ABDOMEN III Flashcards
What’s the blood flow per minute to the liver?
1.5L per minute
What does percussion of the liver give?
Percussion gives an area of dullness compared with the resonant lung above and the abdominal contents below, as the liver is solid
Where does the liver develop?
In the ventral mesogastrium
Name the 4 lobes of the liver?
The left lobe, right lobe, caudate lobe and quadrate lobe
What ‘fences’ the bare area on the diaphragmatic surface of the liver?
Peritoneal reflections which pass from the surface of the liver to the diaphragm
What are the boundaries of the bare area of the diaphragmatic surface of the liver?
The anterior and posterior coronary ligaments
What do the coronary ligaments unite to form on the left and right of the superior surface?
The left and right triangular ligaments
What’s the clinical significance of the bare area of the liver?
It represents a site where infection can spread from the abdominal cavity to the thoracic cavity
What does the falciform ligament separate?
The left and right lobes of the liver
What does the falciform ligament attach the liver to?
The anterior abdominal wall
What is the thickening in the free edge of the falciform ligament?
The round ligament (ligamentum teres)
What lobe is the ligamentum teres adjacent to on the visceral surface of the liver?
The quadrate lobe
What is the ligamentum teres the remnant of?
The embryonic umbilical vein
Where is the ligamentum venosum?
Adjacent to the caudate lobe on the visceral surface of the liver
What is the ligamentum venosum a remnant of?
The ductus venosus of the foetal circulation
What does the ductus venosus do in foetuses?
It shunts a portion of umbilical vein blood flow directly into the inferior vena cava to allow oxygenated blood from the placenta to bypass the liver
What is the porta hepatis?
A transverse fissure that allows the passage of the portal triad into/out of the liver. It actually contains 5 structures, not 3.
What is the portal triad?
The proper hepatic artery, the hepatic portal vein and bile ducts
What does the portal triad run through?
The free edge of the lesser omentum
What are the 5 structures of the porta hepatis?
The proper hepatic artery The hepatic portal vein The Common bile duct Lymphatic vessels A branch of the vagus nerve
What is Pringle’s manoeuvre?
A surgical manoeuvre used in certain abdominal operations, where a large atraumatic haemostat is used to clamp the hepatoduodenal ligament , interrupting the flow of blood through the hepatic artery and portal vein, helping to control bleeding from the liver
How many hepatic veins are there usually and where do they drain?
There are usually 3 hepatic veins that drain directly into the inferior vena cava from the central veins of the liver
What makes up the dual blood supply of the liver
The hepatic portal vein and hepatic arteries
What proportion of the livers blood supply comes via the hepatic portal vein?
Around 75%
What does the hepatic portal vein carry?
It carries venous blood drained from the spleen, GI tract and its associated organs
Why does the hepatic portal vein carry venous blood from the spleen, GI tract, pancreas and gallbladder to the liver?
The blood contains toxins and nutrients extracted from digestive contents so it’s taken to the liver for filtration
What veins unite to form the hepatic portal vein?
It’s formed by the merging of the superior mesenteric vein and splenic veins behind the upper edge of the head of the pancreas. It also receives blood from the inferior mesenteric, left and right gastric, and cystic veins
What causes portal hypertension?
When scarring and fibrosis from cirrhosis obstruct the portal vein in the liver, causing pressure in the portal vein and its tributaries to rise
What does portal hypertension cause at the sites of the porto-systemic anastomoses?
Portal Hypertension causes enlarged varicose veins and blood flows from the portal system to the systemic system of veins
What are oesophageal varices?
Extremely dilated submucosal veins in the lower 1/3 of the oesophagus, often due to obstructed blood flow through the portal vein
What is splenomegaly?
A condition of enlargement of the spleen which can commonly be caused by portal hypertension
What are anorectal varices?
Extremely dilated submucosal vessels due to back flow in the veins of the rectum. This typically occurs due to portal hypertension, which shunts venous blood from the portal system through the Portosystemic anastomosis present at this site into the systemic venous system
What is caput medusa?
The appearance of distended and engorged superficial epigastric veins, which are seen radiating from the umbilicus across the abdomen. It’s a sign of portal hypertension
What are gastric varices?
Dilated submucosal veins in the stomach, which can be a life-threatening cause of bleeding in the upper GI tract. They are most commonly found in patients with portal hypertension
Name 5 clinical presentations that can result from portal hypertension?
Oesophageal, anorectal and gastric varices, splenomegaly and caput medusa
How much bile can the gall bladder store?
Up to 50ml
Where is the gall bladder?
Behind the tip of the right 9th costal cartilage, where the lateral margin of the rectus abdominis crosses the costal margin
Name the 4 features of the gall bladder
The fundus
The body
The neck
The infundibulum (Hartmann’s pouch)
What artery supplies the gallbladder and where does it arise?
The gallbladders blood supply comes from the cystic artery- a branch of the right hepatic artery
Name 7 features of the biliary tree?
The right and left hepatic ducts The common hepatic duct The cystic duct The common bile duct The hepatico-duodenal ampulla (of Vater) The major duodenal papilla
What is cholelithiasis?
The formation of gallstones
What is cholecystectomy?
One of the most common surgical procedure worldwide. It’s open or laparoscopic removal of the gallbladder as treatment for gall stones
Where do gall stones commonly collect?
In the infundibulum
What happens when a gallstone blocks the bile duct?
A cramp-like pain in the right upper quadrant of the abdomen, known as biliary colic, can result
What may happen 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
What is a peptic ulcer?
An open sore that develops on the inside lining of the stomach or the duodenum
What causes a peptic ulcer?
Infection with the bacterium Helicobacter pylori and long-term use of aspirin and NSAIDs
What are the 2 types of gall stones?
Cholesterol gall stones and pigment gall stones
Cholesterol gall stones are a yellow-green colour and account for around 80%. Pigment gall stones are small and dark brown. They’re made of bilirubin
What increases risk of gallstones?
Female Fair Fat Forty Fertile
What are the main functions of the pancreas?
Blood glucose regulation- Islets of Langerhans
Digestion- secretion of pancreatic juices- acinar cells
Secretes pancreatic polypeptide and VIP. Enterochromaffin cells secrete motilin, serotonin and substance P
Is the pancreas retroperitoneal or intraperitoneal?
The majority of the pancreas is retroperitoneal, but the tail is intraperitoneal
What is the tail of the pancreas closely associated with?
The hilum of the spleen
What is the head of the pancreas closely associated with?
The duodenum
What space separates the pancreas from the stomach?
The triangular space in which the gastrohepatic ligament is found
What forms the gastrohepatic ligament?
The left lateral extension of the peritoneal layers of the greater omentum
What does the gastrosplenic ligament connect?
It connects the greater curvature of the stomach with the splenic hilum
What is the uncinate process?
The formed prolongation of the angle of junction of the lower and left lateral borders in the head of the pancreas
What is annular pancreas?
A congenital defect whereby the uncinate pancreas splits and encircles the pancreas
Where do the superior mesenteric artery and vein run in relation to the uncinate process?
Anterior to the uncinate process
What vessels run posterior to the neck of the pancreas?
The superior mesenteric artery, superior mesenteric vein and the portal vein
What attaches to the anterior surface of the body of the pancreas?
The transverse mesocolon
What compartment of the peritoneal cavity does the pancreas lie in?
Both the supra-colic and infra-colic compartments due to its attachment to the transverse mesocolon
What ligament does the tail of the pancreas run in?
The spleno-renal ligament
What is a pancreatic pseudocyst?
A collection of enzyme rich fluid and blood encapsulated in the area of the pancreas, often caused by pancreatitis or abdominal trauma
What accounts for most cases of extra-hepatic obstruction of the biliary system?
Cancer involving the head of the pancreas
What does extra-hepatic obstruction of the biliary system cause?
Obstructive jaundice, resulting in the retention of pigments, enlargement of the gall bladder and jaundice
What may cancer of the neck and body of the pancreas cause?
Obstruction of the portal vein or inferior vena cava
What is a Whipple’s procedure?
An operation to remove the head of the pancreas, the duodenum, the gall bladder and the bile duct to treat tumours and other disorders of the pancreas, duodenum and bile duct. It’s most often used to treat pancreatic cancer confined to the head of the pancreas. The remaining organs are then reconnected
What is Kocher’s manoeuvre?
A surgical manoeuvre to expose structures in the retroperitoneum behind the duodenum and pancreas to control haemorrhage from the IVC or aorta, or to facilitate removal of a pancreatic tumour
Is the spleen intraperitoneal or retroperitoneal?
Intraperitoneal
What is the spleen derived from and where does it develop?
The embryological foregut
Within the dorsal mesogastrium
What connects the spleen to the stomach?
The gastrosplenic ligament
What connects the spleen to the kidney?
The splenorenal ligament
What ribs is the spleen behind?
The left 9th, 10th and 11th ribs
What do 1,3,5,7,9,11 mean in the context of the spleen?
Its dimensions are 1” x 3” x 5”, it weighs 7 oz and it lays behind ribs 9-11
Where does the splenic artery arise?
The coeliac trunk
What does the splenic artery run superior to to enter the spleen at the hilum?
The body of the pancreas
What categorises a splenic artery aneurysm?
A dilation of the splenic artery that exceeds a diameter of 1cm. SAA rupture is associated with relatively high mortality
What drains blood from the spleen?
The splenic vein, which also receives blood from the inferior mesenteric vein
Where does the splenic vein form the hepatic portal vein?
Where it unites with the superior mesenteric vein posterior to the neck of the pancreas
Where would you begin palpitation for splenomegaly?
The patient should be supine and with knees flexed. The examiner should begin well below the left costal margin and feel considerately firmly for the splenic edge by pushing down, then cephalad, then releasing.
How much bigger would the spleen have to be to extend below the costal margin?
It would have to have doubled in size
