9. Abdomen III Flashcards
1
Q
What are the 6 functions of the liver?
A
- storage,metabolism and release of nutrients and some vitamins
- detoxification and elimination of toxins, drugs and metabolites
- synthesis of proteins : albumin and clotting factors
- synthesis and secretion of bile, important for lipid digestion and absorption
- role in immune function and clearance of intestinally absorbed bacteria
- removal of red blood cells
2
Q
What is the blood flow rate to the liver?
A
- 1.5L/min
3
Q
What ribs is the liver protected by?
A
- 7-11
4
Q
What areas of the abdomen does the liver occupy?
A
- Starts in the right hypochondrium and extends to the epigastrium
5
Q
What surface of the liver is not covered in peritoneum?
A
- superior surface
6
Q
Is the liver retro or intraperitoneal?
A
- intraperitoneal
7
Q
What are the 4 anatomical lobes of the liver?
A
- Left lobe
- Right lobe
- Caudate lobe
- Quadrate lobe
8
Q
Why is the liver intraperitoneal?
A
- develops in the ventral mesogastrium
9
Q
What are the two surfaces of the liver?
A
- diaphragmatic
- visceral
10
Q
How many functional segments of the liver are there?
A
- 8
11
Q
Label this diagram
A
12
Q
What structure is the quadrate lobe close to?
A
- gallbladder
13
Q
What lobe does the quadrate lobe work with functionally?
A
- the left lobe
14
Q
What happens if you remove one of the segments of the liver and why?
A
- nothing
- Each segment (8) has its own individual blood supply
- so if one segment is removed it wonโt affect the other segments
15
Q
What is the falciform ligament?
A
- double fold of peritoneum connecting the liver to the anterior abdominal wall
16
Q
What divides the left lobe from the right lobe?
A
- falciform ligament
17
Q
Label this diagram
A
18
Q
What is the porta hepatis equivalent to?
A
- the hilum of the lung
19
Q
What is the thickening on the free edge of the falciform ligament?
A
- round ligament (ligamentum teres)
20
Q
What is the ligamentum teres?
A
- embryological remnant of the umbilical vein (brings oxygenated blood from the placenta)
21
Q
How is bile transported to the duodenum?
A
- via the common bile duct
22
Q
Where does the common bile duct receive bile from?
A
- the common bile duct receives bile from the cystic duct which comes from the gallbladder
- or it receives bile directly from the liver through the common hepatic duct
23
Q
What 2 structures come together to form the common hepatic duct?
A
- The right and left hepatic duct come together and form the common hepatic duct
24
Q
What structures come together to form the common bile duct?
A
- cystic duct will join the common hepatic duct to create the common bile duct
25
What does the proper hepatic artery divide into?
* divides into the right hepatic and left hepatic artery
26
Where is the portal triad?
* runs though the free edge of the lesser omentum
27
What is the lesser omentum?
* double fold of peritoneum that attaches the liver to the stomach
28
What is โPringleโs manoeuvre?
* hemostat is used to clamp the hepatoduodenal ligament (free border of the lesser omentum)
* interrupting the flow of blood through the hepatic artery and the portal vein
29
What are the 5 structures that are contained in the porta hepatis?
* common bile duct
* left and right hepatic duct
* cystic duct
* hepatic portal vein
* hepatic artery
30
Label this image
31
Label this image
32
What is the round ligament?
* thickening of the falciform ligament
33
Label this image
*
34
What happens to the falciform ligament as it ascends?
* it ascends and splits into two layers so one layer goes to the right and the other goes to the left because the falciform ligament is made of 2 layers
35
What is the falciform ligament called when it splits?
* coronary ligament of the liver
36
What does the top surface of the coronary ligament attach to?
* top surface attaches to the bottom of the diaphragm
37
What do the coronary ligaments fuse to become?
* fuse and become the triangular ligament (left and right)
38
Label this image
39
Why does the bare area occur?
* liver undergoes a really accelerated growth within vental mesogastrium so the two layers of peritoneum separate apart (like hulk and his clothes)
40
What are the boundaries of the bare area?
* anterior and posterior coronary ligaments
41
Why is the bare area clinically important?
* bare area of the liver is clinically important because of the portacaval anastomosis and it represents a site where infection can spread from the abdominal cavity to the thoracic cavity
42
What is the subphrenic space?
* gap between the liver and diaphragm
43
What is the clinical significance of the peritoneal recesses of the liver?
* the liver recesses are areas where fluid can fill if there is an infection
44
What is the pouch of Morrison?
* gap between the liver and the kidney
* hepatorenal pouch (of Morrison)
45
What is the subhepatic space?
* space is between the inferior surface of the liver and the kidney
46
Label this image
47
Label this image with :
pouch of morrison
subphrenic space
right subhepatic space
48
What does the gastric artery supply and where does it go?
* left and right go inbetween the lesser omentum to supply the stomach
49
Label this image
50
Label 1 and 2
* 1) hepatogastric ligament
* 2) hepatoduodenal ligament
51
Where does the portal triad run?
* free edge of lesser omentum
52
What are the superior, inferior, posterior and anterior borders of the lesser sac?
* superior : caudate process of liver
* inferior : 1st part of duodenum
* posterior : inferior vena cava and right crus of diaphragm
* anterior : portal triad (in free edge of lesser omentum)
53
How many vessels is the liver supplied by?
* two
54
What vessels make up the livers dual supply?
* 25% is from the hepatic artery proper
* 75% of the blood comes from the GI tract through the hepatic portal vein
55
Where is blood processed?
* blood is processed in the sinusoids
56
What veins unite to form the hepatic portal vein? Draw a schematic below.
* three main vessels:
* the gastric, pancreaticomesenteric, and lienomesenteric veins
57
After blood is processed in the sinusoids of the liver what happens?
* sinusoids collect into the central vein and unite into the three hepatic veins and the hepatic veins join directly into the IVC
58
What brings blood to the liver from the midgut?
* superior mesenteric vein brings blood from the midgut
59
Where does the inferior mesenteric vein bring blood from?
* hindgut
60
Label this image
1) hepatic portal vein
2) superior mesenteric vein
3) splenic vein
4) inferior mesenteric vein
61
How does portal hypertension arise?
* When scarring and fibrosis from cirrhosis obstruct the portal vein in the liver
* pressure rises in the portal vein and its tributaries producing portal hypertension
62
Why can the spleen become enlarged with cirrhosis?
* The splenic vein enters directly into the hepatic portal vein
* If the vessel is blocked and blood canโt flow out of the spleen, it will continue to grow and you get splenomegaly
63
What are portosystemic anastomoses?
* blood can flow into the portal system or straight into the systemic venous circulation so it is not processed by the liver
64
What are the oseophageal portal and systemic veins?
* portal via left gastric
* systemic via azygos vein
65
What are the anal portal and systemic veins?
* portal via inferior mesenteric veins
* systemic via inferior and middle rectal veins
66
What are the portal and systemic peri-umbilical veins?
* portal via paraumbilical veins
* systemic via epigastric veins
67
What is caput medusae?
* If the portal system is blocked and blood canโt flow through the paraumbilical veins
* the majority of the blood will travel via the epigastric veins, (like a traffic jam)
* so more blood is flowing through them and they become more dilated
68
How does the biliary system develop?
* as an outgrowth of the foregut
69
Where is bile produced and where does it go?
* Bile is produced in the liver and travels through the right or left hepatic duct to enter the common hepatic duct
70
Label this image
71
Where is the gallbladder located?
* behind the tip of the right 9th costal cartilage, where the lateral margin of rectus abdominis crosses the costal margin
72
What are the 2 routes bile can take once it reaches the common hepatic duct?
* can travel through the cystic duct to be stored in the gallbladder
* or it can travel down the common bile duct to fuse with the main pancreatic duct to form the hepatopancreatic ampulla of vater
73
Where does the ampulla of vater open into?
* major duodenal papilla which enters into the lumen of the duodenum
74
What is the release of bile controlled by?
* spiral folds
75
What artery supplies the gallbladder and where does it arise?
* cystic artery
* arises from right hepatic artery
76
Label this image with
1) right and left hepatic ducts
2) common hepatic duct
3) cystic duct
4) common bile duct
5) hepatico-duodenal ampulla of vater
6) major duodenal papilla
7) fundus
8) body
9) neck
77
What is cholelithiasis?
* formation of gallstones
78
What is Hartmann's pouch?
* diseased states of the gallbladder, a dilation or pouch appears at the junction of the neck of the gallbladder and the cystic duct
79
Where do gallstones normally collect?
* Infundibulum/ Hartmann's pouch
80
What is Hartmann's pouch caused by?
* dilation above the neck of the gallbladder and is a pathological entity produced by a contained gallstone
81
How can gallstones enter the duodenum?
* If a peptic duodenal ulcer ruptures, a false passage may form between the infundibulum and the superior part of the duodenum, allowing gallstones to enter the duodenum
82
What are the 2 types of gallstones?
* Cholesterol (yellow) versus pigment (dark brown or black) gallstones
83
What are the common associations of gallstones? (5 Fs)
* female
* fair
* fat
* forty
* fertile
84
Where can gallbladder pain be referred?
* back of the shoulder
85
What 3 things is the neck of the pancreas anterior to?
* SMA
* SMV
* portal vein
86
What is the head of the pancreas anterior to?
* portal vein
87
What is anterior and posterior to the body of the pancreas?
* posteriorly - peritoneum
* anterior surface - bed of stomach, floor of lesser sac
88
Where does the tail of the pancreas pass?
* between folds of splenorenal ligament
89
Is the tail of the pancreas intra or retro peritoneal?
* intraperitoneal
90
What passes anterior to the uncinate process of the pancreas?
* SMA
* SMV
91
When does jaundice arise?
* when the normal passage of bile into duodenum is blocked, either partially or wholly
92
What are the 3 types of jaundice?
* pre-hepatic
* hepatocellular
* post-hepatic
93
What is pre-hepatic jaundice caused by?
* excessive red cell breakdown
94
What is hepatocellular jaundice caused by?
* dysfunction of hepatic cells
95
What is post-hepatic jaundice caused by?
* obstruction of biliary drainage e.g. gallstones or tumours
96
What are the 3 signs of post-hepatic jaundice?
* Dark urine
* Pale stools
* Yellow discoloration of sclera and skin
97
Why does inflammation of the gallbladder cause shoulder pain?
* The gallbladder is very closely related to the diaphragm
* The diaphragm is supplied by the phrenic nerve (C3,C4,C5)
* The dermatomes of the shoulder are also C3,C4, and C5
* Inflammation of the gallbladder can cause irritation of the diaphragm
98
Label this image
99
What can be used to visualize the biliary system?
* Endoscopy and fluoroscopy
100
How does endoscopy and fluoroscopy work?
* An endoscope is passed through the pylorus and a cannula is inserted through the ampulla of vater.
* Radiocontrast medium is injected into the CBD allowing visualisation of the biliary tree.
101
What is the procedure called to visualize the biliary tree?
* Endoscopic retrograde cholangiopancreatography (ERCP)
102
What is the clinical term for inflammation of the gallbladder?
* cystitis
103
What is Murphyโs sign?
* patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area.
* If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner's hand, Murphy's sign is positive
104
What are the main functions of the pancreas?
* exocrine - pancreatic juice : acinar cells
* endocrine - glucagon and insulin : pancreatic islets of Langerhans
105
Where is the splenic artery and vein in relation to the body of the pancreas?
* splenic vein runs immediately posterior to the length of the body of the pancreas
* in front of the pancreas
106
What vertebral level is the transpyloric plane and where does it pass?
* through neck of pancreas
* L1
107
Where does the accessory pancreatic duct?
* accessory pancreatic duct enters into the minor duodenal papilla
108
What is the pancreas supplied by?
* pancreas is mainly supplied by branches of the celiac trunk and from the superior mesenteric artery
109
Where do the celiac trunk and the SMA arise with?
* abdominal aorta
110
What are the head and the uncinate process of the pancreas supplied by?
* head and the uncinate process are supplied by branches of the gastroduodenal artery
111
What does the superior pancreaticoduodenal artery anastomose with and where does this arise from?
* inferior pancreaticoduodenal artery which arises from the superior mesenteric artery
112
What does the pancreas develop from?
* from the ventral and dorsal buds
113
How does the pancreas develop?
* The duodenum rotates as it develops and rotates to the right causing the ventral bud to migrate around the back of the duodenum and fuse with the dorsal bud
114
What is annular pancreas?
* Annular pancreas is a condition where a ring of pancreatic tissue surrounds and constricts the duodenum
115
What is a pancreatic pseudocyst caused by?
* caused by pancreatitis or abdominal trauma
116
What is a pancreatic pseudocyst?
* a collection of enzyme rich fluid and blood encapsulated in the area of the pancreas
117
Label this image
118
What does the ventral bud become?
* uncinate process
119
What does obstructive jaundice cause?
* resulting in the retention of bile pigments, enlargement of the gallbladder, and jaundice
120
How does annular pancreas arise?
* the two buds of the pancreas migrate in different directions
121
What does cancer of the pancreatic head and neck lead to?
* obstruction of the portal vein or inferior vena cava
122
What is Whipple's procedure?
* pancreaticoduodenectomy
* removal of : head of pancreas, duodenum, gallbladder, bile duct
123
When would Whipple's procedure be done?
* cancer in head of pancreas
124
Why does cancer of the head of the pancreas cause extrahepatic obstruction?
* obstructs the major duodenal papilla
125
How is the pancreas related to the portal vein and IVC ?
* Goes anterior to both
126
What is Kocherโs manoeuvre?
* surgical manoeuvre to expose structures in the retroperitoneum behind the duodenum and pancreas
127
What is the function of the duodenum?
* Responsible for the emulsification of fat
* Also responsible for chemical digestion via enzymes produced in the pancreas
128
What 3 places does the duodenum receive things from and what does it receive?
* chyme from pyloric part of stomach
* bile from liver and gallbladder via common bile duct
* enzymes from pancreas via main and accessory pancreatic duct
129
Is the duodenum retro or intraperitoneal?
* the first part is intraperitoneal while the rest is retroperitoneal
130
What is the first part of the duodenum enclosed by?
* hepatoduodenal ligament
131
What are the vertebral levels of the retroperitoneal part of the duodenum?
* L1-L3
132
Where do the greater and lesser omenta arise from?
* arise from the upper and lower surfaces of the proximal portion of the superior part of the duodenum
133
What is the vertebral level of the first part of the duodenum?
* L1
134
What are the 2 names for the first part of the duodenum?
* duodenal cap
* ampulla
135
What artery runs behind the first part of the duodenum?
* gastroduodenal artery
136
What 3 structures run posteriorly to the superior part of the duodenum?
* common bile duct, hepatic portal vein and gastroduodenal artery
137
Where are peptic ulcers most likely to occur?
* first part of duodenum
138
What structure can be damaged if a peptic ulcer ruptures?
* If a peptic ulcer ruptures through the mucosa of the first part of the duodenum, the gastroduodenal artery can rupture
139
What 2 structures are inferior to the first part of the duodenum?
* head and neck of pancreas
140
What structure is medial to the first part of the duodenum?
* pylorus
141
What 2 structures are superior to the first part of the duodenum?
* epiploic foramen
* neck of gallbladder
142
What 5 structures are posterior to the first part of the duodenum?
* lesser sac
* bile duct
* hepatic portal vein
* gastroduodenal artery
* IVC
143
What 3 structures are anterior to the first part of the duodenum?
* gallbladder
* quadrate lobe of the liver
* peritoneum
144
What is the radiological significance of the duodenal cap?
* can be seen as a bright spot in the duodenum
145
What is the vertebral level of the second part of the duodenum?
* L2/ L3
146
What is the second part of the duodenum lined with and what is their function?
* lined with circular folds called plicae circulares which increase the surface area
147
What 3 structures are medial to the second part of the duodenum?
* bile duct
* pancreatic duct
* head of pancreas
148
What structure is inferior to the second part of the duodenum?
* inferior duodenum
149
What 4 structures are posterior to the second part of the duodenum?
* hilum of right kidney
* renal vessels
* right ureter
* psoas major
150
What 5 structures are anterior to the second part of the duodenum?
* right lobe of the liver
* fundus of gallbladder
* transverse colon
* transverse mesocolon
* coils of small intestine
151
What is found in the medial part of the second part of the duodenum?
* Medially you can find the opening of the hepatopancreatic ampulla through the major duodenal papilla and superior to it is the minor duodenal papilla
152
What is the blood supply of everything above the major duodenal papilla supplied by?
* celiac trunk
153
What is the blood supply of everything below the major duodenal papilla?
* superior mesenteric artery
154
Where is the most common site for diverticula?
* second part of duodenum
155
What is the relationship of the transverse mesocolon to 2nd part of duodenum?
* transverse mesocolon is anterior to the 2nd part of duodenum
156
What vertebral level is the third part of the duodenum?
* L3
157
What 3 structures pass anteriorly to the 3rd part of the duodenum?
* SMA/SMV
* coils of small intestine
* root of mesentery
158
What 4 structures pass posteriorly to the 3rd part of the duodenum?
* right psoas major
* IVC
* aorta
* right ureter
159
What structure is medial to the 3rd part of the duodenum?
* 4th part of duodenum
160
What structure passes inferiorly to the 3rd part of the duodenum?
* coils of the ileum
161
What 3 structures are superior to the 3rd part of the duodenum?
* head of pancreas
* uncinate process of pancreas
* SMA/SMV
162
What is the vertebral level of the 4th part of the duodenum?
* L1
163
Where does the 4th part of the duodenum join the jejunum?
* duodenojejunal flexure
164
What is the suspensory muscle of the duodenum?
* Ligament of Treitz
165
What 2 structures are anterior to the 4th part of the duodenum?
* root of mesentery
* coils of jejunum
166
What are the 2 posterior structures to the 4th part of the jejunum?
* left psoas major
* left margin of aorta
167
What are the 2 medial structures to the 4th part of the duodenum?
* SMA/SMV
* uncinate process of pancreas
168
What is found inferiorly and superiorly to the 4th part of the duodenum?
* inferior : coils of jejunum
* superior : body of pancreas
169
What is the blood supply to the duodenum?
* proximal segment of the duodenum is supplied by the gastroduodenal artery and its branches which include the superior pancreaticoduodenal artery.
* The distal segment of the duodenum is supplied by the superior mesenteric artery and the inferior pancreaticoduodenal artery
170
Label this image
171
Where do the lymphatic nodes of the duodenum drain?
* Above the major duodenal papilla they will travel to the hepatic lymph nodes which drain into the celiac nodes
* The inferior pancreaticoduodenal nodes drain to the superior mesenteric nodes
172
Where do the lymphatics of the duodenum go?
* follow arteries superiroly from superior pancreaticoduodenal to celiac nodes
* follow arteries inferiorly from pancreaticoduodenal to superior mesenteric nodes
173
Where is the spleen found?
* left upper quadrant/left hypochondrium
174
What are the dimensions of the spleen?
* 1โx 3โx 5โ, weighs 7oz and situated between 9th - 11th ribs
175
What is the function of the spleen?
* white cell proliferation
* immune surveillance
* filters and stores RBC and platelets
* recycles iron and Hb
176
How can the spleen be injured?
* penetrating wounds of the thorax
177
How is the spleen connected to the stomach?
* stomach by the gastrosplenic ligament
178
How is the spleen connected to the kidney?
* splenorenal ligament
179
Where does the spleen develop within in embryological development?
* dorsal mesogastrium
180
Where is the splenic notch found?
* antero-inferior border
181
Is the spleen retro or intraperitoneal?
* intraperitoneal
182
Where does the splenic artery arise from?
* from the coeliac trunk
183
Where does the splenic artery pass?
* superior to the body of the pancreas to enter the spleen at the hilum.
184
What 2 veins unite to form the hepatic portal vein?
* splenic vein unites with the superior mesenteric vein, to form the hepatic portal vein.
185
Label this image
186
Label this image
187
Where would you begin palpation for an enlarged spleen (splenomegaly)?
* right iliac fossa
