1. Anatomy Flashcards by J L

The LIVER
• \_\_\_\_ gland
• 2nd largest \_\_\_\_
• Multiple physiological
functions

largest

organ

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The liver occupies much of the ____ of the abdomen…

… largely protected by elements of the thoracic cage including both ____ and ____

upper right quadrant
ribs
costal cartilages

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The liver moves with the
excursions of the ____
and is located more ____ when one is erect because of gravity

diaphragm

inferiorly

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The liver bud arises from the embryonic ____ and grows into the ____
of the developing stomach and duodenum…

foregut

ventral mesentery

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TWO remnants of ventral mesentery persist in the developed human

____:
____
____

falciform ligament
ligamentum teres hepatis
round ligament of the liver

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The round ligament of the liver (ligamentum teres hepatis) is the remnant of the ____

fetal umbilical vein

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Roughly half of the highly oxygenated, nutrient-rich blood returning under high pressure from the placenta bypasses the hepatic sinusoids via the ____

ductus venosus

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TWO remnants of ventral mesentery persist in the developed human

____

The free edge of
the lesser omentum contains the ____

lesser omentum

hepatic triad

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The LESSER OMENTUM is comprised of two distinct portions

____
____ contains the hepatic triad

hepatogastric ligament

hepatoduodenal ligament

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HEPATIC (Portal) TRIAD

____
____
____

proper hepatic artery
common bile duct
hepatic portal vein

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Branches of the vascular elements of the triad enter the liver through a transverse fissure in the ____ surface known as the
____

visceral

porta hepatis

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Arterial blood to the liver is derived from the ____

____
____

celiac trunk
proper hepatic artery
common hepatic

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The COMMON BILE DUCT

is formed at the confluence of the ____ and ____ Ducts

common hepatic

cystic

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The
HEPATIC
PORTAL VEIN
drains the abdominal gut from the ____ to the ____

distal esophagus

superior rectum

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he liver is often described as “wedge-shaped” in sagittal section, featuring two surfaces…

A convex
____ SURFACE

A relatively flat, concave ____ SURFACE

… separated anteriorly by a sharp ____ following the
____ costal margin

diaphragmatic
visceral
inferior border
right

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The diaphragmatic surface of the liver is covered with serous peritoneum, except posteriorly at the so-called ____

bare area

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The bare area is
in contact with the ____ surface of the diaphragm

Though the bare area
is covered by the fibrous
coat of ____ which surrounds the entire organ, the absence of ____ here is significant…

hepatic
glisson’s capsule
peritoneum

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The DIAPHRAGMATIC
SURFACE is smooth and ____-shaped where it relates to the concavity of the underside of the ____

These anatomical lobes, separated by the ____, are only secondarily related to the liver’s internal architecture

dome
diaphragm
falciform ligament

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Retraction and elevation of the inferior border enables clearer visualization of the ____

visceral surface

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VISCERAL SURFACE

____ lobe
____ lobe

Quadrate and Caudate lobes are part of the anatomical ____ lobe

Between the quadrate and caudate lobes lies the ____

quadrate
caudate
right
porta hepatis

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With gallbladder retracted, the ____ is exposed

Also passing through the porta hepatis are:
• ____
• ____ vessels

gallbladder fossa
hepatic nerve plexus
lymphatic

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POSTERIOR VIEW OF LIVER

Note once again the remnants of the foetal circulation

____
____

ligamentum venosum

ligamentum teres hepatis

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At the porta hepatis, elements of the ____ begin to divide, reflecting the functional segmentation of the organ

Most notable
is the bifurcation of the ____ into the ____ arteries

triad
proper hepatic artery
left and right

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The liver has functionally independent LEFT and RIGHT parts, also known as the left and right ____ lobes, each of which receives its own primary branch of the proper hepatic ____ and the hepatic ____ which continue in turn to divide

portal
hepatic
portal vein

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Whereas the falciform ligament clearly demarcates the boundary between the left and right ____ lobes... CANTLIE’S LINE, extending from the ____ posteriorly to the middle of the ____ anteriorly, demarcates the approximate boundary between the ____ (portal) lobes.

anatomical inferior vena cava gallbladder fossa functional

CANTLIE’S LINE is of significance in performing | ____ after which significant regeneration occurs

partial hepatectomy

The two PORTAL LOBES (aka left and right livers) are further divided into ____ vascular segments, each of which is served by a branch of the left or right hepatic ____ as well as a branch of the ____

eight artery portal vein

While the microanatomy of the hepatic lobule, the “functional unit” of the liver, will be presented by others... ... each lobule is comprised of millions of ____, the basic metabolic cells of the liver that detoxify ____ and produce ____.

hepatocytes blood bile

The sinusoids are lined with resident macrophages known as ____ Between hepatocytes, ____ mix oxygen-rich blood from the hepatic artery with nutrient rich blood from the portal vein

kupffer cells | hepatic sinusoids

The contents of the hepatic sinusoids drain toward numerous ____ of the liver lobules, tributaries of the ____

hepatic sinusoids | hepatic veins

Three HEPATIC VEINS usually drain parts of the adjacent vascular segments, and open into the ____ - ____ - ____ - ____

inferior vena cava right hepatic vein middle hepatic vein left hepatic vein

Posterior view HEPATIC VEINS open into the ____

inferior vena cava

The green arrows indicate the flow of bile from hepatocytes through ____ to ____

bile canaliculi | biliary ducts

The biliary ducts converge until each functional segment is drained by a branch of either the ____ Right and left hepatic ducts converge as they approach the ____ to form the ____

right or left hepatic duct porta hepatis common hepatic duct

The CYSTIC DUCT communicates between the ____ and the ____

common hepatic duct | gallbladder

Surrounded by peritoneum, the gallbladder is bound to the ____ of the visceral surface of the liver The hepatic surface of the gallbladder is attached to ____

gallbladder fossa | glisson's capsule

GALL BLADDER A ____ shaped structure Ca. 10 cm. in length Ca. 25 cm. in diameter Stores and concentrates ____ produced by the liver. ``` Releases concentrated bile to the ____ when needed to emulsify fat in preparation for absorption distally in the intestines upon stimulation by ____ and ____ ```

``` pear bile duodenum vagal efferents cholecystokinin (CCK) ```

The FUNDUS of the gallbladder normally lies adjacent to the tip of the ____ cartilage in the ____ line The convergence of the ____ and ____ forms the COMMON BILE DUCT

ninth costal cartilage right mid-clavicular cystic common hepatic ducts

The common bile duct descends posterior to the ____ part of the duodenum in proximity to the ____

superior (first) | gastroduodenal artery

Cystic artery Crosses the ____ triangle Is ligated in ____ Gastroduodenal artery may bleed profusely as a result of ____

hepatocystic cholecystectomy peptic ulcer disease

The common bile duct then descends either in a groove on the posterior aspect of the ____ OR in the substance of the ____ itself

head of the pancreas | pancreatic head

Embedded in the pancreatic head, the ____ and ____ parallel each other before converging and merging to form a dilation, the ____

common bile duct main pancreatic duct hepatopancreatic ampulla (of vater)

Bile and pancreatic secretions drain into the ____ part of the duodenum at the ____

second | major duodenal papilla

Why may gallbladder pain be (Biliary Colic) be referred to the “shoulder pad” region? • Pain associated with inflammation of the gallbladder / often secondary to cholelithiasis (gallstones) not only experienced along right costal margin, but also in the shoulder pad area • Has to do with the innervation of the gallbladder • Specifically: diaphragm, pericardium, pleura = ____ nerve • Somatic afferent fibers that contribute to innervate of pericardium, pleura in the thorax and peritoneum in the abdominal cavity that will help bind the gallbladder to the glalbladder fossa on visceral surface of liver • Experience of pain resulting from afferents from the ____ nerve, referral to ____ dermatome to shoulder pad region = explains why we see gallbladder pain possibly in the right side in the supraclavicular area

phrenic phrenic D4

The liver is a major ____ producing organ, responsible for 25-50% of the lymph carried in the thoracic duct ____ and ____ lymphatics drain to HEPATIC NODES accompanying the portal triad Hepatic nodes in turn drain to the ____ From which efferent vessels drain directly to the ____

``` lymph anterior superficial deep celiac nodes cisterna chyli ```

POSTERIOR SUPERFICIAL lymphatics drain to ____ NODES around the caval foramen which drain to ____

phrenic | mediastinal nodes

The HEPATIC PLEXUS consists of: Preganglionic parasympathetics from the ____ and ____ trunks Postgangionic sympathetics arising from the ____

anterior posterior vagal celiac ganglia

Celiac ganglia The significance of both efferent and afferent components of the hepatic plexus will presumably be presented in subsequent lectures Recall that Pregangionic sympathetic inputs to the CELIAC GANGLIA arise from the ____ nerves

greater thoracic splanchnic

The pancreas: | • Component of the ____ of the abdomen

upper left quadrant

The pancreas lies on the posterior abdominal wall, posterior to the ____, between the ____ on the right and the ____ on the left

stomach duodenum spleen

Removal of the ____ enables clearer visualization of the pancreas

stomach

The PANCREATIC HEAD is embraced by the ____ curve of the duodenum... ...while the he TAIL of the PANCREAS is like a dagger pointed at the ____

S-shaped | splenic hilum

Pancreatic juice produced by the exocrine pancreas includes • ____ • ____ ions (to neutralize gastric acid) and is carried to the small intestine by the ____ and ____ pancreatic ducts

digestive enzymes bicarbonate major minor

The PANCREAS is derived from the fusion of embryonic ____ AND ____ primordia

foregut | midgut

Note in this view why cancer of the ____ accounts for most cases of extrahepatic obstruction of the biliary ducts, producing symptoms which will presumably be discussed in subsequent lectures The ____ marks the boundary between foregut and midgut derivatives - Santorini's duct - Wirsung's duct = ____ duct

pancreatic head major duodenal papilla main pancreatic

We have already discussed the relations of the pancreas to the ____

extrahepatic bile ducts

As we look at the uncinate process and the neck of the pancreas = superior mesenteric artery and vein *remember: • Superior mesenteric artery = blood supply to ____ derivatives • Superior mesenteric vein = major tributary of the ____

midgut | hepatic portal vein

Note the potential for COLLATERAL CIRCULATION around the duodenum and pancreatic head between the ____ and ____ circulations

``` celiac (foregut) superior mesenteric (midgut) ```

Similarly, autonomic elements derived from both the ____ and ____ plexuses contribute to the innervation of the pancreas Though parasympathetic elements are ____, most pancreatic secretion is ____ mediated

celiac superior mesenteric secretomotor hormonally

While details of the lymphatic drainage of the pancreas are unlikely to be significant to the dental practitioner, the fact that the pancreas drains to relatively inaccessible nodes deep in the abdomen, and that pancreatic cancer typically metastasizes to the liver early, explains why surgical resection of the cancerous pancreas is nearly ____

futile

Pancreatic pain = area of ____ region Pain doesn't necessarily reflect cancer - but could reflect inflammatory, cysts, but either way will occur in the epigastric ____ region along the posterior abdominal wall

epigastric | mid-thoracic

The HEPATIC PORTAL SYSTEM drains the GI tract from the ____ through the ____ as well as ____, pancreas and ____

lower esophagus superior rectum spleen gallbladder

The ____ is normally formed deep to the neck of the pancreas by the confluence of two veins ``` So pancreatic neck pathology may impede flow and produce ____ ``` - Splenic - Superior mesenteric

hepatic portal vein | pre hepatic portal hypertension

For reasons having to do primarily with the prenatal development of the GI tract, ____ exit between tributaries of the ____ and tributaries of the ____

anastomoses portal system caval system

Sites of PORTO-CAVAL anastomosis 1. ____ 2. PARAUMBILICAL 3. ____ 4. RETRO-PERITONEAL

esophageal | rectal

Dilation of these anastomoses resulting from ____ (also caused by ____ – involving the destruction of hepatocytes), may produce... 1. ____ 2. ____ 3. ____

``` portal hypertension cirrhosis esophageal varices caput medusae hemorrhoids ```

Caput Medusae is normally accompanied by ____ which can make the patient unable to sit ____ in the dental chair

ascites | comfortably

Hemorrhoids ____ and ____ veins drain to the ____ veins

middle inferior rectal iliac

Rupture of ____ in the ____ submucosal plexus can produce extensive bleeding

esophageal varices | inferior