22 Structure of the liver, gall bladder, biliary tract and pancreas

Question 1

Liver:
• Where does it lie?
• Moves with?
• Surrounded by?

Answer 1

• Largest organ
• Lies in upper abdomen under diaphragm
• Moves with position and respiration
• Surrounded by peritoneum except for bare area (related to diaphragm posteriorly)
• Should not be palpable below costal margin

Question 2

Bile production vs storage location?

Answer 2

• Production of bile = liver

* Storage and concentration = gallbladder

Question 3

What is Glisson’s capsule?

Answer 3

Deep to its peritoneal covering, the liver is completely surrounded by Glisson’s capsule that is a thin connective tissue layer sending extensions into the organ in-between the lobules

Question 4

Liver arterial supply?

Venous drainage?

Answer 4

• (Hepatic) portal vein - brings absorbed nutrients from the stomach/intestine
• Hepatic artery proper - supplies hepatocytes (liver cells) with O2

• Venous drainage - by hepatic veins that enter IVC

Question 5

Bile drainage of liver?

Answer 5

Bile is drained via canaliculi that lie between the hepatocytes –> bile ductules –> bile ducts –> gall bladder

Question 6

Functions of liver?

Answer 6

1. Synthesis and secretion of bile
2. Storage of glucose, glycogen, proteins, vitamins and fats
3. Detoxification of metabolic waste
4. Synthesis of blood clotting and anticoagulant factors (fibrinogen and prothrombin)

Question 7

Constituents of bile?

Answer 7

• Bile pigments (chiefly bilirubin)
• Cholesterol
• Phospholipids (lecithin)
• Fatty acids
• Water
• Electrolytes

Question 8

Where do bile pigments derive from?

Answer 8

Breakdown of haemoglobin

Question 9

What is the role of Kupffer cells?

Answer 9

• Fixed phagocytes

* Play a role in formation of bile pigments

Question 10

What are functions of bile salts?

Answer 10

• Responsible for detergent and emulsifying effect of bile on fats
• Increase absorption of fats by the small intestine

Question 11

What is the structure of a liver lobule?

Answer 11

• Sheets of cells (hepatocytes) radiate outwards from the central vein that forms the central axis of the lobule
• Sinusoids lie between these sheets of cells carrying blood from the hepatic artery + portal vein (mixed oxygenated + de-oxygenated blood) –> central vein
• Bile flow is in opposite direction in the canaliculi between the hepatocytes

Question 12

What is another name for hepatorenal recess?

Answer 12

Morrison’s pouch

Question 13

What may collect in hepatorenal recess and result in?

Answer 13

• Blood/pus may collect here

* Pus - forms abscesses particularly if the patient is recumbent

Question 14

What is the rectovesical pouch?

Answer 14

• Males

* Separate rectum from urinary bladder

Question 15

What is the rectouterine pouch (of Douglas)?

Answer 15

• Females

* Separate rectum from uterus

Question 16

What is the vesicouterine pouch?

Answer 16

• Females

* Separate urinary bladder from uterus

Question 17

What are the lobes of the liver?

Answer 17

• Right lobe
• Left lobe
- Caudate lobe
- Quadrate lobe

Question 18

What structures make up portal triad?

Answer 18

• Portal vein
• Hepatic artery proper
• Hepatic (biliary) ducts

Question 19

What is the ligament teres (round ligament of liver)?

Answer 19

Obliterated umbilical vein in the free border of the falciform ligament

Question 20

What is the ligament venosum?

Answer 20

Obliterated ductus venosus

Question 21

What is the Couinaud Classification?

Answer 21

• Division of liver into 8 functionally independent segments
• Each segment has its own vascular inflow, vascular outflow and biliary drainage
• Each segments can be surgically removed

Question 22

What are liver “ligaments”?

Answer 22

Reflections of peritoneum that surround the bare area (which is related to the diaphragm, IVC, right kidney and right suprarenal/adrenal gland on the posterior abdominal wall)

Question 23

Blood supply and venous drainage of liver?

Answer 23

• Hepatic artery proper, a branch of celiac trunk, divides into right and left terminal branches that enter the portal hepatis
• Portal vein divides into right and left terminal branches that enter the portal hepatic behind the arteries
• Hepatic veins (3 or more) emerge from the posterior surface of the liver and drain into the IVC

Question 24

Lymphatic drainage of liver?

Answer 24

• Liver produces a large amount of lymph (~1/3 or 1/2 of all body lymph)
• Lymph vessels leave the liver and enter several lymph nodes in the portal hepatis
• Efferent vessels pass –> celiac nodes
• A few vessels pass from the bare are of the liver through the diaphragm