Clinical Anatomy of jaundice Flashcards
what is jaundice?
= yellowing the sclera (white of eyes) and skin
what causes jaundice?
= an increase in blood levels of bilirubin
what is bilirubin?
= normal by-product of break down of red blood cells mainly occurring in spleen
what is bilirubin used to form?
= bile in the liver
what does Bille travel through?
= the biliary tree
- a set of tubes connective the liver to the 2nd part of the duodenum
what role does the gallbladder ave?
= plays an important role in storage and concentration of bile
what is bile important for?
= normal absorption of fats from small intestine
what does the pancreas?
= excretes digestive enzymes into 2nd part of duodenum
- necessary for digestion of food
Yes or No.
Is liver the largest organ in the body?
= Yes.
what 3 functions does the liver have?
= glycogen storage
= bile secretions
= other metabolic functions
where is the liver located in terms of quadrants and ribs?
- Right upper quadrant
- protected by ribs 7-11
when does the location of liver change?
in breathing
where is the liver in terms of hemi-diaphragm, gall bladder, hepatic flexure, stomach and right kidney, right adrenal gland, ICC and abdominal aorta?
= inferior to right hemi-diaphragm
Gallbladder
- posterior and inferior
Hepatic flexure
= inferior
Right kidney, right adrenal gland, IVC, adominal aorta
= posterior
Stomach
= posterior at mid/left side
what are the 4 anatomical lobes to the liver?
1) right lobe
2) left lobe
3) quadrate lobe
4) caudate lobe
how many functional lobes are there?
8
wha is the portal hepatis?
= site of entrance for portal triad structure
what are the right and left lobes separated by?
= falciform ligament
what is the thicker part of the falciform ligament called?
= round ligament of liver
what do the 8 functional segments allow?
= vasculature and bile drainage
= segmentectomy
what 4 things do each segment have?
1) branch of hepatic artery
2) branch of hepatic portal vein
3) bile orange (to bile duct)
4) venous drainage (to IVC)
what do the inferior vena cava and hepatic veins lack?
= valves
where is the increased central venous pressure directed to?
= liver
what sort of blood is there in bile drainage and blood supply?
= oxygenated and nutrient rich
what do the hepatic veins direct?
= deoxygenated blood from liver which comes together as 3 veins before entering IVC
what does the portal triad contain?
= contains structures that enter or leave the liver parenchyma
what do the structures that enter or leave the liver parenchyma run within?
= the hepattoduodenal ligaments
what 2 thins are contained within the lesser omentum?
- hepatoduodenal ligament
- hepatogastric ligament
what is the coeliac trunk?
= first 3 midline branches of aorta
- retroperitoneal
where does the coeliac trunk leave the aorta?
at T12 vertebral level
what does the coeliac trunk supply?
- organs of foregut
what does the coeliac trunk trifurcate into?
1) splenic artery
2) left gastric artery
3) common hepatic artery
what is the course of the splenic artery?
= superior border of pancreas
Is the spleen an intra- or retroperiitotneal organ?
= intra-peritoneal organ within left hypochondria
what 4 things is the spleen related to?
what what does the spleen do?
Posteriorly - diaphragm
Anteriorly - Stomach
Inferiorly - Splenic Flexure
Medially - Left kidney
= breaks down red blood cells to produce billirubin
what is the spleen protected by?
= rings 9-11
what could the rib fractures do?
= pierce the soft, delicate spleen leading to substantial internal bleeding
why do the spleen and liver move with respiration?
= as they are anatomically related to the diaphragm
what are the 2 major blood supply’s of the stomach and describe their location?
1) right and left gastric arteries
= along junction of lesser curvature and lesser momentum
= anastomose together
2) right and left gastro-mental arteries
- along junction of greater curvature & greater omentum
= anastomose together
what are the 2 minor blood supplies to the stomach?
- posterior gastric arteries
- short gastric arteries
what sort of blood supply does the liver have?
where does then blood supply from the liver come from?
= dual blood supply
- Right and left hepatic arteries
- branches of hepatic artery proper
= only accounts for 20-25% if blood received by liver, rest is from hepatic portal vein
describe the blood supply in each liver lobule?
= central vein in middle
= inter-lobular portal triad at each corner
what 3 things does the inter-lobular portal triad contain?
1) branch of HPV
2) branch HA
3) bile duct
what are 2 important areas of the peritoneal cavity related to liiver?
1) hepatorenal recess
2) sub-phrenic recess
where are the 2 recesses located?
= within the greater sac
what can peritonitis result in?
= collection of pus in these recesses leading to an abscess formation
why does pus from an abscess in sub-phrenic recess drain into hepatorenal recess when a patient is bedridden?
= as hepatorenal recess is one of lowest parts of peritoneal cavity when patient is supine
where does the hepatic portal vein drain blood from?
- foregut, midgut and hindgut to liver for first pass metabolism (cleaning)
what 2 things forms the HPV?
1) splenic vein (drains foregut)
2) superior mesenteric vein (midgut)
what does the infioeiir mesenteric vein drain?
= blood from handgun to splenic vein
describe the inferior vena cava?
= retro-peritoneal
- drains cleaned blood from hepatic veins into right atrium
where does the gallbladder lie?
on posterior aspect of liver (often firmly attached)
- lies anterior to duodenum
what is the function of the gallbladder?
= stores and concentrates bile in between means
what does narrowing of gallbladder a potential site for?
= gallstone impaction
how does bile flow in and out of gallbladder?
via cystic ducts
how is blood supplied in the gall bladder?
= via the cystic artery
- branch of right hepatic artery
- located in cysto-hepatic triangle (of Clalot)
what can inflammation of gallbladder or cystic duct follow?
= irritation or impaction of a gallstone
what kind of organ is the gallbladder?
= a foregut organ
where do the visceral afferents of the foregut enter spinal cord?
= between T6-T9
where will early pain of gallbladder present in?
= epigastric region
and
where else can pain present in?
= hypochondria
(with or without pain referral to right shoulder)
(a result of anterior diaphragmatic irritation)
what is cholecystectomy?
= surgical removal of gallbladder
PART 2
PART 2
what is the biliary tree made up of?
= ducts which transport bile
what do right and left hepatic ducts unite to form?
= common hepatic ducts
what do common hepatic ducts unity with to form bile ducts?
= unity with cystic ducts
what does the bile ducts drain into?
= 2nd part of duodenum, along with main pancreatic duct
what are the 4 parts to the duodenum?
1) superior (part intra-peritoneal)
2) descending (retroperitoneal)
3) horizontal (retroperitoneal)
4) ascending (retroperitoneal)
what does the superior part of the duodenum contain?
= duodenal cap (monile)
where does the duodenum begin and end?
BEGINS
= at pyloric sphincter
(controls flow of chyme from stomach to duodenum)
(smooth muscle, autonomic nerves, contractions, relaxations)
ENDS
= at duodenojejunal flexure
what does the duodenum secrete and were into?
Secretes peptide hormones (Gastrin,CCK) into blood
where does pain from peptic ulcer tend to be?
= in epigastric region
what type of organ is the pancreas and where does it lie in relation to the abdomen?
= retro-peritoneal organ
- lying transversely across posterior abdomen
what is the pancreas describe as having?
- head(with uncinate process)
- neck
- body
- tail
what is the pancreas ultimately associated with?
duodenum
- head of pancreas is described as being surrounded by C shape from by duodenum
describe the pancreas’ anatomical relationships with the kidney/adrenal gland, IVC, bile duct, abdominal aorta, superior mesenteric vessels, left kidney/adrenal gland and part of portal venous system?
POSTERIOIRLY to all of them
describe the anatomical relationship between the pancreas and stomach, duodenum and splenic vessels?
Anteriorly lies stomach
Duodenum surrounds head of pancreas
Supero-posterioirly = splenic vessel
what are the functions of the pancreas?
1) exocrine
- acinar cells (pancreatic digestive enzymes which are secreted into main pancreatic duct)
2) endocrine
- islets of langerhans (insulin and glucagon into bloodstream)
where does the bile ducts descend posteriorly to and then how does it travel? SEE DIAGRAM on slide 10
= to 1st (superior) part of duodenum.
- then travels into a groove on the posterior aspect of he pancreas
= then joins with main pancreatic duct, forming ampulla of Vater/hepatopancreatic ampulla (widened part)
= both hen drain into 2nd part of duodenum
what are anatomical sphincters?
= discrete areas where muscle completely encircles the lumen of the tract
name 3 of the smooth muscle sphincters of this area?
1) bile duct sphincter
2) pancreatic duct sphincter
3) sphincter of Oddi
what is ERCP?
= endoscopic retrograde Cholangiopancreatography
- an investigations which studies the biliary tree and pancreas and treats pathologies with it
- endoscope is 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 dye-filled biliary tree
what are 2 possible mechanisms of obstructive the biliary tree?
1) gall stones
2) carcinoma at head of pancreas
what happens if there is an obstruction of the biliary tree?
= flow of bile back up to liver
= overspills into blood, one of its constituents being bilirubin
= this is an extra hepatic (outside liver) obstructive cause of jaundice
- post-hepatic jaundice
what are 6 of the suppliers of blood to the duodenum and pancreas?
1) splenic arteries (cell trunk)
2) gastro-duodenal artery (common hepatic a)
3) superior pancreaticoduuodenal artery (from gastro-duodenal a)
4) inferior pancreatic-duodenal arteries (from superior mesenteric a)
5) superior mesenteric artery (from aorta at L1)
6) dorsal pancreatic arteries (from splenic a)
what do the superior pancreaticoduuodenal artery
and inferior pancreatic-duodenal arteries form?
anastomosis
what is one of the reasons for pancreatic pain?
= pancreatitis
what is one cause of pancreatitis?
= blockage of ampulla by gallstones
- bile is then diverted into pancreas leading to irritation and inflammation
what type of organ is the pancreas?
= foregut AND midgut
where does pancreatic pain present?
= in epigastric region and/or umbilical region
- it can also radiate to patients back
what happens in acute pancreatitis?
= gall obstruction
= cause reflux of bile and pancreatic juice into main pancreatic duct
- in more advanced cases vascular haemorrhage can occur, leading to blood/fluid accumulation in retroperitoneal space
what is Grey-Turners sign and Cullen’s sign?
Grey-turners
= right or left flanks
Cullen’s sign
= around umbilicus via falciform ligament
what type of organs is the 1st and 2nd part of the duodenum and what type of organ is the rest of he small intestine?
1st and 2nd
= foregut organs
Rest of small intestine
= midgut
what makes up most of the small intestines?
= jejunum and ileum
where are the jejunum and ileum found?
= in all 4 quadrants
where does jejunum begin and ileum end?
jejunum begins
= at duodenal-jejunal flexure
ileum ends
= at ileo-caecal junctions
describe the differences between jejunum and ileum in terms of their colour?
Jejunum
= deep red
Ileum
= lighter pink
describe the differences between jejunum and ileum in terms of their wall and vasculature?
Jejunum
= thicker and heavy
= more vascular
Ileum
= thinner and lighter
= less vascular
describe the differences between jejunum and ileum in terms of their mesenteric fat?
Jejunum
= less fat
Ileum
= more fat
describe the differences between jejunum and ileum in terms of their circular folds (L. place circulars)?
Jejunum
= large, tall and closely packed folds
Ileum
= low and parse folds (absent distally)
describe the differences between jejunum and ileum in terms of their lymphoid tissue?
present in ileum
where does the artery blood supply come from in jejunum and ileum?
= from superior mesenteric artery
- via jejunal and leal arteries
describe the venous drainage of jejunum and ileum?
Venous drainage from;
- jejunal and ileal veins
- to superoir mesenteric veins
- to hepatic portal veins
describe where proteins and carbohydrates are absorbed from and into?
= from small intestine into portal venous system to be taken to liver
- vessels travel within the mesentery
describe the superior mesenteric vessels?
= leaves aorta at L1 vertebral level
- posterior to neck of pancreas
- travels inferiorly, anterior to uncinate process of pancreas to enter the mesentery proper
what helps the absorption of fats from GI tract lumen into the intestinal cells?
= bile
describe what happens to the fats (within chylomicrons) once absorbed from intestinal cells?
are absorbed from intestinal cells into specialised lymphatic vessels of small intestine called lacteals
- drain via lymphatic system to eventually drain into venous system
= at left venous angle
where do lymph vessels tend to lie?
= alongside artereis
what are the 4 main group of lymph nodes draining abdominal organs?
1) Celiac (foregut organs)
2) Superior mesenteric (midgut organs)
3) Inferior mesenteric (hindgut organs)
4) Lumbar (kidneys, posterior abdo wall, pelvis and lower limbs)
what do superficial lymph vessels drain into?
= deep lymph vessels
depending on where it is originated form, where will lymph drain into?
either;
1) thoracic duct (from 3/4 of body)
or
2) right lymphatic duct (from 1/4 of body)
where will the lymph then eventually drain into?
= venous system for ‘recycling’ at venous angles;
what are venous angels?
- junctions between subclavian and internal jugular veins
- left venous angle = thoracic duct drainage
- right venous angel = right lymphatic duct drainage
