Anatomy- Jaundice Flashcards
what is jaundice
yellowing of the sclera (white of the eyes) and the skin
what causes jaundice
an increase in bilirubin in the blood
what is bilirubin
is a normal bi product of the breakdown of red blood cells
where does the break down of red blood cells mainly occur
in the spleen
what is bilirubin used to form and where does this hapen
bile, in the liver
how does bile leave the liver
travels through a set of tubes connecting the liver to the 2nd part of the duodenum
THE BILIARY TREE
what is the role of the gallbladder
the storage and concentration of bile
why is bile important
for the normal absorption of fats from the small intestine
what does the pancreas do
excretes digestive enzymes into the 2nd part of the duodenum- necessary for digestion
what is the largest organ in the body
the liver
what are the functions of the liver
glycogen storage,
bile secretion,
other metabolic functions
what quadrant is the liver in
right upper
what ribs protect the liver
7-11
why does the location of the liver change
during breathing as it is attached to the diaphragm
anatomical relations: the liver is… to the right hemi-diaphragm
inferior
anatomical relations: gallbladder to the liver
posterior and inferior
anatomical relations: hepatic flexure to thr liver
inferior
anatomical relations: right kidney, right adrenal gland, IVC and abdominal aorta to the liver
posterior
anatomical relations: stomach to the liver
posterior at mid/left side
why do pathologies of spread from the liver to the IVC
as very connected
how many anatomical lobes does the kidney have and what are they called
4 right left caudate quadrate
why is the caudate lobe called that
as it looks like a tail, isn’t caudal
what is the porta hepatis
site of entry for portal triad structures
how many functional lobes does the liver have and what are they related to
8
vasculature and drainage
what divides the right and left lobes of the liver
the falciform ligament
what is the round ligament of the liver
at end of falciform ligament
is a remnant of the umbilical vein
where does the falciform ligament attach to
the abdominal wall
what do the functional lobes allow for and how
segmentectomy
what does each functional segment have
branch of hepatic artery, branch of a hepatic portal vein, bile drainage, venous drainage
where does the venous drainage of the liver drain into
the IVC
where does bile drain from the liver into
the bile duct
what do the IVC and hepatic veins lack
valves
why can an increase in central venous pressure cause liver disease
as no valves, can lead to an back pressure directed at the liver
how do you remeber the segments of the liver
thumb in fist, knuckles divinding line
thumb 1, 1st upper 2 lower 2, 2nd whole 4, 3rd lower 5, pinky lower 6 upper 7, 3rd upper 8
what happens to the hepatic veins carrying blood from the liver before they enter the IVC
the 3 come together
what structures are within the portal triad
hepatic portal vein, hepatic artery proper, bile duct
what do the structures in the portal triad run within
the hepatoduodenal ligament
what is the coeliac trunk
the first three midline branches of the aorta
where is the coeliac trunk found
retroperitoneal, leaves aorta at T12
what does the coeliac trunk supply
organs of the foregut
what does the coeliac trunk split into
3 branches
- splenic artery
- left gastric artery
- common hepatic artery
what artery supply the lesser curvature of the stomach
the left gastric
describe the splenic artery
wiggly and big, goes posteriorly to stomach to spleen
where does the hepatic artery proper originate from
common hepatic artery (commener gives of gas and becomes proper) (gas= gastroduodenal artery)
what is the course of the splenic artery
tortuous course along the superior border of the pancreas to the spleen
where is the spleen found
intraperitoneal organ
in left hypochondrium
what ribs protect the spleen
9-11
anatomical relations: diaphragm to the spleen
posterior
anatomical relations: stomach to the spleen
anterior
anatomical relations: splenic flexure to the spleen
inferior
anatomical relations: left kidney to the spleen
medially
what could a rib fracture do to the spleen
pierce it as its soft, delicate and this can lead to substantial internal bleeding
where is the spleen in relation to the mid axillary line
posterior, ruptured by trauma to the back
what organs in the abdomen move with respiration
spleen and liver
when is the spleen usually felt in a clinical exam
under pathological conditions
where are the right and left gastric arteries
anastomose together, travel along the junction of lesser curvature and lesser omentum
what are the major blood supplies to the stomach
right and left gastric, right and left gastro-omental arteries
where are the right and left gastro-omental arteries
along junction of greater curvature and greater omentum, anastomose together
what are the minor blood supplies to the heart
posterior gastric arteries, short gastric arteries
where does the blood supply to the liver come from
right and left hepatic arteries (branches of the hepatic artery proper)
describe the dual blood supply of the liver
20-25% of the blood received by the liver is from the hepatic artery proper branches, rest is from hepatic portal vein
describe the structure of a liver lobule
central vein in middle,
interlobular portal triad at each corner (hexagon)
what is the interlobular portal triad
branch of hepatic portal vein, branch of hepatic artery, biliary duct
where does bile formed in the hepatocytes drain into
drains into biliary duct
what is a hepatocyte
liver cell
what does the central vein collect and where does it take it
‘cleaned’ blood,
drains into the hepatic veins
what is the role of hepatocytes
remove toxins and produce bile
what are the two clinically important recesses relating to the liver
hepatorenal recess (morison's pouch), sub-phrenic recess
what are both recesses associated with the liver in
the greater sac
how can the recess be associated with peritonitis
peritonitis can result in a collection of pus in these recesses leading to an abscess formation
what is the role of the hepatic portal vein
drains blood from the foregut, midgut and hindgut to the liver for first pass metabolism (cleaning)
what forms the hepatic portal vein
splenic vein and superior mesenteric vein
what vein drains the foregut
the splenic vein
what vein drains the midgut
superior mesenteric vein
what does the inferior mesenteric vein do
drains the blood from the hindgut to the splenic vein
where is the IVC in relation to the peritoneum
retroperitoneal
what is the role of the IVC in relation to the liver
drains the cleaned blood from the hepatic veins into the right atrium
where is the gall bladder
lies of the posterior aspect of the liver (often firmly attached), anterior to the duodenum
what risk does the narrowing of gall bladder create
gallstone impaction
via what structure does the bile flow in and out of the gall bladder
via the cystic duct
what is the blood supply of the gall bladder
cystic artery
what is the triangle of calot
‘cystohepatic’ triangle made by cystic duct and common hepatic duct, in which the cystic artery is found
what is the cystic artery a branch of in 75% of people
right hepatic artery
what causes gall bladder pain
inflammation of the gallbladder or cystic duct following irritation/impaction from a gallstone
where do the visceral afferent for the gallbladder enter the spinal chord
t6-9 as gallbladder a foregut organ
where will early gallbladder pain present
in the epigastric region
where is a secondary site if gallbladder pain
can present in the hypochondrium, with/without pain referral to the right shoulder as a result of anterior diaphragmatic irritation
what is a cholecystectomy
surgical removal of gallbladder
what is bilirubin used to form and where
bile in the liver
what is jaundice a symptom of
liver disease
what do the right and left hepatic ducts combine to form
the common hepatic duct
what does the common hepatic duct unite with to form what
unites with the cystic duct to form the bile duct
what is the bile duct also known as
the common bile duct
where does the bile duct drain into
the 2nd part of the duodenum
what drains with the bile duct into the duodenum
the pancreatic duct
what are the four parts of the duodenum
superior (+ duodenal cap), descending, horizontal, ascending
what parts of the duodenum are retro-peritoneal
descending, horizontal, ascending
how mobile is the duodenal cap
relatively
where does the duodenum begin
at the pyloric sphincter
what is the pyloric sphincter made of and what innervates it
smooth muscle- autonomic nerves (symp contraction, para relaxation)
where does the duodenum end
at the duodenojejunal flexure
what does the duodenum secrete into the blood
peptide hormones (gastrin, CCK)
where does the duodenum go retroperitoneal
at the head of the pancrease
when is CCK released in to the blood and what does it do
released as fat enters the duodenum and stimulates the digestion of fat and protein- increases bile production
where does pain from duodenal ulcers tend to present
in the epigastric region
where is the pancreas
retroperitoneal, lies transversely across the abdomen
what are the part of the pancreas
head (with uncinate- hook- process), neck, body, tail
how is the duodenum associated with the pancreas
the head of the pancreas is surrounded by the duodenum
where does the tail of the pancreas lie
close to the hilum of the spleen
why is the pancreas secondarily retroperitoneal
as in embryo is it peritoneal (e.g. kidneys primary peritoneal)
what is posterior to the pancreas
- right KIDNEY and adrenal glad
- IVC
- bile duct
- abdominal aorta
- superior mesenteric vessels
- left kidney and adrenal gland
- part of the portal venous system
what is anterior to the pancreas
the stomach
what surrounds the head of the pancread
the duodenum
what is superoposterior to the pancreas
the splenic vessels
where does the aorta lie
anterior to the body of vertebrae
what are the two functions of the pmacreas
exocrine (acinar cells release digestive enzymes into main pancreatic duct)
endocrine (islets of langerhans release hormones (insulin and glucagon) into the blood stream)
what stimulates acinar cells
sympathetic stimulation
what part of the duodenum does the bile duct drain posterior to
the 1st (superior) part
where does the bile duct pass via the pancreas
in a groove on the posterior aspect of the pancreas
what duct does the bile duct join with
the main pancreatic duct
what is the lepatopancreatic ampulla of vater
formed when bile and main pancreatic ducts combine
where does the ampulla of vater drain
into the second part of the duodenum
how does the ampulla of vater drain into the duodenum
via the major duodenal papilla, found on the major duodenal papilla
what are the sphincters of the biliary system
bile duct sphincter, pancreatic duct sphincter, sphincter of oddi
what is the role of the sphincter of oddi
controls amount of bile and pancreatic juices that get into duodenum
what controls the spincters
hormonal and neurological control
what is an ERCP
an investigation used to study the biliary tree and pancreas
how does an ERCP work
Endoscope inserted through oral cavity, oesophagus, stomach and into duodenum
Cannula placed into major duodenal papilla and radio-opaque dye injected back into biliary tree
Radiographic images are taken of the dye-filled biliary tree
why does the cystic duct look wispy on an ERCP
as a spiral duct- acts as storage mechanism due to slow drainage
what would happen to the levels of bilirubin in the blood if there was an obstruction somewhere in the biliary tree
there would be a flow of bile back up to the liver an it would overspill into the blood (including bilirubin)
what would cause an onbstruction of the biliary tree
gallstones or carcinoma at the head of the pancreas (enlarges it)
what is post hepatic jaundice caused by
extra- hepatic (outside the liver) obstructions
where does the gastroduodenal artery come from
common hepatic
where does the splenic artery come from
the celiac trunk
where does the pancreaticoduodenal artery come from
gastroduodenal
what does the superior pancreaticoduodenal artery anastosmose with
the inferior pancreaticoduodenal artery
where does the inferior pancreacticoduodenal artery come from
the superior mesenteric
where does the superior mesenteric artery come from
aorta at L1
where do the dorsal pancreatic arteries come from
splenic arteries
why does the pancreas have high vasculature
due to its endocrine function
where do the vasculature of the fore gut and mid gut combine
at the superior and inferior pancreaticoduodenal artery anastomoses
what is a common cause of pain arising from the pancreas
secondary to pancreatitis
what is a common cause of pancreatitis
blockage of the ampulla by a gallstone- bile is diverted into the pancreas leading to irritation and inflammation
is the pancreas a fore or mid gut organ
both
where can pain from the pancreas present
in the epigastric and/ or umbilical region- can also radiate through to patients back
what can happen when acute pancreatitis causes vascular haemorrhage
blood/fluid accumulation in the retroperitoneal space
how can pancreatitis cause vascular haemorrhage
digestive enzymes in blood stream from overfill of pancreatic juice in pancreatic duct
what is an anatomical clinical sign of vascular haemorrhage due to acute pancreatitis
grey-turners sign (righto or left flanks)
cullens sign (around umbillicus)
why is the umbillicus affected by acute pancreatitis
due to embryological remnant of round ligament- leads to falciform ligament
what are the three parts of the small intestine
duodenum, jejunum, ilieum (DJ ileum)
what parts of the small intestine are in the foregut
the 1st and second parts of the duodenum- rest mid gut organs
where does the jejunum begin
at the duodenaljejunal flexure
where does the ileum end
ileocaecal junction
what are the difference between the jejunum and ileum
Colour
Jejunum is deep red
Ileum is lighter pink
Wall
Jejunum is thicker and heavy
Ileum is thinner and lighter
Vascularity
Jejunum is more vascular
Ileum is less vascular
Mesenteric Fat
Jejunum has less
Ileum has more
Circular Folds (L. plicae circularis)
Jejunum has large, tall and closely packed fold
Ileum has low and sparse folds (absent distally)
Lymphoid Tissue (Peyer’s Patches) - Present in ileum
why is the jejunum a darker colour than the ileum
as it is more vascularised
what is a plicae
fold
why is the jejunum more absorptive
as it has more folds
what is the arterial supply to the jejunum and ileum
superior mesenteric arteries via jejunal and ileal arteries
what is the venous drainage of the jejunum and ileum
jejunal and ileal veins to superior mesenteric vein
and to hepatic portal vein
where do proteins and carbs go after they have been absorbed
from small intestine into the portal venous system to be taken to the liver
where do vessels travel within to get to the small intestine
within the mesentery
where does the SMA leave the aorta
L1
what is the path of the SMA in relation to the pancreas
Posterior to the neck of the pancreas
Travels inferiorly, Anterior to the Uncinate process of pancreas to enter the mesentery proper
what helps in the absorption of fats from the GI tract lumen into the intestinal cells
bile
where does fat go from the intestinal cells
Fats (within chylomicrons) are then absorbed from intestinal cells into specialised lymphatic vessels of the small intestine called lacteals
They travel via the lymphatic system to eventually drain into the venous system
where does fat drain into the venous system
at the left venous angle
alongside what do lymph vessels tend to lie alongside
arteries
what is the group of lymph nodes for the foregut called
celiac
what is the group of lymph nodes for the midgut called
superior mesenteric
what is the group of lymph nodes for the hindgut called
inferior mesenteric
what is the group of lymph nodes for the kidneys, posterior abdo wall, pelvis and lower limbs called
lumbar
where do superficial lymph vessels drain into
deep lymph vessels
Depending on where it originated from, lymph will either drain into where
Thoracic duct (from ¾ of body)
or
Right lymphatic duct (from ¼ of body)
why and where does lymph drain into the venous system
It will eventually drain into venous system for ‘recycling’ at venous angles:
where are the venous angles
junction between subclavian and internal jugular veins
what does the left venous angle collect
thoracic duct drainage
what does the right venous angle collect
right lymphatic duct drainage
