Urinary tract and Suprarenal glands pdf - Abdomen

Basic Anatomy

renal

contains the upper expanded end of the ureter, the

The renal sinus, which is the space within the hilum,

medullary rays.

striations known as

ing from the bases of the renal pyramids into the cortex are

Extend

renal columns.

between adjacent pyramids as the

medially (Fig. 5.64). The cortex extends into the medulla

projecting

renal papilla,

toward the cortex and its apex, the

each having its base oriented

renal pyramids,

a dozen

The medulla is composed of about

medulla.

brown inner

and a light

cortex

Each kidney has a dark brown outer

Renal Structure

inal wall.

kidneys and hold them in position on the posterior abdom

The perirenal fat, renal fascia, and pararenal fat support the

toneal fat.

is often in large quantity. It forms part of the retroperi

This lies external to the renal fascia and

Pararenal fat:

with the fascia transversalis.

kidneys and suprarenal glands; it is continuous laterally

sue that lies outside the perirenal fat and encloses the

This is a condensation of connective tis

Renal fascia:

This covers the fibrous capsule.

Perirenal fat:

closely applied to its outer surface.

This surrounds the kidney and is

Fibrous capsule:

The kidneys have the following coverings (Fig. 5.64):

Coverings

pathetic fibers also pass through the hilum.

branch of the renal artery (VAUA). Lymph vessels and sym

207

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diaphragm

rib 12

iliacus

transversus
abdominis

quadratus
lumborum

psoas

peritoneum

ascending colon

fascia
transversalis

capsule of kidney

perirenal fat

renal fascia

pararenal fat

anterior layer of lumbar fascia

quadratus lumborum

latissimus dorsi

middle layer of lumbar fascia

posterior layer of
lumbar fascia

erector spinae
muscle

spinous process

body of second
lumbar vertebra

psoas

lumbar artery

aorta

inferior vena cava

hilum of right kidney

coils of small
intestine

RIGHT

FIGURE 5.62

Retroperitoneal space.

verse section of the posterior abdominal wall showing structures in the retroperitoneal space as seen from below.

Trans

Structures present on the posterior abdominal wall behind the peritoneum.

Trauma to Organs in the Retroperitoneal Space

(the peritoneum forms the anterior boundary of the space; Fig.

Palpation of the anterior abdominal wall in the lumbar and iliac

regions may give rise to signs indicative of peritoneal irritation

5.62). In other words, tenderness and muscle spasm (rigidity)

may be present. Palpation of the back in the interval between the

12th rib and the vertebral column may reveal tenderness sugges-

tive of kidney disease.

Abdominal radiographs may reveal air in the extraperito-

neal tissues, indicating perforation of a viscus (e.g., ascending

or descending colon). CT scans can often accurately define the

extent of the injury to the extraperitoneal organs.

Abscess Formation

Infection originating in retroperitoneal organs, such as the kid-

neys, lymph nodes, and retrocecal appendix, may extend widely

into the retroperitoneal space.

Leaking Aortic Aneurysm

The blood may first be confined to the retroperitoneal space

before rupturing into the peritoneal cavity.

C L I N I C A L N O T E S

208

CHAPTER 5

artery and drains into the inferior vena cava.

The renal vein emerges from the hilum in front of the renal

Veins

lobular arteries.

arise as branches of the inter

ent glomerular arterioles

affer

that ascend in the cortex. The

interlobular arteries

pyramids (Fig. 5.65). The arcuate arteries give off several

which arch over the bases of the

arcuate arteries,

off the

of the cortex and the medulla, the interlobar arteries give

cortex on each side of the renal pyramid. At the junction

(Fig. 5.64). The interlobar arteries run toward the

arteries

interlobar

stance, each lobar artery gives off two or three

one for each renal pyramid. Before entering the renal sub

arise from each segmental artery,

Lobar arteries

kidney.

They are distributed to different segments or areas of the

that enter the hilum of the kidney.

segmental arteries

five

2nd lumbar vertebra. Each renal artery usually divides into

The renal artery arises from the aorta at the level of the

Arteries

layers of peritoneum. For details, see Figure 5.65.

with the kidneys, whereas others are separated by visceral

Note that many of the structures are directly in contact

ward and laterally (Fig. 5.34).

iliohypogastric, and ilioinguinal nerves (L1) run down

transversus abdominis muscles. The subcostal (T12),

and 12th ribs; and the psoas, quadratus lumborum, and

recess of the pleura; the 11th (the left kidney is higher)

The diaphragm; the costodiaphragmatic

Posteriorly:

num (Figs. 5.4 and 5.65)

ach, the pancreas, the left colic flexure, and coils of jeju

The suprarenal gland, the spleen, the stom

Anteriorly:

Important Relations, Left Kidney

(L1) run downward and laterally (Fig. 5.34).

subcostal (T12), iliohypogastric, and ilioinguinal nerves

tus lumborum, and transversus abdominis muscles. The

recess of the pleura; the 12th rib; and the psoas, quadra

The diaphragm; the costodiaphragmatic

Posteriorly:

part of the duodenum, and the right colic flexure (Figs.

The suprarenal gland, the liver, the second

Anteriorly:

Important Relations, Right Kidney

renal papilla.

mid, the

Each minor calyx is indented by the apex of the renal pyra

(Fig. 5.64).

minor calyces

which divides into two or three

each of

major calyces,

This divides into two or three

pelvis.

The Abdomen: Part II—The Abdominal Cavity

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5.4 and 5.65).

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Blood Supply

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right kidney

right ureter

psoas

rectum

external iliac artery

common iliac artery

aorta

renal pelvis

left kidney

suprarenal
gland

urinary bladder

FIGURE 5.63

Posterior abdominal wall showing the kidneys and the ureters in situ.

ureter is narrowed.

Arrows indicate three sites where the

Basic Anatomy

pressure of the glomeruli.

contractions of the muscle coat, assisted by the filtration

5.63). The urine is propelled along the ureter by peristaltic

kidneys to the posterior surface of the urinary bladder (Fig.

The two ureters are muscular tubes that extend from the

Location and Description

nal cord in the 10th, 11th, and 12th thoracic nerves.

ent fibers that travel through the renal plexus enter the spi

The nerve supply is the renal sympathetic plexus. The affer

Nerve Supply

origin of the renal artery.

Lymph drains to the lateral aortic lymph nodes around the

Lymph Drainage

209

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Ureter

perirenal fat

renal fascia

pararenal fat

medulla

medullary rays

pyramid

renal papilla

ureter

pelvis
of kidney

renal vessels

hilum

major calyx

minor
calyces

interlobar
artery
and vein

cortex

capsule

superior pole

lateral
border

anterior
surface

inferior pole

ureter

pelvis
of kidney

hilum

cortex

pyramid

collecting
tubule

loop of Henle

interlobular artery and vein

acuate artery and vein

vasa recta

pyramid

renal papilla

major calyx

capsule

glomerulus

interlobar artery and vein

minor calyx

medulla

FIGURE 5.64

sels within the kidney.

Section of the kidney showing the position of the nephrons and the arrangement of the blood ves

papillae, and calyces.

Right kidney, coronal section showing the cortex, medulla, pyramids, renal

Right kidney, anterior surface.

210

CHAPTER 5

The Abdomen: Part II—The Abdominal Cavity

right suprarenal gland

liver

colon

duodenum

left suprarenal gland

stomach

colon

small intestine

ureter

pancreas

spleen

small intestine

FIGURE 5.65

isceral peritoneum covering the kidneys has been left in position. Brown

Anterior relations of both kidneys. V

areas indicate where the kidney is in direct contact with the adjacent viscera.

Renal Mobility

Anastomosis of the branches of the internal iliac arteries on the

is anastomosed end to side to the external iliac vein (Fig. 5.67).

the distribution of the subcostal nerve (T12) to the flank and the

spinal cord at the level of T12. Pain is commonly referred along

nerve in the thorax and the sympathetic trunk. They enter the

and ascend to the spinal cord through the lowest splanchnic

fibers pass through the renal plexus around the renal artery

of the smooth muscle in the renal pelvis. The afferent nerve

pain can result from stretching of the kidney capsule or spasm

that may radiate downward into the lower abdomen. Renal

Renal pain varies from a dull ache to a severe pain in the flank

stab wounds or gunshot wounds and often involve other viscera.

eration of the organ. Penetrating injuries are usually caused by

undisturbed because the latter occupies a separate compart

abdominal musculature. Should the amount of perirenal fat be

and the lower pole may be palpated in the right lumbar region

abdominal pressure and by their connections with the perirenal

The kidneys are maintained in their normal position by intra-

fat and renal fascia. Each kidney moves slightly with respiration.

The right kidney lies at a slightly lower level than the left kidney,

at the end of deep inspiration in a person with poorly developed

reduced, the mobility of the kidney may become excessive and

produce symptoms of renal colic caused by kinking of the ure-

ter. Excessive mobility of the kidney leaves the suprarenal gland

ment in the renal fascia.

Kidney Trauma

The kidneys are well protected by the lower ribs, the lumbar

muscles, and the vertebral column. However, a severe blunt

injury applied to the abdomen may crush the kidney against the

last rib and the vertebral column. Depending on the severity of

the blow, the injury varies from a mild bruising to a complete lac-

Because 25% of the cardiac outflow passes through the kidneys,

renal injury can result in rapid blood loss. A summary of the inju-

ries to the kidneys is shown in Figure 5.66.

Kidney Tumors

Malignant tumors of the kidney have a strong tendency to spread

along the renal vein. The left renal vein receives the left testicular

vein in the male, and this may rarely become blocked, producing

left-sided varicocele (see page 132).

Renal Pain

anterior abdominal wall.

Transplanted Kidneys

The iliac fossa on the posterior abdominal wall is the usual site

chosen for transplantation of the kidney. The fossa is exposed

through an incision in the anterior abdominal wall just above the

inguinal ligament. The iliac fossa in front of the iliacus muscle is

approached retroperitoneally. The kidney is positioned and the

vascular anastomosis constructed. The renal artery is anasto-

mosed end to end to the internal iliac artery and the renal vein

two sides is sufficient so that the pelvic viscera on the side of

the renal arterial anastomosis are not at risk. Ureterocystostomy

is then performed by opening the bladder and providing a wide

entrance of the ureter through the bladder wall.

C L I N I C A L N O T E S

Basic Anatomy

of the small intestine (Fig. 5.27)

ticular or ovarian vessels, and the root of the mesentery

ileum, the right colic and ileocolic vessels, the right tes

The duodenum, the terminal part of the

Anteriorly:

Relations, Right Ureter

detail on pages 269 and 278.

the bladder. The pelvic course of the ureter is described in

ischial spine and turns forward to enter the lateral angle of

runs down the lateral wall of the pelvis to the region of the

in front of the sacroiliac joint (Fig. 5.63). The ureter then

vis by crossing the bifurcation of the common iliac artery

verse processes of the lumbar vertebrae. It enters the pel

psoas muscle, which separates it from the tips of the trans

behind the parietal peritoneum (adherent to it) on the

from the hilum of the kidney and runs vertically downward

receives the major calyces (Fig. 5.64). The ureter emerges

end of the ureter. It lies within the hilum of the kidney and

The renal pelvis is the funnel-shaped expanded upper

and where it pierces the bladder wall (Fig. 5.63).

the ureter, where it is kinked as it crosses the pelvic brim,

constrictions along its course: where the renal pelvis joins

resembles the esophagus (also 10 in. long) in having three

Each ureter measures about 10 in. (25 cm) long and

211

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FIGURE 5.66

Injuries to the kidney.

the renal pedicle involving the renal vessels and possibly the renal pelvis.

Injury to

tion of blood and urine into the perirenal and pararenal fat; blood also enters the calyces and appears in the urine.

Shattered kidney with extensive hemorrhage and extravasa

the perirenal and pararenal fat and into the peritoneal cavity.

the medulla. Note the escape of blood into the calyces and therefore the urine. Urine as well as blood may extravasate into

Tearing of the capsule, the cortex, and

Tearing of the capsule and cortex with bleeding occurring into the perirenal fat.

Contusion, with hemorrhage confined to the cortex beneath the intact fibrous capsule.

inferior vena cava

abdominal
aorta

common iliac

artery

internal iliac artery

external iliac artery

external iliac vein

transplanted
kidney

FIGURE 5.67

The transplanted kidney.

are surrounded by renal fascia (but are separated from the

organs that lie on the upper poles of the kidneys. They

The two suprarenal glands are yellowish retroperitoneal

1st and 2nd lumbar segments.

with the sympathetic nerves and enter the spinal cord in the

hypogastric plexuses (in the pelvis). Afferent fibers travel

The nerve supply is the renal, testicular (or ovarian), and

Nerve Supply

nodes.

The lymph drains to the lateral aortic nodes and the iliac

Lymph Drainage

arteries.

Venous blood drains into veins that correspond to the

Veins

artery; and in the pelvis, the superior vesical artery.

the renal artery; middle portion, the testicular or ovarian

The arterial supply to the ureter is as follows: upper end,

Arteries

the left ureter (Fig. 5.27).

The inferior mesenteric vein lies along the medial side of

tion of the left common iliac artery (Fig. 5.63)

from the lumbar transverse processes, and the bifurca

The left psoas muscle, which separates it

Posteriorly:

sels (Figs. 5.13 and 5.27)

the left colic vessels, and the left testicular or ovarian ves

The sigmoid colon and sigmoid mesocolon,

Anteriorly:

Relations, Left Ureter

tion of the right common iliac artery (Fig. 5.63)

from the lumbar transverse processes, and the bifurca

The right psoas muscle, which separates it

Posteriorly:

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Blood Supply

Suprarenal Glands

Location and Description

212

CHAPTER 5

The Abdomen: Part II—The Abdominal Cavity

Traumatic Ureteral Injuries

at a lower level and is often referred to the testis or the tip of the

strong peristaltic waves of contraction pass down the ureter in

spinal cord at segments T11 and 12 and L1 and 2. In renal colic,

processes of the lumbar vertebrae, crosses the region of the

essary. The ureter runs down in front of the tips of the transverse

stones may be arrested, namely, the pelviureteral junction,

into the retroperitoneal tissues on the posterior abdominal

the ureters are retroperitoneal in position, urine may escape

and, in a few individuals, penetrating stab wounds. Because

ureter are rare. Most injuries are caused by gunshot wounds

Because of its protected position and small size, injuries to the

wall.

Ureteric Stones

There are three sites of anatomic narrowing of the ureter where

the pelvic brim, and where the ureter enters the bladder. Most

stones, although radiopaque, are small enough to be impossible

to see definitely along the course of the ureter on plain radio-

graphic examination. An intravenous pyelogram is usually nec-

sacroiliac joint, swings out to the ischial spine, and then turns

medially to the bladder.

Renal Colic

The renal pelvis and the ureter send their afferent nerves into the

an attempt to pass the stone onward. The spasm of the smooth

muscle causes an agonizing colicky pain, which is referred to

the skin areas that are supplied by these segments of the spinal

cord, namely, the flank, loin, and groin.

When a stone enters the low part of the ureter, the pain is felt

penis in the male and the labium majus in the female. Sometimes,

ureteral pain is referred along the femoral branch of the genito-

femoral nerve (L1 and 2) so that pain is experienced in the front of

the thigh. The pain is often so severe that afferent pain impulses

spread within the central nervous system, giving rise to nausea.

C L I N I C A L N O T E S

Development of the Kidneys and Ureters

urinary stasis, which may result in infection and stone formation.

come to rest in the low lumbar region. Both ureters are kinked

trapped behind the inferior mesenteric artery so that the kidneys

ascend from the pelvis, but the interconnecting bridge becomes

mal ascent; it usually is found at the brim of the pelvis (Fig. 5.70).

aorta. The kidneys reach their final position opposite the 2nd

its blood supply from the pelvic continuation of the aorta, the

The developing kidney is initially a pelvic organ and receives

The metanephrogenic cap condenses around the ureteric bud

Three sets of structures in the urinary system appear, called

the pronephros, mesonephros, and metanephros. In the human,

the metanephros is responsible for the permanent kidney. The

metanephros develops from two sources: the ureteric bud from

the mesonephric duct and the metanephrogenic cap from the

intermediate cell mass of mesenchyme of the lower lumbar and

sacral regions.

Ureteric Bud
The ureteric bud arises as an outgrowth of the mesonephric duct

(Figs. 5.68 and 5.69). It forms the ureter, which dilates at its upper

end to form the pelvis of the ureter. The pelvis later gives off

branches that form the major calyces, and these in turn divide

and branch to form the minor calyces and the collecting tubules.

Metanephrogenic Cap

(Fig. 5.69) and forms the glomerular capsules, the proximal and
distal convoluted tubules, and the loops of Henle. The glomeru-

lar capsule becomes invaginated by a cluster of capillaries that

form the glomerulus. Each distal convoluted tubule formed from

the metanephrogenic cap tissue becomes joined to a collecting

tubule derived from the ureteric bud. The surface of the kidney

is lobulated at first, but after birth, this lobulation usually soon

disappears.

middle sacral artery. Later, the kidneys “ascend” up the poste-

rior abdominal wall. This so-called ascent is caused mainly by

the growth of the body in the lumbar and sacral regions and by

the straightening of its curvature. The ureter elongates as the

ascent continues.

The kidney is vascularized at successively higher levels by

successively higher lateral splanchnic arteries, branches of the

lumbar vertebra. Because of the large size of the right lobe of

the liver, the right kidney lies at a slightly lower level than the

left kidney.

Polycystic Kidney
A hereditary disease, polycystic kidneys can be transmitted by

either parent. It may be associated with congenital cysts of the

liver, pancreas, and lung. Both kidneys are enormously enlarged

and riddled with cysts. Polycystic kidney is thought to be caused

by a failure of union between the developing convoluted tubules

and collecting tubules. The accumulation of urine in the proximal

tubules results in the formation of retention cysts.

Pelvic Kidney
In pelvic kidney, the kidney is arrested in some part of its nor-

Such a kidney may present with no signs or symptoms and may

function normally. However, should an ectopic kidney become

inflamed, it may—because of its unusual position—give rise to

a mistaken diagnosis.

Horseshoe Kidney
When the caudal ends of both kidneys fuse as they develop, the

result is horseshoe kidney (Fig. 5.70). Both kidneys commence to

as they pass inferiorly over the bridge of renal tissue, producing

Surgical division of the bridge corrects the condition.

E M B R Y O L O G I C N O T E S

(continued)

Basic Anatomy

213

Unilateral Double Kidney

the urinary stasis, the ureter is prone to infection. Plastic surgery

absence of motility (Fig. 5.71). The cause is unknown. Because of

more liable to become infected or to be the seat of calculus for

chance on radiologic investigation of the urinary tract. They are

ureter crosses its fellow and may produce urinary obstruction. The

independently into the bladder (Fig. 5.71). In the latter case, one

may open through a common orifice into the bladder, or may open

In bifid ureter, the ureters may join in the lower third of their course,

outflow of urine, producing dilatation of the calyces and pelvis, a

Both kidneys may fuse together at their hila, and they usually

fuses with the lower pole of the normally placed kidney (Fig.

blood vessels. In unilateral double kidney, the ureteric bud on

The kidney on one side may be double, with separate ureters and

one side crosses the midline as it ascends, and its upper pole

5.70). Here again, angulation of the ureter may result in stasis of

the urine and may require surgical treatment.

Rosette Kidney

remain in the pelvis. The two kidneys together form a rosette

(Fig. 5.70). This is the result of the early fusion of the two ureteric

buds in the pelvis.

Supernumerary Renal Arteries
Supernumerary renal arteries are relatively common. They rep-

resent persistent fetal renal arteries, which grow in sequence

from the aorta to supply the kidney as it ascends from the pelvis.

Their occurrence is clinically important because a supernumer-

ary artery may cross the pelviureteral junction and obstruct the

condition known as hydronephrosis (Fig. 5.70).

Double Pelvis
Double pelvis of the ureter is usually unilateral (Fig. 5.71). The

upper pelvis is small and drains the upper group of calyces;

the larger lower pelvis drains the middle and lower groups of

calyces. The cause is a premature division of the ureteric bud

near its termination.

Bifid Ureter

cause of bifid ureter is a premature division of the ureteric bud.

Cases of double pelvis and double ureters may be found by

mation than a normal ureter.

Megaloureter
Megaloureter may be unilateral or bilateral and shows complete

is required to improve the rate of drainage.

Postcaval Ureter
The right ureter may ascend posterior to the inferior vena cava

and may be obstructed by it (Fig. 5.71). Surgical rerouting of the

ureter with reimplantation of the distal end into the bladder is the

treatment of choice.

pronephros

mesonephros

metanephros

lateral cell mass

intermediate cell mass

paraxial cell mass

glomerular
capsule

glomerulus

mesonephric
duct

gut

mesonephric tubule

stomach

pronephros

mesonephros

metanephros

mesonephric duct

rectum

anterior part of
the cloaca

FIGURE 5.68

The origins and positions of the pronephros, mesonephros, and metanephros.

on the diaphragm.

creas, the lesser sac, and the stomach and rests posteriorly

upper pole to the hilus (Fig. 5.4). It lies behind the pan

extends along the medial border of the left kidney from the

is crescentic in shape and

left suprarenal gland

The

diaphragm.

behind the inferior vena cava. It rests posteriorly on the

behind the right lobe of the liver and extends medially

caps the upper pole of the right kidney (Fig. 5.4). It lies

is pyramid shaped and

right suprarenal gland

The

norepinephrine.

epinephrine

the catecholamines

the sex organs. The medulla of the suprarenal glands secretes

which probably play a role in the prepubertal development of

sex hormones,

drates, fats, and proteins; and small amounts of

are concerned with the control of the metabolism of carbohy

which

glucocorticoids,

trol of fluid and electrolyte balance;

which are concerned with the con

mineral corticoids,

include

The cortex of the suprarenal glands secretes hormones that

medulla.

and a dark brown

cortex

kidneys by the perirenal fat). Each gland has a yellow

and

214

CHAPTER 5

The Abdomen: Part II—The Abdominal Cavity

anterior part of cloaca

rectum

mesonephric duct

ureteric bud

metanephrogenic cap

glomerulus

glomerular capsule

distal convoluted tubule

collecting tubules

Henle's loop

proximal convoluted tubule

pelvis of ureter

major calyx

ureter

minor calyx

FIGURE 5.69

The origin of the ureteric bud from the mesonephric duct and the formation of the major and minor calyces and

indicates the point of union between the collecting tubules and the convoluted tubules.

Arrow

the collecting tubules.

pelvic kidney

unilateral double kidney

rosette kidney (cake kidney)

aorta

horseshoe kidney

aberrant renal arteries

aberrant renal artery causing

urinary obstruction

inferior

mesenteric

FIGURE 5.70

Some common congenital anomalies of the kidney.

Basic Anatomy

medulla of the gland.

nic nerves supply the glands. Most of the nerves end in the

Preganglionic sympathetic fibers derived from the splanch

The lymph drains into the lateral aortic nodes.

Lymph Drainage

renal vein on the left.

drains into the inferior vena cava on the right and into the

A single vein emerges from the hilum of each gland and

Veins

inferior phrenic artery, aorta, and renal artery.

The arteries supplying each gland are three in number:

Arteries

215

Blood Supply

Nerve Supply

postcaval ureter

double pelvis

bifid ureter

ectopic ureteric orifice

megaloureter

FIGURE 5.71

Some common congenital anomalies of the ureter.

rior mesenteric artery, and inferior mesenteric artery

Three anterior visceral branches: the celiac artery, supe

Branches

Figure 5.73.

The surface markings of the aorta are shown in

azygos vein. On its left side lies the left sympathetic trunk.

rior vena cava, the cisterna chyli, and the beginning of the

mon iliac arteries (Fig. 5.72). On its right side lie the infe

of the 4th lumbar vertebra, it divides into the two com

surface of the bodies of the lumbar vertebrae. At the level

5.72). It descends behind the peritoneum on the anterior

of the diaphragm in front of the 12th thoracic vertebra (Fig.

The aorta enters the abdomen through the aortic opening

Location and Description

Wall

Arteries on the Posterior Abdominal

Aorta

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Cushing’s Syndrome

The suprarenal glands, together with the kidneys, are enclosed

close relationship of the suprarenal glands to the crura of the

ment; however, when interpreting CT scans, remember the

wall, few tumors of the suprarenal glands can be palpated.

Because of their position on the posterior abdominal

Adrenocortical insufficiency (Addison’s disease), which is

ism), and hypertension; if the syndrome occurs later in life, it may

Suprarenal cortical hyperplasia is the most common cause of

Cushing’s syndrome, the clinical manifestations of which include

moon-shaped face, truncal obesity, abnormal hairiness (hirsut-

result from an adenoma or carcinoma of the cortex.

Addison’s Disease

characterized clinically by increased pigmentation, muscular

weakness, weight loss, and hypotension, may be caused by

tuberculous destruction or bilateral atrophy of both cortices.

Pheochromocytoma

Pheochromocytoma, a tumor of the medulla, produces a parox-

ysmal or sustained hypertension. The symptoms and signs result

from the production of a large amount of catecholamines, which

are then poured into the bloodstream.

CT scans can be used to visualize the glandular enlarge-

diaphragm.

Surgical Significance of the Renal Fascia

within the renal fascia; the suprarenal glands, however, lie in a

separate compartment, which allows the two organs to be sepa-

rated easily at operation.

C L I N I C A L N O T E S