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Major abdominal landmarks
SECTION 3 VESSELS OF THE ABDOMEN
Major abdominal landmarks
24.1 USEFUL VISCERAL LANDMARKS Before locating the main abdominal pulses, we will look at a few key landmarks, invaluable in the manual approach to the abdomen (Fig. 24.1).
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fingerwidths above the umbilicus. This slightly variable point is more or less symmetrical with the duodenojejunal junction. Remember that the sphincter of Oddi is in the posterior medial wall of the duodenum. Manipulation of this sphincter affects both the hepatopancreatic ampulla and the major duodenal papilla (of Vater).
24.1.1 Gastroesophageal junction The area opposite T11 and inferior to the xiphoid process is an area we approach only in the seated position.
24.1.2 Gallbladder The gallbladder is located where the right mid-clavicular umbilical line meets the ninth costal cartilage. The gallbladder is only pal pable under the ribs and in the seated position.
24.1.3 Duodenojejunal junction The duodenojejunal junction is found on the left mid-clavicular umbilical line, three fingerwidths above the umbilicus. It is a dependable landmark for radiologists.
24.1.4 Sphincter of Oddi (hepatopancreatic ampulla) The sphincter of Oddi is situated on the right mid-clavicular umbilical line, three ©
2011 Elsevier Ltd
24.1.5 Pylorus The pylorus is usually found just to the right of the xiphoid umbilical line, a handswidth superior to the umbilicus. If the person is stressed or the pylorus is active, this sphincter could move more towards the right. Despite its mobility, it is easily palpated.
24.1.6 Ileocecal valve The ileocecal valve is located one-third of the way towards the umbilicus on the right umbilical–anterior superior iliac spine (ASIS) line.
24.1.7 McBurney’s point This point is two fingerwidths below the ileocecal valve. Note that it receives sensory innervation from the right 12th intercostal nerve, which anastomoses with the first lumbar nerve root.
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The practice of visceral vascular manipulation
Left mid-clavicular–umbilical line (LMCUL)
RMCUL
1 2 5 3
6 ASIS
4
2/3
1/3 7
8
2/3
1/3 1. Gastroesophageal junction (esophagocardio-tuberosity) 2. Gallbladder 3. Sphincter of Oddi (hepatopancreatic ampulla) 4. Duodenojejunal junction 5. Pylorus 6. Ileocecal valve 7. Ovary 8. Ovary
Fig. 24.1 Useful visceral landmarks.
24.1.8 The ovaries The ovaries are located one-third of the distance from the pubis on an ASIS–symphysis pubis line. Their location varies as a function of age and hormonal activity.
24.2 PRINCIPAL ABDOMINAL PULSES 24.2.1 The abdominal aorta
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The abdominal artery is found between the xiphoid process and the umbilicus, slightly left of the xiphoid–umbilical line (Fig. 24.2). The aortic pulse is easiest to feel either superior or inferior to the border of the
pancreas. Never place your fingers in an anteroposterior direction. Commence lateral of the artery to avoid picking up the beat of the superior mesenteric artery. Proceed towards the aorta, delicately and gradually. It is only by placing your fingers on either side of the aorta that you can feel an abdominal aortic aneurysm. Beware if you have the impression that the aorta is more than 4–5 cm wide. Its normal dimension is no more than 3 cm. Sometimes, for emotional reasons, the abdominal pulse is very powerful and distinct. This can worry the patient, even though it is a normal somatic reaction. One of the first signs of aortic aneurysm is lumbago or low back pain. If the slightest
Major abdominal landmarks
Inferior vena cava
24
Celiac trunk (superior border of L1)
Aorta
Superior mesenteric artery (superior border of L2)
Transpyloric plane
Renal artery (L2) Umbilicus Inferior mesenteric artery (L3) Transtubercular plane Aortic bifurcation (L4) Confluence of the common iliac veins (L5)
Pubic symphysis
Fig. 24.2 Landmarks for palpation of the abdominal aorta.
doubt arises, refer the patient to their physician. As a preliminary, compare the blood pressure of the upper and lower extremities. The systolic index normally sits at about 0.9 mmHg (see Chapter 6). Check that both femoral pulses are clearly perceptible. Some aneurysms are located higher up by the renal arteries. These are very difficult to feel manually.
24.2.2 Celiac trunk The celiac trunk lies opposite the lower part of the 12th vertebral body (T12), left of pylorus in the xiphoid hollow to the right of the ligament of Treitz (suspensory muscle of the duodenum). First locate the aortic pulse and then gently move your fingers very slightly to the right, near the lesser curvature of the stomach. The
189
The practice of visceral vascular manipulation
Left mid-clavicular umbilical line (MCUL)
MCUL
2
3
1
4 5 6
7
11
Bi-iliac line
8 9
10
1. Celiac trunk 2. Hepatic artery 3. Left gastric artery 4. Splenic artery 5. Superior mesenteric artery 6. Inferior mesenteric artery 7. Right colic artery 8. Common iliac artery 9. External iliac artery 10. Internal iliac artery 11. Left colic artery
Fig. 24.3 Abdominal pulses.
more pressure you apply, the greater your chances of mistaking the abdominal aorta for the celiac trunk. This confusion is common (Fig. 24.3). This pulse is an indicator of the vascular effects of our manipulations with regard to the liver, stomach, spleen, and pancreas.
24.2.3 Left gastric artery
190
The left gastric artery lies opposite T12, a little superior and to the left of the celiac trunk. It is sometimes confused with the splenic artery, and is not an easy pulse to detect.
24.2.4 Common hepatic artery The common hepatic artery is found to the right of a xiphoid–umbilical line, close to pylorus, inferior to the gallbladder. With practice this pulse is fairly easily perceived (Fig. 24.4).
24.2.5 Splenic artery The splenic artery is located inferior and to the left of the celiac trunk. Try to find the superior border of the pancreas by gliding your fingers beneath the xiphoid process. The superior border of the pancreas can be
Major abdominal landmarks
24
Fig. 24.4 Hepatic and splenic artery pulses.
mistaken for the transverse colon. This pulse is fairly easy to feel. Palpate for it to the left, beyond the abdominal aorta.
24.2.6 Superior mesenteric artery The superior mesenteric artery lies opposite L1, one or two fingerwidths inferior to the celiac trunk, slightly to the right of the duodenojejunal junction, close to the left midclavicular–umbilical line. Note that beneath the caudal border of the pancreas the superior mesenteric artery is more superficial than the inferior mesenteric artery. This pulse is a circulatory indicator of the right part of the colon. In addition to its supposed function of orienting the duodenojejunal flexure, another purpose of the ligament of Treitz is to surround and protect the superior mesenteric artery and the celiac trunk.
24.2.7 Inferior mesenteric artery The inferior mesenteric artery is about two to three fingerwidths superior and slightly to the left of the umbilicus, opposite L3 and sometimes L4. Often difficult to appreciate, this pulse serves as a vascular indicator of the left part of the colon and the small intestine.
24.2.8 Right colic artery The right colic artery is found just inside McBurney’s point.
24.2.9 Left colic artery The left colic artery is about three fingerwidths inferior to the umbilicus, and inferior and to the left of the inferior mesenteric pulse. Tip: When the pulse is difficult to perceive, there is a trick to make it stand out. Lightly compress the caudal part of the abdominal aorta. This has the momentary effect of increasing blood flux in the adjacent arterial branches.
24.2.10 Common iliac artery The common iliac arteries bifurcate from the aorta inferior to the umbilicus, between L4 and L5. These arteries diverge as they descend.
24.2.11 External iliac artery The external iliac artery separates from the common iliac artery at the level of the sacroiliac joint and descends along the lateral border of the sacrum.
191
The practice of visceral vascular manipulation
Right common carotid artery
Brachiocephalic trunk Right subclavian artery
Arch of aorta
Posterior intercostal artery Thoracic aorta
Diaphragm
Right inferior phrenic artery Celiac trunk Common hepatic artery Right renal artery Abdominal aorta Right ovarian and testicular artery Right lumbar artery Right common iliac artery
Fig. 24.5 Branches of the aorta.
192
Left gastric artery Left inferior phrenic artery Splenic artery Superior mesenteric artery Inferior mesenteric artery
Median sacral artery
Major abdominal landmarks
24
24.2.12 Internal iliac artery The internal iliac artery begins at the common iliac bifurcation, anterior to the sacroiliac joint, and descends along the lateral border of the anterior sacral foramina (Fig. 24.5).
24.2.13 In summary The most perceptible pulses are those of the: • aorta • hepatic artery • splenic artery • iliac arteries • superior mesenteric artery.
24.2.14 Manipulation of the abdominal aorta Place your fingers in the same position as when locating an aortic aneurysm. Surround the aorta with your thumbs and fingers to feel its right and left boundaries clearly (Fig. 24.6). The aorta is best perceived inferior to the caudal border of the pancreas. Begin by placing your fingers to the left of the xiphoid– umbilical line. Once you feel the aortic pulse, place your thumbs to the right of the xiphoid– umbilical line, to come up against the right side of the aorta. Elongate the aorta along its axis and perform several lateral stretches to stimulate
Fig. 24.6 Manipulation of the abdominal aorta.
the aortic mechanoreceptors. Complete the treatment with induction. Always think in three dimensions, picturing the aorta as a pipe that might have a fixation on any part of its contour.
193
Major abdominal landmarks
24.1 USEFUL VISCERAL LANDMARKS Before locating the main abdominal pulses, we will look at a few key landmarks, invaluable in the manual approach to the abdomen (Fig. 24.1).
24
fingerwidths above the umbilicus. This slightly variable point is more or less symmetrical with the duodenojejunal junction. Remember that the sphincter of Oddi is in the posterior medial wall of the duodenum. Manipulation of this sphincter affects both the hepatopancreatic ampulla and the major duodenal papilla (of Vater).
24.1.1 Gastroesophageal junction The area opposite T11 and inferior to the xiphoid process is an area we approach only in the seated position.
24.1.2 Gallbladder The gallbladder is located where the right mid-clavicular umbilical line meets the ninth costal cartilage. The gallbladder is only pal pable under the ribs and in the seated position.
24.1.3 Duodenojejunal junction The duodenojejunal junction is found on the left mid-clavicular umbilical line, three fingerwidths above the umbilicus. It is a dependable landmark for radiologists.
24.1.4 Sphincter of Oddi (hepatopancreatic ampulla) The sphincter of Oddi is situated on the right mid-clavicular umbilical line, three ©
2011 Elsevier Ltd
24.1.5 Pylorus The pylorus is usually found just to the right of the xiphoid umbilical line, a handswidth superior to the umbilicus. If the person is stressed or the pylorus is active, this sphincter could move more towards the right. Despite its mobility, it is easily palpated.
24.1.6 Ileocecal valve The ileocecal valve is located one-third of the way towards the umbilicus on the right umbilical–anterior superior iliac spine (ASIS) line.
24.1.7 McBurney’s point This point is two fingerwidths below the ileocecal valve. Note that it receives sensory innervation from the right 12th intercostal nerve, which anastomoses with the first lumbar nerve root.
187
The practice of visceral vascular manipulation
Left mid-clavicular–umbilical line (LMCUL)
RMCUL
1 2 5 3
6 ASIS
4
2/3
1/3 7
8
2/3
1/3 1. Gastroesophageal junction (esophagocardio-tuberosity) 2. Gallbladder 3. Sphincter of Oddi (hepatopancreatic ampulla) 4. Duodenojejunal junction 5. Pylorus 6. Ileocecal valve 7. Ovary 8. Ovary
Fig. 24.1 Useful visceral landmarks.
24.1.8 The ovaries The ovaries are located one-third of the distance from the pubis on an ASIS–symphysis pubis line. Their location varies as a function of age and hormonal activity.
24.2 PRINCIPAL ABDOMINAL PULSES 24.2.1 The abdominal aorta
188
The abdominal artery is found between the xiphoid process and the umbilicus, slightly left of the xiphoid–umbilical line (Fig. 24.2). The aortic pulse is easiest to feel either superior or inferior to the border of the
pancreas. Never place your fingers in an anteroposterior direction. Commence lateral of the artery to avoid picking up the beat of the superior mesenteric artery. Proceed towards the aorta, delicately and gradually. It is only by placing your fingers on either side of the aorta that you can feel an abdominal aortic aneurysm. Beware if you have the impression that the aorta is more than 4–5 cm wide. Its normal dimension is no more than 3 cm. Sometimes, for emotional reasons, the abdominal pulse is very powerful and distinct. This can worry the patient, even though it is a normal somatic reaction. One of the first signs of aortic aneurysm is lumbago or low back pain. If the slightest
Major abdominal landmarks
Inferior vena cava
24
Celiac trunk (superior border of L1)
Aorta
Superior mesenteric artery (superior border of L2)
Transpyloric plane
Renal artery (L2) Umbilicus Inferior mesenteric artery (L3) Transtubercular plane Aortic bifurcation (L4) Confluence of the common iliac veins (L5)
Pubic symphysis
Fig. 24.2 Landmarks for palpation of the abdominal aorta.
doubt arises, refer the patient to their physician. As a preliminary, compare the blood pressure of the upper and lower extremities. The systolic index normally sits at about 0.9 mmHg (see Chapter 6). Check that both femoral pulses are clearly perceptible. Some aneurysms are located higher up by the renal arteries. These are very difficult to feel manually.
24.2.2 Celiac trunk The celiac trunk lies opposite the lower part of the 12th vertebral body (T12), left of pylorus in the xiphoid hollow to the right of the ligament of Treitz (suspensory muscle of the duodenum). First locate the aortic pulse and then gently move your fingers very slightly to the right, near the lesser curvature of the stomach. The
189
The practice of visceral vascular manipulation
Left mid-clavicular umbilical line (MCUL)
MCUL
2
3
1
4 5 6
7
11
Bi-iliac line
8 9
10
1. Celiac trunk 2. Hepatic artery 3. Left gastric artery 4. Splenic artery 5. Superior mesenteric artery 6. Inferior mesenteric artery 7. Right colic artery 8. Common iliac artery 9. External iliac artery 10. Internal iliac artery 11. Left colic artery
Fig. 24.3 Abdominal pulses.
more pressure you apply, the greater your chances of mistaking the abdominal aorta for the celiac trunk. This confusion is common (Fig. 24.3). This pulse is an indicator of the vascular effects of our manipulations with regard to the liver, stomach, spleen, and pancreas.
24.2.3 Left gastric artery
190
The left gastric artery lies opposite T12, a little superior and to the left of the celiac trunk. It is sometimes confused with the splenic artery, and is not an easy pulse to detect.
24.2.4 Common hepatic artery The common hepatic artery is found to the right of a xiphoid–umbilical line, close to pylorus, inferior to the gallbladder. With practice this pulse is fairly easily perceived (Fig. 24.4).
24.2.5 Splenic artery The splenic artery is located inferior and to the left of the celiac trunk. Try to find the superior border of the pancreas by gliding your fingers beneath the xiphoid process. The superior border of the pancreas can be
Major abdominal landmarks
24
Fig. 24.4 Hepatic and splenic artery pulses.
mistaken for the transverse colon. This pulse is fairly easy to feel. Palpate for it to the left, beyond the abdominal aorta.
24.2.6 Superior mesenteric artery The superior mesenteric artery lies opposite L1, one or two fingerwidths inferior to the celiac trunk, slightly to the right of the duodenojejunal junction, close to the left midclavicular–umbilical line. Note that beneath the caudal border of the pancreas the superior mesenteric artery is more superficial than the inferior mesenteric artery. This pulse is a circulatory indicator of the right part of the colon. In addition to its supposed function of orienting the duodenojejunal flexure, another purpose of the ligament of Treitz is to surround and protect the superior mesenteric artery and the celiac trunk.
24.2.7 Inferior mesenteric artery The inferior mesenteric artery is about two to three fingerwidths superior and slightly to the left of the umbilicus, opposite L3 and sometimes L4. Often difficult to appreciate, this pulse serves as a vascular indicator of the left part of the colon and the small intestine.
24.2.8 Right colic artery The right colic artery is found just inside McBurney’s point.
24.2.9 Left colic artery The left colic artery is about three fingerwidths inferior to the umbilicus, and inferior and to the left of the inferior mesenteric pulse. Tip: When the pulse is difficult to perceive, there is a trick to make it stand out. Lightly compress the caudal part of the abdominal aorta. This has the momentary effect of increasing blood flux in the adjacent arterial branches.
24.2.10 Common iliac artery The common iliac arteries bifurcate from the aorta inferior to the umbilicus, between L4 and L5. These arteries diverge as they descend.
24.2.11 External iliac artery The external iliac artery separates from the common iliac artery at the level of the sacroiliac joint and descends along the lateral border of the sacrum.
191
The practice of visceral vascular manipulation
Right common carotid artery
Brachiocephalic trunk Right subclavian artery
Arch of aorta
Posterior intercostal artery Thoracic aorta
Diaphragm
Right inferior phrenic artery Celiac trunk Common hepatic artery Right renal artery Abdominal aorta Right ovarian and testicular artery Right lumbar artery Right common iliac artery
Fig. 24.5 Branches of the aorta.
192
Left gastric artery Left inferior phrenic artery Splenic artery Superior mesenteric artery Inferior mesenteric artery
Median sacral artery
Major abdominal landmarks
24
24.2.12 Internal iliac artery The internal iliac artery begins at the common iliac bifurcation, anterior to the sacroiliac joint, and descends along the lateral border of the anterior sacral foramina (Fig. 24.5).
24.2.13 In summary The most perceptible pulses are those of the: • aorta • hepatic artery • splenic artery • iliac arteries • superior mesenteric artery.
24.2.14 Manipulation of the abdominal aorta Place your fingers in the same position as when locating an aortic aneurysm. Surround the aorta with your thumbs and fingers to feel its right and left boundaries clearly (Fig. 24.6). The aorta is best perceived inferior to the caudal border of the pancreas. Begin by placing your fingers to the left of the xiphoid– umbilical line. Once you feel the aortic pulse, place your thumbs to the right of the xiphoid– umbilical line, to come up against the right side of the aorta. Elongate the aorta along its axis and perform several lateral stretches to stimulate
Fig. 24.6 Manipulation of the abdominal aorta.
the aortic mechanoreceptors. Complete the treatment with induction. Always think in three dimensions, picturing the aorta as a pipe that might have a fixation on any part of its contour.
193