tubular structure that receives
urine from the kidney and delivers it to the
urinary bladder.
 It is a long and muscular tube is about 25 cm
long in the abdomen and 5mm wide.
 The ureter is considered the continuation of
the renal pelvis. It provides peristaltic waves
to push the urine to the bladder
 The ureters enter the posterolateral aspect of
the urinary bladder at the ureterovesical
junction (UVJ). 82
 There are three normal narrowings of the ureters (where
stones most commonly impact):

 • at the pelvi-ureteric junction

 • as the ureter crosses the pelvic brim

 • at the vesico-ureteric junction.

83
INTRAVENOUS
CONTRAST ADMINISTRATION. AT THIS TIME, CONTRAST IS SEEN WITHIN THE
URETERS, WHICH
RUN DOWN ALONG THE MEDIAL ASPECT OF THE PSOAS MUSCLES, JUST
ANTERIOR TO THE
COMMON ILIAC VESSELS.

Rt
ureter
Lt
ureter
Rt
common
iliac
artery

Lt
Rt common
common iliac vein
Rt and
iliac vein lt psoas
muscle 84
Rt sacro s
iliac joint
FIG.CT OF THE ADRENAL GLANDS (ARTERIAL PHASE IMAGE). THE
ADRENAL GLANDS ARE OF SOFT TISSUE ATTENUATION,
SURROUNDED BY LOW ATTENUATION FAT.

Rt
adrenal
gland
Lt
adrenal
gland

85
 Anatomical variants of the renal tract

 Several normal anatomical variants are seen which

include:
 • persistent fetal lobulation

 • vascular anomalies

 • renal duplication (the most common type of variant)

 • incomplete or aberrant migration of the kidneys during

embryogenesis.

86
 Persistent fetal lobulation is a relatively common
finding. Embryologically, each kidney arises from
separate lobes that fuse together; in some cases, the
lobulation remains visible.
 Renal duplication has an incidence of 2% and is bilateral
in 20% of cases. In a classical duplex kidney, there are
upper and lower pole moieties. Each moiety has a
separate renal pelvis that drains into a separate ureter.
The two ureters may join part of the way down between
the kidney and bladder, forming a single distal ureter or,
less commonly, may be duplicated throughout their
length.

87
 Abnormalities of migration occur less commonly. A
pelvic kidney occurs in approximately 1 in 1500
deliveries. A horseshoe kidney (1 in 700 deliveries)
occurs if there is fusion of the lower poles of both
kidneys in the midline, with the upper poles lying on
either side of the vertebral column. Crossed fused
ectopia is where the lower pole of a normally sited
kidney fuses with the upper pole of the contralateral
kidney.

88
THE BLADDER
 This is a hollow muscle which functions to hold urine.
 The bladder is a very distensible organ that has folds
called rugae, except in the trigone where it is smooth.
 The trigone is the triangular shaped area in the base of
the bladder. which is formed by the three orifices: the
upper two ureteral orifices and the inferior urethral
orifice.
The urethra
 It is a canal which extends from the neck of the bladder
to the exterior.
 The female urethra is approximately 4 cm long and runs
down wards & forwards posterior to the symphysis pubis
& is embedded in the anterior wall of the vagina.
 The male urethra is approximately 20 cm long
89
prepared by coca fekadu
90
IMAGING
 Imaging the GUS through an x-ray is poor unless it
is supported by the other mechanisms.
 Imaging of the urinary system by injecting an
iodinated CM through a vein is called Urography.
 Excretory Urography, Retrograde pyelography,
Cystography, Urethrography, Voiding (Micturition
cystourethrography) are the difft procedures of
Urography that helps to study both the structure
and function of the US.
 From this all procedures we will focus on intra
venoous pyelogram.
91
IVU (EXCRETORY UROGRAPHY,)
 An intravenous pyelogram is performed by injecting
iodinated contrast material into a vein.
 As the contrast is excreted by the kidney, x-rays are
obtained.
 An IVP is a useful test to determine both anatomy and
function. It provides high resolution images so that the
renal pelvis, calyces and ureter are all well seen. One
can detect absence of function or perfusion to a kidney
when no contrast is excreted
 Usefulness - An IVP is useful in patients with
suspected Kidney stones, obstruction, hematuria,
hydronephrosis, or abdominal pain thought to be
related to the kidneys.
 What are its contraindications?
92
RADIOGRAPHIC SEQUENCES OF IVP
After the full injection of CM, radiographs are taken at specific
time intervals
1. PRE CONTRAST- helps to investigate exposure and presence of
radiopaque calculi
2. NEPHROGRAM -is the film taken immediately after the
injection in what is some times referred to as the nephron or
“ blush” phase. At this time, the contrast is seen in the
parenchyma of the kidney, but not yet in the calyces.

93
3. 5 MIN - This film is taken to determine if excretion is
symmetrical, to demonstrate suspected calculus in
the lower ureter .
4. 10 MIN- full view with compression in place
- the proximal ureter & pelvicalyceal system will be
seen distended with CM

94
5. 10-MIN "Release," "flush," or "X" film
- compression is released 10 minutes after injection
of CM and should demonstrate both ureters filled
with contrast.
6. 15-20 MIN - should use the AP, LPO and RPO
positioning and show the bladder well filled with
opacified urine.

95
7. POST MICTURAN - is taken after the patient has
voided and used to asses residual volume and to
provide further detail of the bladder
It helps to-
- Assess bladder emptying to demonstrate a return to
normal of the dilated upper ureters with relief of
bladder pressure, to aid the diagnosis of bladder
tumor and to confirm ureterovesical junction clculi

96
 The male genital tract

 The prostate gland

 The prostate gland is a pyramidal fibromuscular gland,
3.5 cm long, which surrounds the prostatic urethra from
the bladder base to the urogenital diaphragm.
 The ejaculatory ducts pierce the upper part of the
posterior surface of the prostate and open into the
prostatic urethra.

97
 Imaging The prostate gland can be imaged by trans
abdominal ultrasound but trans rectal ultrasound (TRUS)
is superior . The seminal vesicles are seen as hypo echoic
sacculated structures posterosuperior to the gland.
 On CT, the prostate is seen as a rounded homogeneous
soft tissue mass up to 3 cm in diameter.
 On MRI, the gland is of uniformly low signal on T1W
sequences, but T2W sequences demonstrate the zonal
anatomy.

98
 The seminal vesicles and ejaculatory ducts

 The seminal vesicles are two lobulated sacs, about 5 cm

long, which lie transversely behind the bladder and store
semen.

99
 Imaging

 On TRUS, the seminal vesicles appear as convoluted

tubules, which contain transsonic fluid. They are less
echogenic than the adjacent prostate.
 On CT, the seminal vesicles characteristically form a
“bow tie” appearance in the groove between the bladder
base and prostate .
 On T2W MR sequences the fluid-containing seminal
vesicles return a high signal.

100
 The testis, epididymis, spermatic cord and vas
deferens

 The testes are ovoid reproductive and endocrine organs

responsible for sperm production (Fig. 6.13). They lie
within the scrotum, an outpouching of the lower anterior
abdominal wall, suspended by the spermatic cord. Each
testis has an upper and lower pole and measures 4 cm by
2.5 cm by 3 cm. Each testis is surrounded by a tough
fibrous capsule, the tunica albuginea.

101
102
FIG.SAGITTAL MR IMAGES OF THE MALE PELVIS: T1
WEIGHTED
Rectus
abdominis

Urinary
bladder

Gluteus
acetabulum medius

Seminal Obturator
vesicles internus

rectum Gluteus 103

maximus
 FIG.SAGITTAL MR IMAGES OF THE MALE
PELVIS: (A) TL WEIGHTED AND (B) T2
WEIGHTED.
B
A

Seminal
vesicles
Urinary
bladder
rectum

prostate

104

Corpus Bulbospon Bulb of penis

cavernosum giosus m.
 Fig. Coronal T2 weighted MR images of the
male pelvis: (a) to (c), from
Iliac Bowel anterior to posterior. (Note chemical shift
arteries loops artifact from superior mid inferior
bladder walls, anterior.)

bladder

Perivesical
plexus
Corpus
cavernosum
Symphysis
pubis 105
Penile Bulb of
urethra penis
 Imaging
 At ultrasound, the testis has homogeneous medium level
echoes throughout . Coronal scans show the
mediastinum as a line of high echogenicity posteriorly.
 At CT, the spermatic cord can be seen within the
inguinal canal as a thin-walled, oval structure of fat
attenuation containing small structures representing the
vas and spermatic vessels .

106
 MR also provides excellent detail of the testis, having a
homogeneous medium to low signal intensity on T1W
images and high signal intensity on T2W images. The
fibrous tunica albuginea is of low signal on all
sequences. T2W images best depict the lower signal
intensity of the mediastinum testis.

107
 Fig. Transrectal ultrasound of the prostate
gland: longitudinal scan through the
bladder
midline demonstrating the line of urethra,

Fibro
muscular
stroma

urethra

Seminal
vesicle Inner Apex of
108
gland gland
 testis

Vas
difference

epididemis 109
 The penis

 The root of the penis is described in the section on the

perineum. The body of the penis comprises the two
corpora cavernosa dorsally, separated by an incomplete
fibrous septum, and the ventral corpus spongiosum
surrounding the urethra

110
 Imaging

 Ultrasound examination of the penis demonstrates low

level echoes within the corpora; the urethra is seen as a
circular anechoic structure. Color flow and pulsed wave
Doppler techniques allow visualization of the penile
arteries, which is important in the assessment of erectile
dysfunction.
 MRI may be used in the assessment of congental
anomalies of the penis.

111
 The female genital tract

 The labia majora

 The labia majora correspond to the scrotal sac of the
male. The vestibular bulbs lie on either side of the
vestibule into which the vagina and urethra open.

112
 The vagina
 The vagina is a muscular tube, approximately 8 cm long,
which extends up and back from the vulva to surround
the cervix of the uterus . The vagina has anterior and
posterior walls.
 Superiorly the vagina is supported by the levator ani, the
transverse cervical (cardinal), pubocervical, and
uterosacral ligaments, all attached to the vagina by
pelvic fascia. Inferiorly, support is provided by the
urogenital diaphragm and perineal body.

113
 The uterus

 The uterus is a pear-shaped muscular organ,

approximately 8 cm long, 5 cm across and 3 cm thick. It
has a fundus, body and cervix. The Fallopian tubes enter
each superolateral angle (the cornu). The body narrows
to a waist, the isthmus, below which lies the cervix,
embraced by the vagina.

114
 The ovaries

 These paired almond-shaped reproductive and endocrine

organs lie In the ovarian f’ossae, situated in the lateral
pelvic sidewalls. Their size and appearance varies with
age. Normal adult dimensions are 3 1.5 2 cm with a
weight of 2–8 g and each ovary contains a few mature
follicles, 70 000 immature follicles.

115
 Imaging

 The commonest method of investigation of the female

genital tract is with ultrasound. The full urinary bladder
provides an acoustic window through which the uterus
and ovaries may be visualized. In the adult the
myometrium is of uniform low echogenicity and the
endometrium is seen as a highly echogenic stripe on
longitudinal images.

116
On CT scans, the uterus is seen as a homogeneous soft
tissue mass dorsal to the bladder , but it is not usually
possible to recognize the ovaries unless they are enlarged
or contain cysts.
On T2W MRI sequences in the adult ,three distinct zones
are seen within the uterus: the endometrium, junctional
zone (JZ), and myometrium. The endometrium and uterine
cavity appear as a high signal stripe, bordered by the low
signal intensity JZ. This represents the inner myometrium
and, at the level of the internal os, it blends with the low
signal band of fibrous cervical stroma. The outer
myometrium is of intermediate signal intensity

117
 On T2W images the cervix has an inner cylinder of low
signal stroma continuous with the JZ. The appearances
do not change with the menstrual cycle or with oral
contraceptives.
 Normal ovaries are low to medium signal on T1W
images and higher signal on T2W images. Follicles stand
out as round hyperintense foci.
 The anatomy of the Fallopian tubes and fine mucosal
detail of the uterine cavity are best demonstrated by
hysterosalpingography (HSG)

118
 FIG.LONGITUDINAL TRANSABDOMINAL SCANS OF THE UTERUS: (A)
SECRETORY PHASE,
(B) PROLIFERATIVE PHASE. NOTE THE DIFFERENCE IN THICKNESS OF
ENDOMETRIUM.

Bladder
wall bladder

end
ome
triu
m

Fundus of
uterus myometrium Vagina with
Cervi uterus echogenic
stripe 119
FIG. TRANSVAGINAL ULTRASOUND OF THE OVARY, LONGITUDINAL
SECTION. THE DETAILED STRUCTURE OF THE OVARY AND FOLLICLES
CAN BE VISUALIZED.

Ovarian Internal Developing

stroma iliac 120
follicles
artery
 (A) SAGITTAL AND (B) PARASAGITTAL T2 WEIGHTED IMAGES OF THE FEMALE PELVIS,
DEMONSTRATING THE ZONAL ANATOMY OF THE UTERUS. SUBCUTANEOUS FAT
RECTUS ABDOMINIS L5/S1 INTERVERTEBRAL DISC FLUID-FILLED BOWEL MYOMETRIUM
JUNCTIONAL ZONE ENDOMETRIUM SYMPHYSIS PUBIS SUPERFICIAL TRANSVERSE
PERINEAL M. LEVATOR ANI

Cervical
canal

Fluid-filled
small bowel

Junctional
zone
endometri
um
myometrium

bladder 121

Bladder Anal
urethra vagina
neck canal
FIG. AXIAL CT OF THE FEMALE PELVIS AT A LEVEL
ABOVE THE ACETABULUM TO SHOW THE NORMAL
UTERUS AND OVARIES.

bladder

ovary

myometriu
122
m endometrium
FIG.Normal hysterosalpingogram (HSG).

Free spill
of contrast Isthmus of
outlining fallopian Ampulla of
cecum tube fallopian tube
and colon Uterine
fundus

Uterine
cornu
Cervical
canal

Free
intraperitoneal
123
spill
THE POSTERIOR ABDOMINAL WALL
 Bones and muscles of the posterior abdominal wall
 Psoas The paired psoas muscles arise from the roots of
the transverse processes, the vertebral bodies and
intervertebral discs of the 12th thoracic to 5th lumbar
vertebrae.It insert into the lesser trochanter of the femur.
 Iliacus This paired fan-shaped muscle arises from the
upper part of the iliac fossa.
 Quadratus lumborum This paired flat muscle arises
below from the iliolumbar ligament, adjoining iliac crest
and the tips of the transverse processes of the lower
lumbar vertebrae . Fibers run superiorly and medially to
insert into the lower border of the 12th rib.
124
 Transversus abdominis This is the deepest of the three
sheets of muscle that form the anterior abdominal wall.

125
MUSCLES OF THE PELVIS
 The pelvic floor
 MR, with its multiplanar capability, is particularly well
suited to demonstration of the pelvic floor . On T1-
weighted sequences (T1W) the high signal pelvic fat
provides excellent contrast with the low signal pelvic
musculature.
 The pelvic floor supports the pelvic viscera and is
composed of a funnel-shaped sling of muscles and fascia
pierced by the rectum, the urethra and, in the female, the
vagina.
126
 . The muscle groups are divided into:
(a) the pelvic diaphragm superiorly: levator ani and
coccygeus.
(b) the perineal muscles inferiorly. the urogenital
perineum anteriorly and the anal perineum posteriorly.

127
 The levator ani is the most important muscle of the
pelvic floor. It arises from the posterior aspect of the
pubis, the pelvic fascia over obturator internus and the
ischial spine.
 The levatores ani act as a muscular support and have a
sphincter action on the anorectal junction and vagina.
They are assisted by the small coccygeus muscles
posteriorly.

128
 The blood and lymph supply to the abdomen and
pelvis
 The abdominal aorta

 Many of the branches of the aorta may be demonstrated

with ultrasound and angiography (including CT, MR
angiography and direct angiography)
 The branches of the aorta include Three anterior arteries:

 • celiac artery (at T12/L1), dividing into the hepatic

artery and splenic arteries, supplying the liver, stomach,
pancreas,and spleen.
 (a) (b)

129
 • superior mesenteric artery (at L1), dividing into the
inferior pancreaticoduodenal artery, the jejunal and ileal
arteries, the middle colic,right colic, and ileocolic
arteries, supplying the mid-gut, to the midtransverse
colon.
 3 pairs of Lateral visceral arteries

 renal arteries
 adrenal arteries
 gonadal arteries

130
 5 pairs of lateral abdominal wall arteries
 1 pair of inferior phrenic artery
 4 pairs of lumbar arteries

131
 FIG. LONGITUDINAL ULTRASOUND SCAN
THROUGH THE AORTA, CELIAC, AND
SUPERIOR MESENTERIC ARTERIES.

Celiac liver
stomach
axis
Superior
mesentric
artery

aorta

vertebrae

132
 FIG. FLUSH AORTOGRAM, FRONTAL PROJECTION. NOTE THE LEFT
HEPATIC ARTERY ARISES FROM THE LEFT GASTRIC ARTERY (A
VARIANT SEEN IN 25% OF NORMAL INDIVIDUALS). THE PATIENT HAS
TWO LEFT RENAL ARTERIES.

Left hepatic artery

Intercostal artery
Hepatic artery
commonHepatic arter

Gastroduodenal
artery
Superior
mesenteric
Right renal artery
artery
Ileocolic artery Jejunal branches

Distal superior Lumbar arteries 133

mesenteric artery
 FIG. NORMAL PELVIC ARTERIOGRAM IN A
FEMALE PATIENT.

Median sacral Common iliac artery

artery
Inferior mesenteric artery
Internal iliac
artery

External iliac
artery Uterine
artery
Deep
Superior circumflex
gluteal iliac artery
artery
Common Obturator
femoral artery
artery 134