Anatomy 3 and 4 - Patient with Jaundice Flashcards
Medical name for jaundice
Icterus
what is jaundicewhat is it caused by
Yellowing of sclera/ skinAn increase in the blood levels of bilirubin
What is bilirubin a normal by-product of?
The break down of red blood cells
Where does the breakdown of red blood cells normally occur (where is bilirubin produced)?
Spleen (and then passes to the liver where it is used to form bile)
what is bilirubin used to form
Bile
Where is bile formed
The liver
Where is bile stored and concentrated?
The gallbladder
what does bile pass through to get to the gallbladder from the liverWhat is this
Biliary treeA set f tubes connecting the liver to the 2nd part of the duodenum
What is bile important for
The normal absorption of fats from the small intestines
What other organ, apart from the gallbladder, excretes digestive enzymes into the 2nd part of the duodenum?
The pancreas
Where is the portal triad found
in the free edge of the lesser omentum
What are the 3 important “tubes” in the portal triad?
Hepatic arteryHepatic portal veinCommon bile duct
What part of the portal triad is part of the biliary tree?
The common bile duct (part of biliary tree)
What does the portal triad also contain (apart from the 3 tubes)
Nerve and lymphatics
Where does the celiac trunk branch from
First of 3 midline branches from the abdominal aorta (retroperitoneal)
At what level does the celiac trunk arise
From around T12
What organs does the celiac trunk supply
The organs of the foregut
What are the 3 branches of the celiac trunk
Splenic arteryHepatic artery Left gastric artery (each of these arteries then give rise to further arteries)
What kind of course does the splenic artery take
A very tortuous course along the superior border of the pancreas
In relation to the peritoneum, what type of organ is the spleenWhich region of the abdomen is it in
Intraperitoenal left hypochondrium
What is the function of the spleen within the haematological system
To break down red blood cells to produce bilirubin
Which ribs protect the spleen
Ribs 9-11 (rib fractures can therefore pierce the soft delicate spleen and cause substantial internal bleeding)
Where does the blood supply to the stomach mainly come from (2)
Right and left gastric arteries which run along the lesser curvature of the stomach and anastomose together Also the right and left gastro-mental arteries which run along the greater curvature and anastomose together
Where does the blood supply to the liver come from?
Hepatic artery which branches into the right and left hepatic arteries (this only accounts for about 20-25% of blood received by the liver - the rest comes from the hepatic portal vein)The liver has a dual blood supply
What is the liver anatomically related to?
The diaphragm, stomach, gallbladder, hepatic flexture, right kidney and right adrenal gland, IVC and abdominal aorta
Where does the gallbladder sit on the liver
Not the posterior and inferior surfaces
What type of organ is the liver
A major metabolic organ and converts bilirubin to bile
Which ribs protect the liver
7-11
4 anatomical segments of the liver
Right lobeleft lobecaudate lobe (more posterior and superior)Quadrate lobe (more anterior and inferior)
What does each of the 8 functional segments of the liver have?
Its own blood supply (hepatic artery and hepatic portal vein), venous drainage and bile drainage
What is hepatic drainage from the liver into
3 main hepatic veins that drain into the IVC
What does the fact that the IVC and hepatic veins lack valves mean
A rise in central venous pressure is directly transmitted to the liver and therefore can cause liver enlargement as it engorges it with blood (hepatomegaly)
What is segment I of the liver
The caudate lobe (rarely seen on images)
What does each liver lobule have in the middle and at each corner
Middle = central veinEach corner = interlobular portal triad
What is the interlobular portal triad made up of
Branch of HPV, branch of HA, biliary duct (bile formed in hepatocytes drains here)
What does the central vein in a hepatocyte do
Collects “cleaned” blood and drains into the hepatic veins
What are the 2 clinically important areas of the peritoneal cavity related to the liver
Hepatorenal recess (Morrison’s Pouch)Subphrenic recess(both within the greater sac)
What can peritonitis result in (in relation to the clinically important areas of the peritoneal cavity related to the liver)
A collection of pus in the hepatorenal recess and subphrenic recess leading to an abscess formation (the hepatorenal recess is one of the lowest parts of the peritoneal cavity when a patient is supine meaning that pus from an access in the subphrenic recess can drain into the hepatorenal recess when a patient is bedridden)
Hepatic portal vein
Drains blood from the foregut, midgut and hindgut to the liver for first pass metabolism (cleaning)
Splenic vein
Drains the blood from the foregut to the hepatic portal vein
Inferior mesenteric vein
Drains the blood from the handgun to the splenic vein (there can be variations in where this joins)
Superior mesenteric vein
Drains the blood from the midgut to the hepatic portal vein
inferior vena cava
RetroperitonealDrains the cleaned blood from the hepatic veins into the right atrium
Ligaments of the liver and where they attach to?
Coronary ligaments (attachment to the diaphragm)Falciform ligament (attachment to the anterior abdominal wall)Ligamentum teres/ round ligament (remnant of the embrylogical umbilical vein)
Where does the gallbladder lie
The posterior aspect of the liver (often firmly attached) - anterior to the duodenum
What is the purpose of the gallbladder
To store and concentrate bile in between meals
Parts of the gallbladder
BodyNeckNeck narrows to form cystic duct (potential site for gallstone impaction)
How does bile flow into and out of the gallbladder
Through the cystic duct
What provides a blood supply to the gallbladder
The cystic artery (branch of right hepatic artery in 75% of people)
What causes gallbladder pain
Inflammation of the gallbladder or cystic duct following irriation from or impaction of a gallstone
Is the gallbladder a foregut/ midgut or hindgut organwhere does the visceral afferents for it enter the spinal cord
Foregut organT6-T9
where will early pain from the gallbladder be presentWhere might pain also be presentWhere can you get referred pain from the gallbladder and why
In the epigastric regionHypochondriumRight shoulder due to anterior diaphragmatic irritation
Name for surgical removal of the gallbladder
Cholecystectomy (must be able to correctly identify the cystic duct and cystic artery)
What do the right and left hepatic ducts unite to form
The common hepatic duct
What does the common hepatic duct unite with and what does this form
Common hepatic duct and cystic duct unite to form the (common) bile duct
What does the bile duct drain intoWhat else drains into here at this point
The 2nd part of the duodenum The pancreatic duct
Where does the bile duct travel in relation to the duodenum and pancreas
It travels posteriorly to the 1st part of the duodenum and then travels in a groove on the posterior aspect of the pancreas before joining with the main pancreatic duct
What does bile duct join with to form
It joins with the main pancreatic duct to form the ampulla (of Vater)/ hepatopancreatic ampulla
What does the ampulla drain into
The 2nd part of the duodenum through the major duodenal papilla
What is the small bump where the ampulla joins the duodenum called
The major duodenal papilla
What are the 4 (5ish) parts of the pancreas
The head (with uncinate process), neck, body and tail
What are the names of the 3 smooth muscle sphincters in the areas around the biliary tree joining to the duodenum?
bile duct sphincterpancreatic duct sphincterSphincter of Oddi (at papilla)
What is endoscopic retrograde cholangiopancreatography?What happens during this?
Investigation used to study the biliary tree and pancreas (also used to treat some pathologies associated with it)An enoscope is inserted through the oral cavity and into the duodenum A cannula is placed into the major duodenal papilla and radio-opaque dye injected back into the biliary tree
What can obstruct the biliary tree?How does this cause jaundice?
Gallstones and carcinoma at the head of the pancreasFlow of bile back up into the liver causing bilirubin to overspill into the blood (there are also many other intra-hepatic causes of jaundice)
What is the head of the pancreas surrounded by
The duodenum
Where does the splenic artery and vein lie in relation to the pancreas
Splenic vein = directly posterior to the pancreasSplenic artery = supra-posterior border of the pancreas
Exocrine and endocrine cells of the pancreas?
Exocrine = acinar cell (pancreatic and digestive into the main pancreatic duct)Endocrine = islets of Langerhans (insulin and glucagon into the bloodstream)
Sympathetic nerve supply to the pancreasParasympathetic supply
Abdomino pelvic splanchnic Vagus (these form celiac ganglia and sup. mesentery ganglia as well as periarterial plexus)
Blood supply to the pancreas (3)
Mainly pancreatic branches of the splenic arteryAlso superior pancreaticoduodenal (continuation of gasproduodenal artery that branches from the hepatic artery)Also inferior pancreaticoduodenal (branch of the superior mesenteric artery)
How does blockage of the ampulla by a gallstone cause pancreatitis?
Bile is diverted up into the pancreas leading to irritation and inflammation
Where can pain from the pancreas be felt
In the epigastric and/or umbilical region (it is a foregut and midgut organ)It can radiate to the back
What parts of the small intestines are foregut organs
The 1st and 2nd part of the duodenum (the rest of the small intestines are midgut organs)
4 parts of the duodenum
1st part = superior (duodenal cap)2nd = descending3rd = horizontal4th = ascending
Is the duodenum retroperitoneal or intraperitoneal
Retroperitoneal except the duodenal cap which is part intraperitoneal and therefore relatively mobile
What does the pyloric sphincter do?Type of muscle forming itNerve supply type
Controls flow of chyme from stomach to duodenum Smooth muscleAutonomic nerves (S = contraction, P=relaxation)
What hormones are secreted by the duodenum
Gastrin?CCK (cholecystokinin)
where does pain from a duodenal ulcer tend to be present
In the epigastric region
Blood supply to the duodenum (2)
superior pancreaticoduodenal (continuation of gastroduodenal artery that branches from the hepatic artery)inferior pancreaticoduodenal (branch of the superior mesenteric artery)
At what flexure does the jejunum begin
The duodenaljejunanal flexure
At what junction does the ileum end
Ileocaecal junction
How can you tell the difference between the jejunum and ileum
The mucosa differs between the jejunum and ileum (jejunum = highly folded with plicae circularis whilst the mucosae of the distal ileum is much smoother)
Where is most of the ileum and most of the jejunum found
Jejunum = LUQIleum = RLQ
What are the folds in the jejunum called
Plicae circularis
What provides arterial blood supply to the jejunum and ileum
Superior messenteric artery via jejunal and ileal arteries
What provides venous drainage from the jejunum and ileum
Jejunal and ileal veins which drain into the superior mesenteric vein which drains into the hepatic portal vein
What does bile do
Helps the absorption of fats from the GI tract lumen into the intestinal cells
What happens to fats within chylomicrons in intestinal cells
They are absorbed into specialised lymphatic vessels of the small intestines called lacteals They then travel via the lymphatic system to eventually drain into the venous system
What do lymph vessels tend to run alongside
Arteries
What are the 4 main groups of lymph nodes draining abdominal organs
Celiac (foregut organs)Superior mesenteric (midgut organs)Inferior mesenteric (hindgut organs)Lumbar (kidneys, posterior abdo. wall, pelvis and lower limbs)
Where does lymph drain into? (2)
Thoracic duct (from 3/4 of body)Right lymphatic duct (from upper right quarter of body)
Where does the thoracic duct and right lymphatic duct drain into
They both drain into the junction between the subclavian and internal jugular vein on the correct side (left venous angle and right venous angle)
