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Anatomy of Endometriosis and Adenomyosis

Anatomy of Endometriosis and Adenomyosis

Ashley Davidoff MD

Endometriosis is a disease  caused by misplaced or ectopic endometrial tissues located beyond the uterus most commonly resulting in pain at the time of menstruation. The ectopic endometrial tissue is controlled by the oestrogen and progesterone cycles.  The ectopic tissue  bleeds at the time of menstruation and causes pain.  Since neither the ectopic endometrium nor the blood can be extruded from the body,  recurrent bleeding eventually results in  scar formation which may cause non cyclical chronic pain.


Chronic Pelvic Pain is Unbearable

Endometriosis and adenomyosis cause horrific pain.  For some the pain  may only occur during the menstrual cycle but for others it can  be constant, day and night, excruciating in nature, invading every aspect of normal daily life .  Pain is a common symptom defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.” This statement characterizes the evolved nature of pain as a warning system and feedback mechanism that influences how we adapt to our environment. However, pain at its core it is  suffering and its persistence can be insufferable for people and diagnostically problematic to those who care for  the sick, as well being  a burdensome cost to society.  

The cause of endometriosis is not truly known.  Long standing hypotheses include spillage of endometrial tissue into the peritoneal cavity via the fallopian tubes or transvascular spread to remote areas .  More recent hypotheses include spillage of stem cells during embryonic development, metaplasia of coelomic epithelium, abnormal vasculogenesis, and environmental factors

Endometriosis occurs in 5-10% of women. When endometrial tissue is located outside of the uterus, it can cause pelvic and back pain, as well as pain with sexual intercourse (dyspareunia). It is also associated with infertility by  distorting  anatomy, (for example Fallopian tube adhesions) , or physiological changes that result in altered immune and hormonal environments with consequent impairment of ovum implantation .

From a structural standpoint, endometriosis most commonly affects the ovaries and Fallopian tubes but can affect any of the pelvic organs including the peritoneal cavity,  bladder, ureters, bowel, broad ligaments, uterosacral ligaments, cul de sac  and even the nerves. Implants range in size from small microscopic implants, but are are commonly about 1-2cm.

genitourinary tract, genitourinary system, uterus, woman, Art in Anatomy, Ashley Davidoff MD

The Intraperitoneal Aspect of the Pelvic Cavity

The peritoneal cavity or coelomic cavity is a large cell lined  space via which almost all the abdominal organs are connected .  It may be considered the suburban space around which the houses of the town are positioned.  The ova are released from the ovary into the peritoneal space, but they are quickly directed by the fimbriae into the Fallopian tubes.


Endometriomas are large hemorrhagic cysts that occur on the ovary and  may be up to to 20cms in size.  They are usually  round in shape, much like a large blood blister after they have bled.  The nodules can be red-blue to yellow-brown in color, (chocolate cysts) and occur just below the serosa of the organ to which they are attached.  As the lesions undergo recurrent hemorrhage, they can become associated with fibrosis as stated.  Rarely they may be associated with malignant transformation.(<1%).


MRI of an Endometrioma

A T2 weighted image of the pelvis (left) with an overlay of colors on the right shows a 10cms endometrioma (overlaid in red) with internal debris better appreciated in the left image.  The large ‘chocolate cyst” lies above the uterus (pink) and compresses the bladder (yellow)

MRI has a 90% specificity and 90% sensitivity for endometriomas.  On T1 weighted images the endometriomas may be bright and do not lose signal on fat suppressed sequences.  Heterogeneity is due to the presence of degraded products.  Septations may also be present.  Both these features are present in the above image . On T2 weighted sequences “shading”   is caused by repeated episodes of bleeding reflecting  hemorrhagic contents in various stages of degradation.  The wall of the endometrioma may contain hemosiderin which leads to a loss of signal on the T2 weighted sequence.

Unusual Locations

Endometriosis is rarely can be more far reaching and may involve the kidneys, brain, diaphragm, and pleura.  When it involves the diaphragm or pleura, shoulder pain may be associated with the entity.  Pleural disease can cause life threatening catamenial pneumothorax induced by the menstrual cycle .

urinary bladder, bladder, genitourinary tract, genitourinary system, woman, Art in Anatomy, Ashley Davidoff MD, endometriosis, CT scan

Endometriosis on the Bladder

A CT scan through the pelvis (left) shows an endometriotic implant  on the bladder wall.  The image on the right shows the endometriotic implant overlaid in maroon on the right anterior surface of the bladder (yellow overlay).  The implant measures about 1.1cms.  The fornix of the vagina is overlaid in pink.  Most peritoneal implants are too small to be visualized by conventional imaging and require laparoscopic evaluation for diagnosis.


Endometriosis in the Skin of the Groin

A CT scan through the pelvis (left) shows an endometriotic implant  in the subcutaneous region of the skin in the left inguinal region (image a, circled).  The region is magnified in image b and the endometriotic deposit is labelled “e” with maroon overlay.  An ultrasound of the left groin(c)  shows the implanted endometriosis (black) medial to the artery (red) and vein (blue).  In image d, the region of endometriosis (e) is overlaid in maroon.

Clinically the entity more commonly occurs in nulliparous women and the degree of pain is variable.  As endometrial tissue, it is responsive to the cyclical hormonal fluxes, and thus may  bleed in response to hormonal changes. Pain commonly occurs at the time of the menses.  The volume of ectopic endometrial tissue does not correlate with the severity of the pain, but rather with the depth of infiltration into the tissue, or the degree of distension that might occur.  The pain is usually recurring and commonly but not necessarily occurs during the menses. With induction of fibrosis, pain may be caused by other structural changes that are unrelated to the menses.

Diagnosis is suspected clinically and confirmed by ultrasound. When a woman in the reproductive phase of her life presents with pain, the imaging study of choice is a pelvic ultrasound.  Hemorrhage into evolving follicles is a common cause of pelvic pain and these could be also quite large.  This entity has to be differentiated from an endometrioma that has a characteristic ultrasonographic appearance shown below

ovary, ovaries, genitourinary tract, genitourinary system, woman, Art in Anatomy, Ashley Davidoff MD, endometriosis, endometrioma, chocolate cyst, ultrasound,

Endometrioma on Ultrasound

A transvaginal ultrasound of the adnexa shows an endometrioma with characteristic low level echoes reminiscent of the texture of the testes on ultrasound.  The image on the right is an overlay in a biloculate cyst.  Some through transmission is present. 


Chocolate Cyst  on US and CT

A 25 year old female presents with painful menses. The ultrasound shows a cystic mass in the pelvis with a large amount of debris in the cystic cavity consistent with a chocolate cyst (a).  Image b is an overlay showing the fine granular appearance of the sediment.  When the patient is in decubitus position (c) , the sediment settles to the dependant portions with a clear supernatant.  Image (d) is a CT scan of the same patient, showing a non specific cyst in the left ovary. In this instance CT has little diagnostic value in the characterization of the abnormality other than localising a large cyst, and excluding other causes for the pain.  Although the appearance on the ultrasound is consistent with endometriosis, a hemorrhagic cysts is possible and the distinction may only be made pathologically.

When a female patient in the reproductive age presents with pelvic pain and ultrasound or  MRI are negative,  laparoscopy is indicated both for diagnosis of small or flat lesions lesions  as well as for therapy.    Microscopic deposits which may cause symptoms will not be identified by imaging techniques and will only be seen laparoscopically.  The reluctance to undergo an “invasive” procedure is understandable, but delaying or worse still missing the diagnosis will cause unnecessary long term suffering.



Laparoscopic image of small blood blisters characteristic of endometriotic lesions of the pelvic wall in the peritoneum 

Courtesy Author Hic et nunc.  Acknowledged work is in public domain


Blood Blisters in the Cul De Sac and Sacrouterine Ligament

Laparoscopic image of endometriotic lesions in the pouch of Douglas and on the sacrouterine ligament.
Courtesy Author Hic et nunc.  Acknowledged work is in public domain

Treatment options depend on patient preference, including whether fertility is desired, but include both medical and surgical options.  Medical management frequently involves suppression of regular menses/hormones .  Surgical options include removal of implants  or surgical induction of menopause (i.e. oophorectomy and hysterectomy).


Adenomyosis is a disease of the myometrium caused by misplaced or ectopic endometrium in the myometrium resulting in myometrial hyperplasia and smooth muscle hypertrophy clinically manifesting as pelvic pain and uterine enlargement.   The entity can be focal or diffuse

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Enlarged and Painful Uterus of Adenomyosis

The exact cause of the displacement is not known but it is presumed that a breach in the endometrial myometrial barrier enables a small amount of endometrium to translocate and remain viable.  There is a high prevalence rate with about 40% of hysterectomy specimens displaying the entity.

The junctional zone of the uterus is the epicenter of the structural abnormality The junctional zone is subendometrial smooth muscle that is more compacted, and contains less water in comparison to the outer myometrium. (McCarthy)  The junctional zone is functionally different from the outer myometrium.

junctional zone, genitourinary tract, genitourinary system, uterus, woman, Art in Anatomy, Ashley Davidoff MD, adenomyosis, MRI

The Normal Junctional Zone on MRI

The normal sagittal view of the uterus is a T2 weighted MRI from a 16 year old female with pelvic pain. The myometrium consists of an outer part (dark red) and an inner more homogeneous part called the junctional zone (light maroon)  Since a T2 weighted image is sensitive to water, we understand from this image that the outer part has greater white signal and therefore contains more  water, and likely more vascularity. The junctional zone (light maroon)  on the contrary has less water and therefore is blacker.  The endometrial canal, cervical canal and vaginal cavity are outlined in yellow and the vaginal wall is overlaid in pink.

 Clinically the patient presents with pelvic pain, dysmenorrhea, menorrhagia and may contribute to infertility.  On exam the uterus is enlarged.

The diagnosis is best made by MRI which shows a thickened junctional zone (>10-12mms) s.  The deposition of acute blood, blood degradation products such as iron, or the presence of fluid filled microglandular deposits in the junctional zone make the MRI findings highly specific for the diagnosis.

Treatment options include pain management with NSAIDS, and hormonal manipulation.  Surgery and hysterectomy is the only current option for cure.



Adenomyosis with a Thickened Junctional Zone and Enlarged Uterus 

A  T2 weighted MRI (a) shows fluid in the endometrial cavity, surrounded by a thick dark layer of the junctional zone, and then surrounded with a slightly brighter outer myometrium.  The  color overlay in b, shows a small amount of fluid in the endometrial cavity (yellow) surrounded by a thickened subendometrial  junctional zone (light maroon) measuring up to 13 mms characteristic of adenomyosis. The outer myometrium (dark maroon) is normal

The junctional zone thickening is key to the diagnosis of adenomyosis on MRI.  The  junctional zone normally measures 8mm or less.  Between 8-11mm it is considered  indeterminate, and when it measures 12mm or  greater, it is considered diagnostic for the disease.  The junctional zone may thicken normally in the first few days of the menstrual cycle or during myometrial contractions.  Cystic changes in the junctional zone are also characteristic and relatively common and represent small blood blisters.  Linear striations radiating from endometrium to myometrium are also seen but these are not as easy to discern.  These probably reflect a breech in the endometrium reflecting microscopic tears extending into the myometrium.


uterus-0030-small sign-catalog

The Normal Junctional Zone on Ultrasound

A transvaginal ultrasound of a premenstrual woman in the sagittal plane (left) reveals a normal view of the uterus with characteristic premenstrual appearance. Image on the right  is an overlay showing the components of the endometrium and subendometrial layers.  The stripe is almost homogeneously echogenic and thick but also shows a hypoechoic halo of the junctional zone or inner myometrium. (salmon) The homogeneous stripe is made up from two histological layers (barely distinguished by this ultrasound)– the inner stratum functionalis (deep orange) that will shed once the spiral arteries vasoconstrict, and the outer stratum basalis (deep yellow) that will not shed, and will be the basis for regenerating the endometrium in the next cycle. The next layer as stated above is the compact myometrium – the junctional zone (aka inner myometrium) , and is followed by the thicker outer myometrium (maroon).

The junctional zone is hypoechoic  due to decreased water content, and is formed by smooth muscle cells that are tightly packed.  The extracellular matrix and water content are sparse.  It usually measures less than 8mm.

junctional zone, genitourinary tract, genitourinary system, uterus, woman, Art in Anatomy, Ashley Davidoff MD, adenomyosis, ultrasound

Adenomyosis with Ectopic Deposits in the Junctional Zone

Two echogenic nodules (overlaid in green in image on the right) are present  in the subendometrial layer, (junctional zone) in a woman with menorrhagia. The nodules are in close proximity and  have appositional relationships with the endometrial stripe (yellow overlay). They distort the endometrial lining. These findings likely  account for the menorrhagia.  Included in the differential diagnosis are dystrophic changes in prior foci of adenomyosis and submucosal fibroids.  An MRI would assist to characterize  the lesions in the subendometrial layer.

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Art, Anatomy, and Wisdom of the Kidneys

Art Anatomy and Wisdom of the Kidneys 

March is NATIONAL KIDNEY MONTH and March 14 2016 is WORLD KIDNEY DAY – dedicated to my teachers Dr Edward Smith and the late Dr Harry Mellins and  …. so here goes.

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The Kidneys and Their Golden Adrenals

serve to preserve our precious water. The kidneys face each other (eye to eye) in the body as trusting life long partners. When the going gets tough for the one, the other is there to fill the void. How much more can one ask of a life long partner?

The Nephron –  The Little People and the Backbone of the Kidney

nephron, proximal tubule, Bowman's capsule, glomerulus, loop of Henle, arteriole, kidneys, renal, genitourinary tract, genitourinary system,bladder, urethra, Art in Anatomy, Ashley Davidoff MDFilter, Flow Concentrate

The story of urine production is the story of the complex physiology.  The diagram simplifies the steps in the production of urine involved in the production of urine using linear and wavy shapes and showing the connectivity and interdependence of the parts.  Blood (red) is filtered by the Bowman’s capsule(blue). The filtered plasma travels through a series of tubes (yellow) called proximal convolued tubule, loop of Henle, then distal convoluted tubule and with the magic of physiology enables water reabsorption and subsequent concentrated urine production. The urine is collected by collecting tubules, and transported via the calyces, renal pelvis and then ureters (orange) to the bladder (oval orange). The final pathway is out back to the environment via the urethra. The art is a combination of minimalism,  linearity, and spherism .

nephron, proximal tubule, Bowman's capsule, glomerulus, loop of Henle, arteriole, kidneys, renal, genitourinary tract, genitourinary system,bladder, urethra, Art in Anatomy, Ashley Davidoff MD

Filter Flow and and Concentate 

Same story – different way of artistically portraying the structural and functional order of urine production

nephron, proximal tubule, Bowman's capsule, glomerulus, loop of Henle, arteriole, kidneys, renal, genitourinary tract, genitourinary system,bladder, urethra

Parts of the Kidney Using Labels

genitourinary tract, genitourinary system, kidneys, nephron, arteriole, glomerulus, proximal convoluted tubule, Bowman's capsule, loop of Henle, distal convoluted tubules, collecting tubules, papilla, calyx, calyces, fornix, infundibulum, pelvis, renal pelvis, ureter, anatomy, kidneys, kidney, renal, Art in Anatomy, Ashley Davidoff MD

Fish Eye View of a Kidney Nephron 

is a sphere providing a view of the tissues making up the micro-tubular structure of the filtering system of the kidneys.  The connections between the tubular systems, arteries and veins, and the positioning of the loops of Henle are essential to the micro-function and macro-function of the kidney.  The style of spherism provides a sense of wholeness.

 kidneys, anatomy, physiology, renal,

An Ocean View of the Nephron

“Ocean View of a Kidney Nephron with Glomerulus Bowman’s Tubules Henle Arterioles and Venules at Sunset”  shows a an out of context depiction of the nephron.    The art piece has a surreal appearance with the sun at the bottom of the ocean and the tubules of the nephron with shapes reminiscent of Miro.  In addition there is a sense of spherism with the vascular system surrounding the nephron and the round shape of the sun. The water theme and the colors create a quiet and peaceful ambiance.

nephron, proximal tubule, Bowman's capsule, glomerulus, loop of Henle, arteriole, venule, kidneys, renal, genitourinary tract, genitourinary system,

Moods of the Kidney Nephron

“Moods of the Kidney Nephron with Glomerulus Bowman’s Tubules Henle Arterioles and Venules in All Colors” is collage of different colors of the nephron indicating different moods.  The art piece has a surreal appearance with a hint of Miro in the shapes of the structures.  The moods projected by the colors are mostly upbeat.


Kidneys – Macro and Micro

“Kidneys- Macro and Micro” combines the histology of the kidney with its macroscopic image.  The nephron with the arteriole, glomerulus, Bowman’s capsule, proximal and distal convoluted tubules, loop of Henle, and collecting ducts are shown in the their distribution in the cortex and medulla of the kidney.  The collecting ducts enter the papilla, then the calyx and reach the ureters via the infundibulum and renal pelvis.


kidneys, nephron, urine, anatomy, water, Art in Anatomy, Ashley Davidoff MD

Kidneys Water to Water

“Water to Water, Dust to Dust – If you have to Pee, then You Must” is one of the captions that has been used to describe this image. 95% of urine is water and the” dust” is represented by organic and inorganic compounds.  These include urea, chloride, sodium, potassium, organic solutes including urea, creatinine, uric acid.  In addition there are trace amounts of enzymes, carbohydrates, hormones, fatty acids, pigments, and mucins.  The inorganic ions include sodium (Na+), potassium (K+), chloride (Cl), magnesium (Mg2+), calcium (Ca2+), ammonium (NH4+), sulfates (SO42-), and phosphates (e.g., PO43-).

kidneys, renal, calyces, ureters, bladder, genitourinary tract, genitourinary system, abdomen. pelvis, X-ray, radiology, Art in Anatomy, Ashley Davidoff MD

Kidneys Ureters and Bladder in Pink

Kidneys, Ureters, and Bladder in Pink” is abdominal X-ray of the abdomen after contrast injection and shows the kidneys, calyces, renal pelvis, ureters and urinary bladder.  The pink hue softens the classical black and white X-ray, but is in contrast to obvious blackened skeletal structures, including the lumbar spine, and pelvic bones. 

The Dancing Kidneys


The Hora at the Royal Renal Wedding 

“The Kidney Hora at the Royal Renal Wedding” shows the bride and groom in the center of the first hora dance at their wedding. The dancing guests are derived from original CT angiograms showing the renal arteries and kidneys . The bride is derived from a nephrostogram (UPJ traumatic disruption) and the groom was created from a retrograde pyelogram.

kidneys, renal, MRI, MRA, MRV dance, renal arterry, renal vein, genitourinary tract, genitourinary system, Art in Anatomy, Ashley DAvidoff MD

Dancing the Rock ‘N Roll

“Kidneys Doing the Rock and Roll with Arteries and Veins Holding Tight” is the venous phase of an MRI angiogram . The kidneys each in different party colors, with a background of pastel colors gives a feeling or mood of celebration and delight.  The way they are bonded with vein on vein, and artery on artery provides the sense of partners holding tight in a rock and roll dance at the festivity.

kidneys, ureters, dance, flamenco, Fall, bladder, CT scan, art, art in anatomy , Ashley Davidoff

Paso Doble

“Paso Doble of the Kidneys in the Autumn” shows a duet in the Fall.  It portrays the passion of  male and female in a fiery dance.  The image was derived from a CT urogram showing the kidneys, calyces, renal pelves, ureters and bladder.  The mature and mellow colors are reflected in the yellows and oranges but are also characteristic Spanish colors.

kidney, arteries, normal, aorta, CTA, CT scan, radiology, dance, rumba

Renal Arteries Doing the Rumba

“The Renal Arteries Doing the Rumba” shows two fashionable folks pairing in an elegant rumba .  The two images are derived from separate CT angiograms and shows a normal aorta with renal arteries in different projections. The dancer on the left has a sleek twist while the the dancer on the right is in upright position with open arms for his partner.

kidney, arteries, normal, aorta, CTA, CT scan, radiology, dance, hip hop

The Renal Arteries Hip Hopping

“The Renal Arteries Doing the Hip Hop” shows two fashionable folks in a high spirited rippin hot wild Hip Hop dance.  The two images are derived from separate CT angiograms and shows the aging atherosclerotic aorta with the renal arteries in different projections. The dancer on the left has two stents at the origin of the renal arteries that look like part of the dress. The dancer on the right has a small infrarenal aortic aneurysm and an accessory renal artery on the right.  The elongated heads of the dancers give them a funky and wild look.

The Kidney Tree 

genitourinary system, genitourinary tract, kidney, arteries, veins, renal veins, renal arteries, normal, radiology, ultrasound, Doppler, power doppler, trees, branching, , Art in Anatomy, Ashley Davidoff MD.,

Summertime in the Kidney Tree

This art piece shows a color Doppler of the kidney and outlines the renovascular tree .  The black and white has been replaced by a skyblue color, while the red and blue of the Doppler has been replaced by the green, blue and purples of summer color. The image has been given an impressionistic feel with a Seurat pointillism effect.  The result is an image that has a feel of Seurat’s “A Sunday Afternoon on the Island of La Grande Jatte”

kidneys, renal, genitourinary tract, genitourinary system, Doppler ultrasound, veins, color Doppler, radiology, Art in Anatomy, Ashley Davidoff MD, trees, forest

Forest of Trees of the Renal Veins

A rendering of a Doppler ultrasound that has been reconstructed in 3D revealing the veins subtending the kidney.  Artistically the tree like structure of the veins has been rendered to create a forest of trees. The work gives a sense that the viewer is deep within the quiet of the forest, since only the base of the tree trunks dominate the view. The color provides a mood of peacefulness, and the magnification of the trunks provides a spirituality and humbles the viewer in the face of the magnificence and grandeur of nature.

kidneys, anatomy, physiology, renal,

Forest of Trees on CT Urogram

The  CT scan has been reconstructed in the coronal plane revealing the bonds between the kidneys, calyces, pelves, ureters, and the bladder.  Artistically the tree like structure of the kidneys has been rendered to create a bunch of flowers or forest of trees depending on the perspective of the viewer.

Lessons from the Kidney Tree 

genitourinary system, genitourinary tract, kidney, arteries, veins, renal veins, renal arteries, normal, radiology, ultrasound, Doppler, power doppler, trees, branching, , Art in Anatomy, Ashley Davidoff MD., winter, summer

Time for the Summer, Time for the Winter

This artpiece teaches us the unpredictability of fate and time .  The power Doppler ultrasound of the kidneys shows a variation of the renal vasculature.  On the left side, the vascular system is abundant, while on the right side, just the skeleton of the veins is demonstrated. The artist saw this image as an opportunity to explore concepts such as opposites, abundance, paucity, situational changes, time, and life lessons.  Relevant quotes include “Make Hay while the Sun Shines” and “There is a Time for Every  Every Season” .  Artistically a sharp line differentiates the left side from the right.  This abrupt change from the one season to the next can also infer unpredictable, and fateful situational change in  life.  In this case -there is a seasonal change, but the situation could just as easily reflect an abrupt change with the arrival of a devastating disease on the doorstep of life.   This image precedes a similar image showing the browns of the fall to the left and the winter to the right (below).

genitourinary system, genitourinary tract, kidney, arteries, veins, renal veins, renal arteries, normal, radiology, ultrasound, Doppler, power doppler, trees, branching, , Art in Anatomy, Ashley Davidoff MD., winter, fall

Time for the Fall, Time for the Winter

This artpiece teaches us the same lesson of unpredictability of fate and time.  Rather than going from summer to winter as time changes, this image goes from the browns of fall to the black and white of winter

Lessons from the Kidneys

kidneys, anatomy, physiology, renal, calyces, pelvis, ureter, urine, Art in Anatomy, Ashley Davidoff MD

The Pair in Purple

The art piece shows the kidneys with calyces, infundibula, renal pelves, and ureters. The pair have a intimate position as they face each other.  They have the same purpose in life -to rid the body of waste and to preserve water.  There is a commitment by the kidneys to each other  The art represents a promise of the kidneys to stay together through thick and thin – till death do them part. Personal ego plays no part in their relationship.  There is a clarity and simplicity in the art piece at the surface with well known underlying extreme complexity of the physiology.

kidneys, anatomy, physiology, renal, calyces, pelvis, ureter, urine, tree

Said the Kidney to the Heart… 

“You allow me to be myself, and do what I do best.  Without you I would be nothing!”  Said the heart to the kidneys “You rid us of waste and toxins, and you recycle our water. Without you, we all would be nothing!”  This profound conversation between the two organs contains the universal wisdom of biology and life .  We all need to do what we do best.  When we do this, the whole society of cells, organs, or people benefit.  The success of the one is the success of all.  The art piece shows the collaborative  form of the two kidneys resulting in a heart shaped tree.  The color of the trunk of golden urine brings the artistic element back to the reality of the kidney function and the gushing forth of urine.


And so ends the story of the Art,  Anatomy and Wisdom of the Kidneys


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Heart Shapes in Nature

Heart shapes in nature abound.  The shape of the heart has a deep meaning in almost every culture and whenever one finds a shape reminiscent of the classical shape of heart shape, it provides a little extra beat of excitement.

I have collected such gems over the years and present some in the following blog.

History of the Heart Shape and Implications in our Culture

heart, history, symbol, Jesus Christ, anatomy, heraldry, Valentine's day, sacred heart, heraldry, mood, emotion, Christianity, symbol, icon

History of the Shape of the Heart Icon

 The collage reveals the symbols that contributed to the shape of the heart icon as we know it.  Elements from anatomy of animals that were exposed during sacrifice, from botany with leaves and seeds that reflected similar emotional connections as the heart, and elements of human anatomy associated with attraction, love and romance combined to result in the shape of the icon of the heart as we know it.

Adapted and modified from public domain photograph by Frank Eugene, taken 1898, called Adam and Eve and published in Camera Work no. 30,1910

The Heart Shape in the Skies

heart, clouds, sky, heaven, heart shape, Valentine's day

Heaven’s Heart 

Found a cloud in the sky that said it all… or at least some of it…heaven’s heart.  The art piece is a photograph that reflects all good things about the heart; its place in the heavens, prayer, love, truth, beauty, honesty, and compassion.  The artistic element reflects a window for two way of love and admiration; from the heavens to humankind and mankind to the heavens.

Heart Shapes in the Leaves


Heart Shaped Leaves of the Linden Tree

The heart shaped leaf of the Linden tree is derived from a photograph taken in Bergen Norway.  The leaf had fallen on a transparent roof and a few drops of water were trapped on its surface.  It reminded me of a tearful end of a romance with tears caught in the heart of the saddened lover.

heart, heart shape, ivy, leaf, heart shape, Valentine's day, romance, love,

Heart Shaped Leaf of the Ivy

The heart shaped Canarian ivy leaf is from a vine. In the art piece the dark green has been lightened to give a freshness to the leaf which is surrounded by a heart shape colored in purple

heart, heart shape, leaf, heart shape, Valentine's day, romance, love,

Heart Shaped Leaf of the Caladium 

The art piece shows a heart-shaped leaf with two beautiful variations of green.  The dark green veins of the leaf are in distinct contrast to the paler green background, creating both complexity to the appearance, and giving us insight into its transport systems. The caladium plant in its many forms has a intensely colored heart shaped and colorful varieties leaf. It belongs to a genus of flowering plants in the family Araceae originating in South America. Almost 1000 variations of the original plant now exist.  Other names include “Angel Wings”, “Heart of Jesus”, and “elephant ear”

heart, heart shape, leaf, heart shape, Valentine's day, romance, love, sweet potato vine

Heart Shaped Leaf of Sweet Potato Vine

The art piece shows the heart-shaped leaf partially illuminated, with an almost mysterious feel of a dark background.  The  leaf of the sweet potato vine arises from a versatile plants around, which grows in sun the sun or shade, in containers, or garden beds. The plant shown here is a bright green or chartreuse. The  beauty of the plant derives not only from the color of the foliage, its flowing nature but also of course  the shape of its leaf

heart, heart shape, leaf, heart shape, Valentine's day, romance, love,

Heart Shaped Leaf of the Black Coral Elephant Ear Plant 

The art piece shows the heart-shaped leaf with unusual black color.  The purple veins of the leaf are difficult to see since they are of a similarly dark color.  The leaf of the Colocasia “Black Coral” Elephant Ear plant is  similar to leaf of the Coladium plant whose members  are also named elephant ears because of the shape.  The leaves can be very large, and are between 8 and 60 inches long.


Yin Yang Heart Shaped Hosta Leaf 

The heart shaped leaf of the Hosta plant is surrounded by a yin yang swirl of green.  The Hosta plant (aka plantain lilies (Britain) giboshi (Japan) is known for its hardiness and the fact that it thrives in the shade.  There are as many as 45 species with foliage of varying sized leaves and shades of green. Yin Yang relates to a Chinese philosophy that uses opposite forces to bring unity and solidarity.  These opposite forces abound. In the context of love it reflects opposite sexes that come together in reproduction of a new single being. Other examples include night and day, dark and light, fire and water, or positive and negative forces.

Heart Shapes in Flowers Fruits and Seeds


Chinese Lantern Flower

The Chinese Lantern flower depending on perspective is also heart shaped – . The dried flower reveals a delicate capillary like infrastructure and therefore even more fitting for Valentine’s day.  The delicate flower enfolds and defends a barely appreciated, delicate fruit buried within its husk. The need to protect the fruit of its loins manifests motherly and fatherly love!The herbaceous perennial plant physalis alkekengi enfold and defend the small, delicate fruit buried within their husks, they may be the perfect symbol for protection. Their fiery orange red hue denotes a passion for life, amiability, endurance and vitality.


Black Walnut Husk

The male and female components occur on the same tree. Imagine the two seeds born out of love between the male and female flowers that occur on the same tree (monoecious species) in a pod that is heart shaped. The image reflects the heart shaped husk with seeds likely removed by squirrels who tore into the heart out of the heart shaped pod – how cruel nature can sometimes be? –  But squirrels will  travel miles, will dig dig deep to retrieve the glorious tasty reward for their tenacious effort. (Acknowledgement Dr Edward Fisher MD Cardiologist)


Heart Shaped Pod of the Goldenrain Tree

 The pod is lantern shaped reminiscent of the the Chinese lantern flower, and Cape Gooseberry and is about 5cms long and 3cm wide and starts as a green to yellow color and becomes orange to pink in the fall.  The black seeds are 5-8mms in diameter. (Acknowledgement Dr Edward Fisher MD Cardiologist)


Heart Shaped Pod of the Amour en Cage

The art piece shows the inverted pod surrounded by the more rotund yellow shape of a heart.  The orange fruit peeks out through a defect in the husk.  The French name Amour en Cage (love in a cage) is the most appropriate and romantic term for the fruit!

Heart Shapes that Tell a Story Through the Natural Elements


Bleeding Heart 

The bleeding heart (aka Lamprocapnos spectabilis, Asian bleeding-heart, Dutchman’s breeches, lyre flower and lady-in-a-bath) belongs to the poppy family Papaveraceae, and is found in China, Japan, Korea and Siberia. It flowers in the early spring with a pink or white flower and is one of the earlier joys of the spring.  It tells a sad story as it opens its heart and pours out its white tears.  The shape is quite unique.


Heart Shape – Tamarind Seeds at Sunset

The heart shape of the Tamarind  seed is the subject of this art piece. The shape of the seed is heterogeneous.  With Valentine’s day in mind, I searched the many seeds of the leguminous edible fruit at the dinner table, and came up with two heart shaped seeds.


Rock Lovers Rock

 Rock Lovers Rock shows a pair of heart shaped rocks in a background of sensuous and gentle curves of surrounding rock formation.  Despite the solid and hard nature of the stone and the almost heartless assigned character, the art piece provides a soft and romantic side to the usually lifeless stone.


Valentine’s Day Walk – a Walnut and a Rock

The male and female components occur on the same tree. Imagine the two seeds born out of love between the male and female flowers that occur on the same tree (monoecious species) in a pod that is heart shaped. The image reflects the heart shaped husk with seeds likely removed by squirrels who tore into the heart out of the heart shaped pod – how cruel nature can sometimes be? –  But squirrels will  travel miles, will dig dig deep to retrieve the glorious tasty reward for their tenacious effort.


Damaged Heart Shaped Leaf

The art portrays that part of the heart has been lost – but also infers that that all is not lost and there is still a lot of love to give.  The color is sombre, and results in a melancholic mood.


Heart Shaped Leaves of Love Lost

The art piece shows two heart-shaped leaves (left) of a Linden tree in Norway at lovers’ odds, with tears streaming down their bodies, a bleeding heart (say no more) and the worst – a black leaf – who has totally given up on love. The whole image reminds me of a “Sergeant Pepper’s Lonely Hearts Club Band”.  The thing about romance is that more often than not, it does not reflect basic love.  Love of a child, parent, spouse friend, or animal has a deeper, more meaningful and more basic element of humanity and compassion that is open to all.  Romance is sometimes a closed club.


Heart Shaped Anthurium at the End of Valentine’s Day

The heart shaped anthurium flower (aka flamingo flower, and laceleaf)  originates in the Americas including northern Mexico and northern Argentina but also in the Caribbean.  In this art piece the flower looks droopy and exhausted after a long day of romance



heart, lungs, ribs, chest, chest cavity, red pepper, grapes, banana, banana peel, X-ray, radiology, anatomy

Chest of Fruit – Heart Lungs and Ribs

The chest with ribs, heart and lungs are created using fruit. The lungs are grapes, the pulmonary arteries – carrots, the ribs a banana peel and the heart is a red pepper.


Dogs Have Hearts Too 

It may take a moment to see the face of  labrador with the heart of the chest projected as his mouth and his two black eyes on either side of his cervical spine!  Once you appreciate the eyes – the rest will fall into place

And so ends our story.


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Emphysema – a Poem


Perspective of an Alveolar Cell

Ashley Davidoff MD Copyright 2015

Healthy Alveolus

When I was young my cell buddies and the tissues around us felt invincible

The ease and elasticity with which we opened and closed –

Allowing the breeze of

Beautiful oxygen ….in

And dirty carbon dioxide ….out

Was executed without effort

It really was a breeze – right through our strong bodies

No effort


Alveolus in Healthy Lungs

Then  one day – when the guy in charge was about 14

When his hormones started to fill his psyche

He went to a party

Lots of little talk

And “cool” this and “cool” that

And “come on … try this” and “try that”

And in his psyche I read

(though he did not consciously know it )

“I want to fit in”…  “I want to look cool”

And suddenly while waiting for my beautiful blue oxygen

A wave of  black and gray stink air imploded in my face

“Yech” I shouted

And that was the beginning of the end

Day after day

Smelly smoke continued to come down the pipeline

.. and it took control of him

Even though he knew better

Early morning when we woke up

After breakfast with a cup of coffee

Same after lunch and after dinner

And just before sweet repose

He blew this black-gray muck in our faces

And we had no power

Over the years

We lost our elasticity

And we lost hope

Then and Now

He hid his habit from his children and grandchildren who said “yech”

His breathing had a deathly rattle

He coughed green and yellow stinky mucus

His breath stank

His clothes stank

He aged before his time

His skin wrinkled

His voice was coarse

And his arteries became rigid and narrowed pipes

And our small airways were stretched and stretched

Till we looked like big black holes in a ghost town

Of rotting and stale air that could not move…

What We Were… and Now …Big Black Holes 

So when we look back

And try to learn, ……

It all started when he wanted to fit in

A human weakness we need to address at a time


The psyche of our children

…. and many adults

Have a need to pursue superficiality to

Look cool and fit in

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Art of Anatomy of the Pancreas

Art of Anatomy of the Pancreas


Ashley Davidoff MD Copyright 2015


Pancreas in the Sky

is a photograph that shows a cloud formation embodying the shape of a pancreas

The anatomy of the pancreas is unusual and the physiology is multifaceted.  It is  a gland and is part of both the digestive and hormonal systems of the body.  Structurally it is characterised by its unusual shape and position and the absence of a capsule.  Functionally it is involved in the digestion of food as well as in the metabolism of glucose.  The most common diseases include pancreatitis, pancreatic carcinoma and diabetes. Serum tests, ultrasound, CT scan, MRI and endoscopy are most commonly used in diagnosis of pancreatic disease.  Treatment options include medical treatment (eg insulin in type 1 diabetes) minimally invasive procedures, and surgery.


“Pancreas in Pink” 

is artwork derived from a CT scan and shows the upper abdominal cavity with the pancreas in bright pink surrounded by the liver, gallbladder, and kidneys. The aorta and inferior vena cava are the major transport vessels and serve to connect the organs.


Unusual Shape

“…and we stare in awe at your odd shape – why oh why did you choose that shape?
What are you supposed to look like? – we have no clue”  

from  “Hermit of the Abdomen” 

anatomy of pancreas

Shapes of the Pancreas

The pancreas has been compared to many objects including an elongated comma on its side, an elongated number 9 on its side, a prism, a banana, an inverted and curved upside down tobacco pipe, and even an old fashioned revolver. Placing a seahorse or a woodpecker with head down and tail up probably brings us closest to the complex shape of the pancreas. The objects used for description are so varied and disparate, that one wonders if we truly have a grasp of the shape of this organ. A more practical way to look at the shape of the organ is to define the shape of its component parts.

Structure – Position

Deep in the Abdomen in the Retroperitoneum

The pancreas lies in the anterior pararenal space of the retroperitoneum surrounded by a vertebral body and kidneys posteriorly, the liver and gall bladder to its right, the spleen to its left, and the stomach and left lobe of the liver in front.  This AiA rendering shows the pancreas cycling through the seasons.  In the  spring it is in shades of  pink, the summer in blue, the fall in  red, and in the winter in ice blue and white. 


The pancreas has dual functions in the the metabolism of the body.  It acts as an as both an exocrine gland (secretes into ducts) and an endocrine gland (secretes into the circulation).

As an exocrine gland it secretes enzymes into ducts that lead to the duodenum.  These enzymes aid in the digestion of fat, proteins, and carbohydrates. As an endocrine gland it is a key player in the control of glucose metabolism which it accomplishes by secreting insulin into the circulation.

The acini are the microscopic glands making up 98% of the parenchyma and they function as the exocrine component.


“Blueberries of the Glands of the Pancreas”

is a rendering of the histological appearance of the pancreatic acinar glands. The artpiece  illustrates the ductules that subtends the acini  which are the exocrine glandular cells. The shape of the acinar cells and ductules are reminiscent of grapes or berries on a stalk.


“Histology of the Glands of the Pancreas”  

The exocrine hormones of the pancreas that aid in the digestion of fats, proteins and carbohydrates are produced in the acinar cells in the glandular unit called the acinus.  The art piece shows the acinus with acinar cells and the duct that transports the secretions to the pancreatic duct and eventually to the duodenum where they aid in the digestion of proteins fats and carbohydrates.

The islets of Langerhans secrete insulin into the blood stream, very soon after ingestion of a meal in order to control blood sugar and intracellular glucose concentrations. The endocrine cells called the islets of Langerhans represent only 1-2% of the tissue volume of the pancreas, but play a vital role in body function and well being. They are most numerous in the tail of the pancreas.


Islets of Langerhans

Immunohistochemistry on mouse pancreas for insulin shows the brown stained Islets of Langerhans that secrete insulin among the acinar cells.  They represent only 2% of the population of pancreatic cells. 

(Modified  Image –  Courtesy  Billyboy Wikipedia Public Domain)



Acute Necrotic Pancreatitis

This is a CT of an elderly man who had severe pancreatitis.  Within the retroperitoneum there is necrotic pancreas (asterisk).  It is enlarged and consists mostly of air (arrow), fluid, and high density hemorrhagic components.  The findings are consistent with a gangrenous pancreatic abscess.  The surgeon noted that the pancreas looked and smelled like a “dead fish…. that had been dead for quite a long time.”  Other structures including the gallbladder(gb), liver, kidneys, spleen and stomach surround the pancreas


Pancreatic Cancer with Spread to the Liver

The CT scan shows a primary pancreatic cancer (red asterisk) with metastases to the liver.  Four of many metastases are identified with white asterisks

acinar cells.8b0115310.8

Normal Pancreatic Cells and Pancreatic Cancer Cells

In the upper image the cellular makeup of the acinar cells of the pancreas manifest with a normal nuclear to cytoplasmic ratio reflecting the relative size of the nucleus to the cytoplasm.   The 2nd image show cancerous cells of the exocrine pancreas.  The blue nuclii are far too large for the amount of the cytoplasm of the cell (abnormal nuclear to cytoplasm ratio).  The malignant cells are also too dark (hyperchromatic) and lack uniformity and organization.  These are all features of malignant cells .  Cancerous cells do not obey the rules of the body and  have no regard for the body at large. Malignant cells are equivalent to rebels in the community. They destroy and do not contribute to the wellbeing of the society.  They also invade the territory of neighboring structures.

feet--0003-catalogue-signedfeet-diabetes magnified.8

Ravages of Diabetes 

The foot of a person with diabetes following amputation of the 2nd, 3rd, and 4th digits as a result of poor circulation of the tissues.  The magnified view shows the calcification and hardening of the arteries. 


“Doppler Ultrasound of the Pancreas-Hermit of the Abdomen”

shows the pancreas in black in front of the splenic vein


“ERCP – Ductal Skeleton of the Pancreas”

is from an ERCP with an injection into normal the dorsal pancreatic duct of Wirsung with contrast also noted in the distal common bile duct

“Arteries of the Pancreas”

is from an angiogram of the celiac axis and shows the multiple arteries that supply the pancreas.  The head of the pancreas is supplied by the  superior pancreatico-duodenal vessels which arises from the gastroduodenal artery,  and inferior pancreatico-duodenal artery which arises from the SMA.  The body is supplied by the splenic artery and the superior mesenteric artery.


Treatment options include medical treatment (eg insulin in type 1 diabetes) minimally invasive procedures for drainage and relief of obstruction, and surgery.

Jawahar Swaminathan and MSD staff at the European Bioinformatics Institute b

3D Nuclear Magnetic Resonance Structure  of Insulin Dimer

(Modified from public domain image from Wikipedia and Courtesy Jawahar Swaminathan Jawahar Swaminathan and MSD staff at the European Bioinformatics Institute) 

“And then a bone guy – for God’s sakes – a bone guy! – called Banting and his student Best
exposed the insular chemistry of your insulin that had given you the power over the sweet
Never mind – in the end it was for the good of all –
And a new era was born 

from “Hermit of the Abdomen” Davidoff


Pancreas and Buddies

This aquatic scene shows the relationship of the pancreas to its neighbours particularly the splenic vein and left renal vein which run a parallel course, almost like a bunch of buddies romping in the water.  The arching bodies with heads all in the same direction is quite beautiful

And then I think of you in your prime and in your happiness
When you are with your two buddies – the splenic vein and the renal vein
And you all look so much alike, and happy swimming in that deep ocean where you hide
And I wish this was forever”

from “Hermit of the Abdomen” Davidoff

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