Abdomen 3 Flashcards
which bones protect the liver?
Rib 7-11
Which arteries run in the lesser curvature to supply the stomach?
Left and right gastric arteries (which are branches of the coeliac trunk and branch of hepatic artery proper)
where is the SMA/SMV in relation to duodenum?
anterior to the 3rd inferior part of the duodenum
Identify the recesses of the liver and what is their significance?
Subphrenic Space = Gap between diaphragm and liver
Hepatorenal pouch of Morrison = Kidney and Liver
Subhepatic space = Below liver
Areas where fluid can accumulate, e.g. pus which may form an abscess. These spaces are in communication with each other and therefore infection can track around the peritoneal cavity e.g. Perforated appendix or peptic ulcer.
A chronic alcoholic comes into your clinic with dilated veins of the abdominal wall.
* As a doctor you must consider how this has occurred.
Obstruction of blood through liver will cause increased pressure in hepatic portal vein
This can cause enlargement of the spleen and caput medusa
(swelling of blood vessels due to increased pressure in portosystemic anastomoses)
caput medusa
Varicose enlargement of epigastric veins of the abdominal wall due to Portal Hypertension.
If we split the abdomen into 9 segments.
Which segment would we find the liver?
Is the liver intraperitoneal or retroperitoneal?
3
Right and left hypochondrium and epigastrium
intraperitoneal (except bare area)
Liver
surfaces
anatomical lobes (where are they??)
and functionality of the lobes
diaphragmatic - anterior
visceral - posterior
Gross anatomical lobes - when liver is flipped over
* Right lobe
* Left lobe
* Caudate lobe
* Quadrate lobe - at teh bottom always
(Caudate and quadrate are described as arising from right lobe)
Functionally:
* Caudate lobe is an independent lobe.
* Quadrate lobe to be considered part of left lobe
How is the liver divided into functional segments?
Why is this important clinically?
8 segments are based on distribution of portal venous branches
Each segment has its own portal blood supply
Thus we can remove parts of the liver without affecting the rest - CANCER, important surgically as removal of one segment will not affect the other segments- surgical resection surgery
What in the liver is equivalent to the hilum of the lung?
Which surface of the liver is it located on?
Porta hepatis (entrance and exit point of portal triad)
Located on the visceral surface
What is present in the porta hepatis
Portal triad (Common bile duct, common hepatic artery + hepatic portal vein)
Also left and right hepatic duct and cystic duct
Note the impressions on the visceral surface of the liver
What are all the ligaments of the liver (remnant ones)?
- falciform - liver to abomen wall connection
- round ligament - runs anteriorly, remnant of umbilical vein which carried O2 blood from placenta
- ligamentum venosum - remnant of ductus venosum, runs on visceral surface and used to be to shunt blood into IVC
What is the bare area of the liver?
clin relevance
No peritoneum on top surface of liver
Fence by the anterior and posterior coronary ligament which meet as the left and right triangular ligament
As a result of massive embryonic growth of liver in ventral mesogastrium
What is the clinical significance of the bare area?
Spread of infection from thorax to abdomen
Can also be a site of portal venous anastamoses
remnants of ligamentum venosum and round ligament?
- ductus venosus
- umbillical vein
label what you can
What is the Pringle maneuver?
Haemostat is used to clamp the hepatoduodenal ligament
Stops bleeding through common hepatic artery and hepatic portal vein during liver surgeries
Explain the blood supply in the liver?
dual blood supply?
Hepatic artery proper and hepatic portal vein will enter and be processed by sinusoids
The sinusoids will form central veins which will form hepatic veins
3 hepatic veins will join directly into the IVC and enter into the right atrium
liver recieves dual blood supply from vessels in teh portal hepatis
1 - portal hepatic vein - brings in 75% of blood to liver - from GIT - brings very nutrient rich blood, formed by superior mesenteric artery and splenic artery behind neck of pancreas
2 - proper hepatic artery - 25% blood of liver supply
all blood is then processed by sinusoids and taken into hepatic veins then IVC then right atrium
How many hepatic veins are there?
3; right, middle, and left
These will join directly into the IVC and enter into the right atrium
What forms the hepatic portal vein?
entry into liver to be processed in sinusoids
Blood from spleen and midgut through splenic vein (IMA) and superior mesenteric
How does blood from the hindgut enter the hepatic portal circulation.
What is an exception to this?
Via the inferior mesentaric which will enter into the splenic vein
1/3 of individuals, will enter directly into the hepatic portal vein
What are portosystemic anastomoses?
Collateral circulation between systemic (into ivc) and portal (into liver) circulation
(two options one to heart one to liver)
What are sites of portosystemic anastomoses? hint: OOO
O oesopphagus, O umbillicus bc its round, O anus bc its round
Oesophageal veins
Portal - left gastric
Systemic - Azygous
Peri-umbilical region
Portal - paraumbilical
Systemic - Epigastric
Anal canal
Portal - Inferior mesentaric vein
Systemic - Inferior and middle rectal veins
what are all teh ligaments of the liver (peritineum) formed from embryonic growth of liver in ventral mesogastrium
falciform
left and right triangular
anterior and posterior coronary
these form bare area
Gall bladder function
Stores extra bile for lipid digestion
Describe the flow of bile into the duodenum from the liver and gall bladder
Coming from liver: Left and right hepatic will form the common hepatic
Coming from gall bladder: Cystic duct
Common hepatic + cystic = form common bile duct which will empty into the duodenum
Label the diagram of the biliary tree
Spiral valve of gall bladder
Spiral folds
Opens cystic duct to release bile
What are common sites of obstruction for gall stones?
Hepatopancreatic ampulla of vater
Cystic duct
Hartmann’s pouch (infundibulum)
What are gallstones? and where do they commonly happen
Stasis of bile forming cholesterol or pigemented crystals
Can result in jaundice when bile does not leave the gallbladder and enters the blood
infundibulum
What artery supplies the gallbladder and where does it arise?
Cystic artery –>Right hepatic artery
what is jaundice
Jaundice occurs when bile cannot leave the gallbladder and enters the blood
There are three types of jaundice:
- Pre-hepatic: excessive red cell breakdown.
- Hepatocellular: dysfunction of hepatic cells.
- Post-hepatic: obstruction of biliary drainage e.g. gallstones or tumours.
o Dark urine
o Pale stools
o Yellow discoloration of sclera and skin
Referred gall bladder pain
inflammation of gallbladder = irritation of diaphragm which is supplied by RIGHT phrenic nerve at C3,4,5 and phrenic nerve has roots that supply back of shoulder
Nerve roots of the phrenic nerve are part of the same dermatome
Pain felt in gall bladder felt in diaphragm bc of right phrenic nerve
Q) what is the clinical term for inflammation of the gallbladder?
Cholecystitis
Location and function of pancreas
Posterior to stomach
Transpyloric plane passes through neck (L1)
Exocrine: Produces pancreatic juices in acinar cells.
Endocrine: Produces glucagon and insulin
What is the relationship of the pancreas and the peritoneum
Retroperitoneal apart from tail (splenorenal ligament)
The majority of the pancreas is retroperitoneal, however the tail is intraperitoneal and
closely associated with the hilum of the spleen.
Identify the structure of the pancreas and its anatomical relations
uncinate process came from ventral bud
What is the relationship of the neck and uncinate process of the pancreas to the superior mesenteric artery and vein?
SMA and SMV Will run behind neck and in front of uncinate process
Where is the splenic artery and vein in relation to the body of the pancreas?
Artery: Runs along superior body of the pancreas.
Vein: Just Inferior to splenic artery, posterior to the body of the pancreas
What is the blood supply to the pancreas?
4 arteries
Both coeliac and superior mesenteric arteries
Coeliac = x2
Splenic artery and Gastroduodenal (from common hepatic) which will branch to form anterior and posterior superior pancreaticoduodenal
Superior mesenteric = x2
superior and Inferior pancreaticoduodenal artery
What is the development of the pancreas?
Pancreas develops from the anterior ventral and dorsal posterior bud
Duodenum will rotate to the right causing ventral bus to migrate around the back of duodenum and fuse with dorsal bud
What is it called if the two components ventral pancreatic buds migrate in wrong directions around the duodenum?
What can this cause?
Annular pancreas
Can constrict duodenum and result in complete obstruction
What is Kocher’s manoeuvre?
Surgical procedure to get to the retroperitoneum (e.g. IVC / Aorta). Duodenum and head of
pancreas reflected to left.
What is the function of the duodenum?
What is the relationship of the duodenum to the peritoneum?
First part intraperitoneal = Hepatoduodenal ligament
Remaining portion = retroperitoneal
4 parts of the duodenum?
Superior
Descending
Horizontal/ inferior
Ascending
Where does the 1st part (superior) of the duodenum lie?
Transpyloric plane (L1) with the neck of spleen
duodenal cap/ ampulla
ulcers mainly occur here
suspended by hepatoduodenal ligament
intraperitoneal
Where is the 2nd part/ descending duodenum located?
What openings are present inside?
structure
L2/L3
Opening of Hepatopancreatic ampulla of Vater –> Major duodenal papilla
Accessory pancreatic duct –> Minor duodenal papilla
a common site for diverticula (Small, bulging)
plicae circulares
Where is the 3rd part of the duodenum located
What crosses it?
clin rel
L3
Superior mesenteric artery and vein cross it
Fistula can occur due to location of aorta - gastric contents flowing into aorta or vice versa
How does the fourth part of the duodenum join the jejunum?
2 important features of 2nd part DD
Major/ ampulla vater (hepatopancreatic ampulla) = bile enters
and minor (accessory pancreatic ampulla) papilla = pancreatic enzymes
What ligament connects holds the fourth part of the duodenum?
Ligament of Treitz/ Suspensory muscle of duodenum
Muscle features of DD
Part 1+2 = skeletal
Part 3+4 = smooth
second (descending) part of the duodenum.
What is the relationship of the transverse mesocolon to 2nd part?
Transverse mesocolon runs anterior to the 2nd part of the duodenum
What is the blood supply to the duodenum?
Superior part: Branches of coeliac trunk
Inferior part: Branches of superior mesenteric artery
Where do the lymphatic nodes of the duodenum drain
follows arteries superiorly from superior
pancreaticoduodenal to gastroduodenal to coeliac nodes.
Follows arteries inferiorly from inferior pancreaticoduodenal to superior mesenteric
nodes.
Where can we find the spleen?
On our left side, left upper quadrant
Left hypochondrium
What is spleens function?
Such a high flow of blood so rupture is urgent
WBC proliferation
Immune surveillance
Filters and stores RBC’s + platelets
Recycles iron and globin
Splenomegaly
What is a cause of splenomegaly?
How can we examine for this?
How can we treat splenomegaly?
Portal hypertension
infection, malaria
Can enlarge 10x normal size
Will need to palpate from right iliac fossa
Treatment is with a splenectomy
What is the blood supply of the spleen?
In what ligament do these run?
Splenic artery and vein
Run in the splenorenal ligament (hence organ is intraperitoneal)
what used to be the round ligaments (ligamentum teres) function?
used to be umbillical vein: bring oxygenated blood into the foetus from the placenta
where is ligamentum venosum
adjacent to caudate lobe on visceral surface of liver
what forms the hepatic portal vein and where?
teh 75% vein in porta hepatis
formed by superiro mesentric vein and the splenic vein
BEHIND (posterior) NECK OF PANCREAS
clinical relevance of 1st part of duodenum
duodenal ulcers happen here (dangerous bc can rupture through the mucosa)
where is hepatic portal vein in relation to superior duodenum
posterior
where is the SMA/SMV in relation to duodenum?
anterior to the 3rd inferior part of teh duodenum
where is the pillae circularis (muscular wall inside) of the duodenum?
2nd, 3rd and 4th part
what is the most common site for derviticula (small bulges or pockets that can develop in the lining of the intestine as you get older)
2nd part of DD
parts of the small intestine?
duodenum
jejunum
illium
what does the 4th part of the duodenum join with and whats the point called
joins jujenum at duodenojujenal flexure
how is the duodenum held up?
2 points (ligaments)
- 1st part of duodenum = hepatoduodenal ligament
- 4th (ascending) part of duodenum = ligament of treitz
what is the ligament of treitz
suspensory muscle of the duodenum that holds up teh ascending 4th part of duodenum
blood supply to duodenum (in relation to ampulla vater/ major hepatopancreatic ampulla)
everything above = coeliac –> gastroduodenal
everything below = SMA
arteries that come from the coeliac/ gastroduodenal and supply the duodenum?
GRASP
1 - gastroduodenal
2 - right gastro omental
3 - supraduodenal
4 - posterior superior pancreaticoduodenal
5 - posterior inferior pancreaticoduodenal
6 - anterior superior pancreaticoduodenal
7 - anterior inferior pancreaticoduodenal
A 52-year-old man has severe portal hypertension. Which portocaval shunt can be created in this patient to help decrease his blood pressure?
Splenic vein to the left renal vein
A portocaval shunt passes between a vein in the portal system and a vein in the systemic system. The left gastric, splenic, right gastric, superior mesenteric, and inferior mesenteric veins are part of the portal system. The right and left renal veins and the right gonadal vein are part of the systemic system. The correct answer is the only one with a vein in the portal system connecting with a vein in the systemic system.
A 12-year-old boy is undergoing liver transplant surgery. During the procedure, the surgeon places the tip of his finger posterior to the free edge of the lesser omentum. Which of the following structures is now positioned posterior to the tip of the surgeon’s finger?
IVC
The surgeon’s finger has been placed in the omental foramen, the entrance to the omental bursa. In the free edge of the lesser omentum and anterior to the surgeon’s finger are the hepatic artery proper, the common bile duct, and the portal vein. Posterior to the omental foramen and the surgeon’s finger is the inferior vena cava.
A 23-year-old woman is injured in an automobile collision. She is brought to the emergency department with severe abdominal pain and diagnosed with internal bleeding. Exploratory surgery indicates she has a severely damaged spleen that must be repaired. Which of the following structures is most likely to be encountered during this procedure?
Pancreas
The most appropriate answer to this question is the pancreas because the splenic artery passes across the superior border of the spleen and the tail of the pancreas is positioned near the hilus of the spleen. The other structures listed are not related to the spleen. The left suprarenal gland, left ureter, and right kidney are all retroperitoneal structures, and the inferior mesenteric artery is inferior to the spleen.
A 65-year-old woman complains to her physician of weight loss, vague abdominal pain, and significant low back pain. Examination shows obstructive jaundice. Pancreatic adenocarcinoma is considered the most likely cause of her problems. In which of the following parts of the pancreas is a tumor most likely located?
head
The jaundice suggests a blockage of the common bile duct, which passes through the head of the pancreas on its way to empty into the second part of the duodenum. Therefore, the tumor is most likely in the head of the pancreas.
A 56-year-old alcoholic has severe portal hypertension. Which of the following veins is most likely enlarged because of this condition?
hepatic
In this condition, the flow of blood through the liver is slowed and blood backs up throughout the portal system. Thus, the vein enlarged in this situation must be a vein that is part of the portal system. The superior rectal vein is the only one listed that satisfies that requirement.
