30-01-23 - Liver, gall bladder, biliary tree & pancreas Flashcards
Learning outcomes
- Describe the anatomy (position, function, relations, neurovascular supply) of the liver
- Describe the anatomy (position, function, relations, neurovascular supply) of the gall bladder and biliary tree (ducts)
- Describe the anatomy (position, function, relations, neurovascular supply) of the pancreas
- State the structures found at L1, the Transpyloric Plane
- Discuss the clinical implications of the anatomy of the liver, gall bladder, biliary tree and pancreas
- Identify components of extrahepatic bile tree on colangiograms
What are 3 functions of the liver?
What are 3 locations of the surface anatomy of the liver?
What are 5 anatomical relations of the liver?
- 3 functions of the liver:
1) Glycogen storage
2) Bile secretion
3) Other metabolic functions
3 locations of the surface anatomy oof the liver:
1) Located mainly in RUQ
2) Protected by Ribs 7-11
3) Closely related with diaphragm - location changes with breathing
- 5 anatomical relations of the liver:
1) The right hemi-diaphragm – superior
2) Gallbladder – Posterior and inferior
3) Hepatic flexure (of large intestine) – Inferior
4) Right kidney, Right adrenal gland, IVC, Abdominal aorta – Posterior
5) Stomach – Posterior/left
Who is Murphy’s sign elicited In?
What are 4 steps in eliciting Murphy’s sign?
- Murphy’s sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area
- 4 steps in eliciting Murphy’s sign:
1) Patient is asked to breath out all the way
2) The hand is placed just under the costal margin in the midclavicular line
3) The patient is asked to breath in
4) As the tender gallbladder hits the upper border of the hand, the patient will wince or their breath will ‘catch’
- Positive = indicative of cholecystitis
What are thew 2 surfaces of the liver?
What is the liver covered in?
Where is it not covered in this?
What are the 4 lobes of the liver?
- The liver has diaphragmatic and visceral surfaces
- The liver is mostly covered in visceral peritoneum except a portion of the diaphragmatic surface called the ‘bare area’.
- 4 lobes of the liver:
1) Left
2) Right
3) Caudate
4) Quadrate lobes
Liver: Ligaments anterior and superior.
What are the 4 different types of ligaments on the liver?
What is the falciform ligament a remnant of?
Where are ligamentum teres, coronary and triangular ligaments located?
- Liver: Ligaments anterior and superior
- 4 different types of ligaments on the liver:
1) Falciform ligament
* Remnant of ventral mesentery
2) Ligamentum teres
* Lies in the free border of the falciform ligament
3) Coronary ligaments (anterior and posterior)
* Superiorly, the two peritoneal layers are continuous with these ligaments on the under surface of the diaphragm
4) Triangular ligaments (left and right)
* Superiorly, the two peritoneal layers are continuous with these ligaments on the under surface of the diaphragm
Liver: Ligaments Posteriorly.
What obliterates to form the ligamentum teres and ligamentum venosum?
- Liver: Ligaments Posteriorly
- The ligamentum teres (round ligament of liver) is the obliterated umbilical vein
- The ligamentum venosum is the obliterated ductus venosus
What are the 2 major vessels flowing into the liver?
What are the vessels flowing out of the liver?
Where do they each come from?
Where do these vessels come from/go to?
- 2 major vessels flowing into the liver:
1) Hepatic Arteries (from Aorta) 25%
1) Portal veins (from GI tract) 75%
- The hepatic veins to the IVC flow out of the liver
Describe the divisions into the hepatic arteries that supply the liver
- Divisions into the hepatic arteries that supply the liver:
- The hepatic artery proper, a branch of the coeliac trunk, divides into right & left hepatic arteries that enter the porta hepatis
- Abdominal aorta to coeliac trunk to common hepatic artery to proper hepatic artery to left and right hepatic artery
- Cystic artery to the gallbladder comes off of the right hepatic artery, or sometimes the proper hepatic artery
Why is the portal vein not a true vein?
What % of blood to the liver is from the portal vein?
What does it carry to the liver?
What % of oxygen does it supply to the liver?
What does the portal vein divide into?
What doe these structures enter?
- The portal vein is not a true vein, because it conducts blood to capillary beds in the liver and not directly to the heart
- 75% of blood supply to the liver is via the Portal vein
- It carries ‘partially’ oxygenated blood with nutrients and toxins from the digestive system for processing in the liver e. from the spleen, GI tract, and some collateral supply to the kidneys
- Supplies 50% of the oxygen to the liver
- The portal vein divides into right & left branches that enter the porta hepatis behind the arteries
What volume of blood goes through the hepatic portal vein?
What will occur if there is obstructions in the hepatic portal vein?
What condition will end up developing?
- 1500 ml/min of blood goes through the portal vein
- Obstruction leads to increased portal venous pressure
- Collaterals will form to attempt to get blood back to the heart
- Gastroesophageal collaterals that drain into the azygos vein will become engorged and lead to the development of oesophageal varices
What procedure can be done if the hepatic portal vein is blocked?
What are potential complications of this procedure?
- If the hepatic portal vein is blocked, we can perform Transjugular intrahepatic portal systemic shunting (TIPSS)
- Blood is shunted from the hepatic portal vein to the IVC
- A potential complication of this is the toxins not being processed by the liver e.g ammonia
- This can lead to toxins entering the circulation, which can cause hepatic encephalopathy (brain fog)
- This can also lead to right side heart failure
What is the pringle manoeuvre?
What does it involve?
Why is this done?
What are 4 potential complications of the pringle manoeuvre?
- The pringle manoeuvre A surgical technique used in some abdominal operations and in liver trauma
- It involves the hepatoduodenal ligament being clamped (temporarily)
- The purpose of this is to limit blood inflow through the hepatic artery and the portal vein, controlling bleeding from the liver while the surgery can be performed
- 4 potential complications of the pringle manoeuvre:
1) Can cause reperfusion issues
2) Can cause ischaemic damage
3) Might be aberrant arteries present, meaning they come don’t come through the hepatoduodenal ligament. The liver can still bleed even though the hepatoduodenal ligament is clamped due to this
4) Can injure common bile duct
What is the porta hepatis similar to?
What are 5 structures lying in the porta hepatis?
What 2 structures does the lesser omentum arise from?
- The porta hepatis is similar to the hilum of the lung
- 5 structures lying in the porta hepatis:
1) The common hepatic duct* (anteriorly and to the right)
2) The hepatic artery* (anteriorly and to the left)
3) The portal vein* (posteriorly)
4) Hepatic nervous plexus
5) Lymphatic vessels
- The lesser omentum arises from the fissures of the porta hepatis and the ligamentum venosum
Where do hepatic veins leaving the liver emerge from?
What do they drain into?
What is their purpose?
- Hepatic veins leaving the liver (3 or more) emerge from the posterior surface of the liver & drain into the inferior vena cava
- The purpose of the hepatic veins is to return the blood that has passed through the liver lobules to the heart (via the IVC) for recirculation
What do hepatic lobules consist of?
What do they form around?
What 3 structures do interlobular triads consist of?
Where does blood from interlobular triads flow to?
Where does bile from interlobular triads flow to?
What are the 2 roles of hepatocytes?
- Hepatic lobules consist of parenchymal cells (hepatocytes)
- Hepatocytes form lobules around a central vein that drains back to the hepatic vein
- 3 structures Interlobular triads consist of:
1) A branch of the hepatic artery proper
2) A venule from the portal vein
3) A bile duct to the hepatic duct - Blood from the interlobular triads flows to the sinusoids (between sheets of hepatocytes), which then flow into the central vein of the lobules
- Bile from interlobular triads flows in the canaliculi between the hepatocytes towards biliary ducts
- 2 roles of hepatocytes:
1) Produce bile
2) Detoxify blood
How many segments of the liver are there?
Describe the different segments (in picture).
What structures splits the segments up?
What 3 structures does each segment have?
What is the portal plane? What does it divide?
- The Liver is divided into 8 functionally independent segments (in picture)
- The right, left, and middle hepatic veins split up the segments of the liver
- 3 structures each segment has its own:
1) Vascular (hepatic artery and portal vein) inflow
2) Vascular outflow (hepatic vein)
3) Biliary drainage - The portal plane is where the portal vein bifurcates
- It splits up the superior and inferior segments of the liver
What is the cantlie line?
What segments does it separate?
Why is this important?
- The cantlie line is a line drawn from the Middle Hepatic Vein (where it joins the IVC) to the gallbladder, and is thought to be the functional midline of the liver
- It separates segments II, III, IV from the rest of the liver
- This is important because when looking at the functional sides of the liver, we separate out these segments from the rest of the liver, not just the segments to the left of the falciform ligament
Where does the liver receive its sympathetic and parasympathetic supply form?
What is the liver capsule composed of?
Why is liver capsule pain like?
What does it possess that other parts of the liver don’t have?
- Sympathetic nerves to the liver are form the coeliac plexus (from foregut therefore greater splanchnic nerve, T5-T9)
- The anterior vagal trunk gives rise to a large parasympathetic hepatic branch that passes directly to the liver
- The liver capsule is composed of two adherent layers: a thick, fibrous inner layer called the Glisson capsule; and an outer serous layer that is derived from the peritoneum
- Liver capsule pain can be intense and hard to treat (stretching kind of pain - not very receptive to pain relief)
- The live capsule is the only part of the liver that has pain receptors
What is the gallbladder?
Where is it located?
What is the role of the gallbladder?
Where are the Spiral valves (of Heister) located?
When is the gallbladder needed in digestion?
What is the role of CCK in the gallbladder?
- The gallbladder is a muscular sac on the visceral surface of the right lobe of the liver
- The gallbladder stores and concentrates bile produced by the liver (nonessential functions)
- The Spiral valves (of Heister) are located on the mucous membrane of the cystic duct & neck of gallbladder
- The gallbladder is digested when we have a high fatty meal that needs to be digested
- Cholecystokinin (CCK) is the major hormone responsible for gallbladder contraction and pancreatic enzyme secretion to digest food stuff
What are the 4 gallbladder surface projections?
- 4 gallbladder surface projections:
1) Fundus of the gall bladder is located at Murphy’s point where the right midclavicular line crosses the costal margin
2) Tip of the right 9th costal cartilage
3) Linea semilunaris crosses the right costal margin
4) The gallbladder is in the RUQ or right hypochondrium
What is the arterial supply and venous drainage of the gallbladder?
What is the lymph drainage of the gallbladder?
What is the sympathetic and parasympathetic supply to the gallbladder?
Where is pain from the gallbladder referred to?
- The arterial supply to the gallbladder is the Cystic artery (branch of right hepatic artery) − High variation
- The venous drainage of the gallbladder are numerous small veins (Cystic vein) from body and neck which drain directly into segmental portal veins
- The lymph drainage of the gallbladder is a cystic lymph node situated near the gallbladder neck
- Lymph then passes to the hepatic nodes along the course of the hepatic artery proper & then into the coeliac nodes
- Sympathetics to the gallbladder come from T5-T9
- Parasympathetics to the gallbladder come from vagal fibers
- Pain from the gallbladder is usually referred to the epigastrium (T7-T9).
What is Kehr’s sign?
What 5 things can cause supraclavicular pain?
- Kehr’s sign is a classic example of referred pain: irritation of the diaphragm is signalled by the phrenic nerve as pain in the area above the clavicle.
- Irritation of the diaphragm/adjacent peritoneum transmitted by the phrenic nerve (C3,4,5)
- Pain ‘felt’ in supraclavicular nerve (C3,4) distribution ipsilaterally
- 5 things that can cause supraclavicular pain:
1) Liver capsule pain
2) Inflamed gallbladder
3) Post-operative pneumoperitoneum
4) Hemoperitoneum
5) Ectopic pregnancies
Biliary tree structure.
What is the common hepatic duct formed from?
What is the common bile duct formed from?
How large is the common bile duct?
What structure does it run in?
What structures join at the hepatopancreatic ampulla (of Vater).
Where does this occur?
Where is the sphincter of Oddi located?
- Biliary tree structure
- The right and left hepatic ducts join to form common hepatic duct
- The cystic duct joins with the common hepatic duct and forms the common bile duct
- The common bile duct is 4-6 mm diameter and runs in hepatoduodenal ligament
- The common bile duct joins with the main pancreatic duct at the hepatopancreatic ampulla (of Vater) before entering into the 2nd (descending) part of the duodenum at major duodenal papilla
- The Sphincter of Oddi is around the final part of common bile duct
What is Mirizzi syndrome?
- Mirizzi syndrome is obstructive jaundice due to an impacted gallstone in the neck of the gallbladder that causes extrinsic compression of the common hepatic bile duct
What is Charcot’s Triad?
What is it indicative of?
- Charcot’s Triad:
1) Jaundice (obstructive)
2) Fever - usually with rigors
3) Right upper quadrant pain - Indicative of ascending cholangitis (inflammation of bile duct system)
What is Courvoisier’s Law?
Explain how this is caused?
What 2 type of patients is this present in?
- Courvoisier’s Law is that patients with painless jaundice and a palpable gallbladder often have a malignant obstruction of the common bile duct
- A mass in the head of the pancreas blocks the hepatopancreatic ampulla (of Vater) and the pancreatic and common bile ducts
- This prevents bile from flowing into the duodenum, so bile goes back into and hardens the gallbladder, which can cause inflammation
- Present in 50%–70% of patients with periampullary cancer or carcinoma of the head of pancreas
What are the 3 borders of the hepatobiliary (hepatocystic) triangle?
What are 3 structures within the hepatobiliary triangle?
- 3 borders of the hepatobiliary (hepatocystic) triangle:
1) Medial – common hepatic duct.
2) Inferior – cystic duct.
3) Superior – inferior surface of the liver - 3 structures within the hepatobiliary triangle:
1) Right hepatic artery
2) Cystic artery
3) Lymph node of Lund
What did bile duct injury rates increase with?
What is the critical view of safety?
- Bile duct injury rates increased as laparoscopic cholecystectomies became more common
- The critical view of safety is a method of identification of the cystic duct and cystic artery that must be confirmed before division of the structures.
- This allows these structures to be clamped to stop bleeding
What is Endoscopic Retrograde Cholangiopancreatogram (ERCP) used for?
What are 3 steps to ERCP?
- Endoscopic Retrograde Cholangiopancreatogram (ERCP) is an Investigation used to study the biliary tree and pancreas and treat some pathologies associated with it
- 3 steps to ERCP:
1) Endoscope inserted through oral cavity, oesophagus, stomach and into duodenum
2) Cannula placed into major duodenal papilla and radioopaque dye injected back into biliary tree
3) Radiographic images are taken of the dye-filled biliary tree
What is a filling defect?
- A filling defect is when the common bile duct is distended due to blockage by a stone at its distal end
- In picture, stone blocks the dye
What is a double duct sign indicative of?
- A double duct sign is indicative of head of pancreas cancer
Is the pancreas intraperitoneal?
Where can we find the pancreas in the body?
Where does it extend from?
What are the 5 parts of the pancreas?
Where are the head and uncinate process of the pancreas found?
- The pancreas is secondary retroperitoneal (except its tail)
- The pancreas lies across the epigastrium close to major blood vessels
- It extends from the duodenum to the hilum of the spleen
- 5 parts of the pancreas:
1) Head
* The head lies in duodenal arch
2) Neck
3) Body
4) Tail
5) Uncinate process
* Uncinate process extends posterior to the superior mesenteric vessels
What are the 2 functions of the pancreas?
- 2 functions of the pancreas:
1) Exocrine functions
* Acinar cells secrete pancreatic digestive enzymes into main pancreatic duct, which goes onto endothelium (i.e Into GI tract at duodenum)
2) Endocrine functions
* Islets of Langerhans glands secrete hormones (insulin, glucagon) or enzymes into the blood
Where does the main pancreatic duct begin?
Where does it join the common bile duct?
Where does it open into the duodenum?
- The main pancreatic duct begins in the tail of the pancreas
- The main pancreatic duct joins the common bile duct at the hepatopancreatic ampulla (of Vater)
- It opens into the duodenum at the major duodenal papilla (sphincter of Oddi)
What are the 3 main arteries that supply the pancreas?
Describe their divisions (in picture)
- 3 main arteries that supply the pancreas:
1) Anterior and posterior superior pancreaticoduodenal artery
* Supplies mostly the head with some anastomoses
2) Inferior pancreaticoduodenal artery
* Supplies uncinate process and head
3) Dorsal and greater pancreatic Arteries
* Supplies neck, body, and little bit of tail
- Divisions of these arteries (in picture)
What are 3 landmarks for the position of the Trans-pyloric Plane?
What 9 structures are located at the level of the Trans-pyloric Plane?
- 3 landmarks for the position of the Trans-pyloric Plane:
1) Midway between the jugular notch & the superior border of the pubic symphysis
2) Corresponds to a plane that is midway between the xiphisternal joint & the umbilicus
3) Intersects with L1 (L2) vertebra and the costal margin of the 9th costal cartilage
- 9 structures are located at the level of the Trans-pyloric Plane:
1) Fundus of gallbladder
2) Pylorus of stomach
3) Neck of pancreas
4) 1st (superior) part of duodenum
5) Hilum of kidney (right lower than left)
6) Duodenojejunal flexure
7) Termination of spinal cord at L1/2
8) Origin of superior mesenteric artery
9) Formation of portal vein
