Anatomy of the liver Flashcards by Emer Mulholland

Where is the subphrenic recess?

between the diaphragm and liver anteriorly (divided longitudinally by the falciform ligament)

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Where is the hepatorenal recess?

between postero-inferior surface of the liver and superior surface on the kidney (on the right)

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What is the hepatorenal recess also known as?

Pouch of Morrison –> site for fluid buildup

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Describe the different lobes of the liver.

There are 4 lobes:

right lobe has 2 accessory lobes: main lobe and then the caudate and quadrate lobes
caudate lobe: between fissure for ligamentum venosum and groove for IVC
left lobe: liver attached to anterior abdominal wall via the falciform ligament (continuation of ligamentum teres)

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Name the different ligaments associated with the liver.

Coronary ligament
Left triangular ligament
Falciform ligament
Ligamentum teres
Ligamentum venosum

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What are the borders of the bare area?

anterior + posterior coronary ligaments (meet at right triangular ligament)
reflection of peritoneum from diaphragm

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Which ligaments connect the liver to the lesser omentum?

hepatoduodenal and hepatogastric

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What structures enter and leave the porta hepatis?

Enter:

proper hepatic artery
hepatic portal vein

Leave:
- common hepatic duct

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What are Couinaud’s segments?

hepatic artery and portal vein subdivide lobes into 8 segments
branches of the hepatic artery and portal vein carry blood into sinusoids of liver lobules –> each segment is independent and has its own blood supply and venous return
caudate lobe is segment 1
numbering of lobes goes in clockwise direction from top left side after that

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What is the Pringle manoeuvre?

close off structures in the porta hepatis (usually in the case of traumatic injury) to try locate the bleeding
if bleeding stops then bleeding is from the portal vein or the hepatic artery

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Which arteries supply oxygenated blood to the liver?

Common hepatic

25% of all blood flowing through the lvier

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Which vein passes through the liver, supplying most of the blood in the liver?

Hepatic portal vein

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Which veins join to form the hepatic portal vein?

inferior mesenteric drains into the splenic vein

splenic and superior mesenteric veins join to form the hepatic portal vein

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What structural changes occur to the liver in cirrhosis?

replacement of liver tissue by fibrosis, scar tissue and regenerative nodules

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What is normal portal pressure and IVC pressure? How is portal pressure gradient calculated?

normal portal pressure: 5-10 mmHg
IVC pressure: 2-6 mmHg
portal pressure gradient = difference between vein + IVC

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What is the portal pressure gradient in the following?

portal hypertension
oesophageal varices
ascites

6-10 mmHg
> 10 mmHg
> 12 mmHg

What complications are associated with portal hypertension?

Can lead to splenomegaly

liver can become hyperactive
result in anaemia, thrombocytopenia, leucopenia

Where do oesophageal varices occur?

at the anastomosis of the left gastric vein with oesophageal veins at the gastrooesophageal junction

How does oesophageal varices usually present?

haematemesis (vomiting blood)

What causes oesophageal varices and how is it diagnosed and treated?

Causes:

tumours
peptic/gastoduodenal ulcers
erosion of oesophagus
gastroenteritis

Diagnosis:
- Contrast MRI: bubbly appearance around oesophageal area

Treatment:
- oesophageal banding

What is ascites and how is it caused?

fluid in the peritoneal space
causes:
1. portal hypertension
2. hypoalbuminaemia (no maintenance of oncotic pressure, fluid leaks into interstitium)
3. aldosterone related renal sodium retention (blood volume expansion)

What is caput medusae?

Recanalised umbilical vein within falciform ligament

- paraumbilical veins radiate superiorly to intercostal veins and inferiorly to the inferior epigastric vein

How do rectal varices arise?

portal hypertension due to the formation of portosystemic shunts
- NOT THE SAME AS HAEMORRHOIDS

Describe the recto anal junction ABOVE the pectinate line in terms of:

embryological origin
epithelium
blood supply
venous drainage
lymphatics
nerves
haemorrhoids

embryological origin: endoderm
epithelium: columnar
blood supply: superior rectal artery (branch of inf mes)
venous drainage: superior rectal –> inf mesenteric
lymphatics: inf iliac and inf mesenteric nodes
nerves: inf hypogastric plexus (autonomic)
haemorrhoids: internal (NOT painful)

Describe the recto anal junction BELOW the pectinate line in terms of: 1. embryological origin 2. epithelium 3. blood supply 4. venous drainage 5. lymphatics 6. nerves 7. haemorrhoids

1. embryological origin: ectoderm 2. epithelium: stratified squamous 3. blood supply: inferior rectal artery (branch of int iliac) 4. venous drainage: inf rectal --> middle rectal --> int iliac 5. lymphatics: inguinal nodes 6. nerves: inf rectal - branches of pudendal (somatic) 7. haemorrhoids: external (painful)

What is the portal venous drainage, systemic venous drainage and S+S of damage of the oesophagus?

portal venous drainage: left gastric systemic venous drainage: azygos and hemiazygos S+S: oesophageal varices + haematemesis

What is the portal venous drainage, systemic venous drainage and S+S of damage of the rectum?

portal venous drainage: superior rectal vein systemic venous drainage: inferior rectal vein S+S: rectoanal varices

What is the portal venous drainage, systemic venous drainage and S+S of damage of the ant abdo wall anastomoses?

portal venous drainage: paraumbilical veins systemic venous drainage: inferior epigastric + intercostal S+S: caput medusae

What is the portal venous drainage, systemic venous drainage and S+S of damage of the retroperitoneal anastomoses?

portal venous drainage: duodenal, pancreatic, r + l colic veins systemic venous drainage: lumbar veins S+S: retroperitoneal haemorrhage

At what rate is bile secreted by the liver?

40mL/hour

What is the role of the gallbladder?

To concentrate and store bile

Where is pain referred to in cholecystitis?

right flank and scapula | gallbladder herniates into the colon and duodenum

What is Murphy's sign? What pathology would produce a positive sign?

1. performed by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line 2. The patient is then instructed to breathe in - -> Normally, during inspiration, the abdominal contents are pushed downward - -> If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner's fingers) and winces with a "catch" in breath, the test is considered positive * In order for the test to be considered positive, the same manoeuver must not elicit pain when performed on the left side. Positive sign = probably cholecystitis