deck_5687596 Flashcards
What is the largest internal organ and gland of the body? How much does it weigh?
LIVERWeighs 1.5 kg
What gives stool its color?
The break down products of RBCs are eliminated in bile and gives the stool its characteristic dark color
Regions occupied by liver?
Right AND LEFT hypochondrium and epigastric regions
What is the bare area of the liver?
Part of liver in direct contact with diaphragm (rest is covered by peritoneum) on the liver’s superior/posterior aspect where visceral peritoneum reflects back around the margins of the borders and becomes parietal peritoneum
What are the coronary ligaments?
Ligaments made of peritoneum forming the borders of the bare area of the liver:1. Anterior border: anterior coronary ligament2. Posterior border: posterior coronary ligament3. Lateral borders: left and right triangular ligaments (where ant and post ligaments come together)
6 structures located inferior to liver aka relating to its visceral surface? List from lateral to medial (right to left).
- Right colic flexure and right transverse colon2. Gallbladder3. Lesser omentum4. Superior part of duodenum5. Esophagus 6. Right side of the anterior aspect of the stomach
2 structures located posterior to liver aka ALSO relating to its visceral surface?
- Right kidney and right adrenal gland2. IVC
What divides the liver into its right and left lobes? Which is larger?
Fossae for gallbladder and IVCRight lobe is larger
What is the right lobe of the liver divided into? Describe each. Which lobe of the liver does it relate to FUNCTIONALLY?
- Quadrate lobe: bounded on left by fissure for ligamentum teres and on right by fossa of gallbladder => functionally related to left lobe 2. Caudate lobe: bounded on left by fissure of ligamentum venosum and on right by groove of IVC => functionally related to neither
What is the hepatic triad?
3 most important vessels of liver:1. Hepatic artery2. Portal vein3. Common bile duct
Liver blood supply? % for each? L/min for each? Origin for each? Total % of CO?
- Right and left hepatic arteries (30% of the blood = 350mL/min): abdominal aorta => celiac trunk => common hepatic artery => hepatic artery proper => R/L hepatic arteries 2. Portal vein (70% of the blood = 1L/min): inferior mesenteric vein + splenic vein => + superior mesenteric vein => portal vein => right and left hepatic branches to enter hepatic sinusoids= 30% of CO
Pathway of biliary system?
Liver: right and left hepatic duct => common hepatic duct + cystic duct from gallbladder => common bile duct with sphincter + main pancreatic duct with sphincter => hepatopancreatic duct => major papilla of descending duodenum
2 lymph drainage pathways of liver?
FIRST WAY: Anterior diaphragmatic and visceral surface of liver + portal triad => superficial hepatic lymphatics => deep hepatic lymphatics at theporta hepatis => hepatic lymph nodes => celiac lymph nodes => chyle cisternSECOND WAY: Posterior diaphragmatic and visceral surface of liver => superficial hepatic lymphatics toward bare area of liver => phrenic lymph nodes OR deep hepatic lymphatics => posterior mediastinal lymph nodes => right lymphatic duct/thoracic duct
Location of deep hepatic lymphatics?
Accompany the hepatic arteries and portal vein to IVC
Location of superficial hepatic lymphatics?
Subperitoneal fibrous capsule of the liver = “Glisson’s capsule”
Location of hepatic lymph nodes?
Scattered throughout the lesser omentum
Lymphatic drainage of gallbladder? What does it follow?
Celiac lymph nodes (following cystic artery)
Diagnosis for hepatomegaly?
Measure length of liver at midclavicular line (>10-12 cm) or midsternal line (>6-8 cm) by using percussionsAND also feel liver beyond the diaphragm
5 fluids going in/out of liver?
- Arterial blood2. Portal blood3. Venous blood4. Bile5. Lymph
Does the liver have a mesentery?
NOPE
What is Morrison’s pouch? Other name?
Part of the peritoneal cavity on the right side between the liver and the right kidney and right suprarenal gland = hepatorenal recess
What are the 2 recesses of the diaphragmatic surface of the liver? Are these continuous?
- Hepatorenal recess2. Subphrenic recess YES, continuous anteriorly
What is the subphrenic recess?
It separates the diaphragmatic surface of the liver from the diaphragm and is divided into right and left areas by the falciform ligament
What is the falciform ligament derived from embryologically?
Derived from the ventral mesentery in the embryo
2 surfaces of liver? Describe each.
- Diaphragmatic surface in the anterior, superior, and posterior directions2. Visceral surface in the inferior direction
Where does liquid in the peritoneal cavity collect if the patient is in the supine position?
- Hepatorenal recess2. Pelvic cavity
Is the visceral surface of the liver covered by visceral peritoneum?
Yes, except for the fossa for the gallbladder and the porta hepatis
What is the porta hepatis?
Gateway to the liver (kinda like hilum to lung)
On what side of liver is caudate lobe visible?
Posterior portion of visceral surface
On what side of liver is quadrate lobe visible?
Anterior portion of visceral surface
What separates functional left and right lobes of the liver?
Supply by left or right hepatic artery
What are the segments of the liver? How many?
Segments with their own branch of a hepatic artery and biliary tract that allow each to function independently and be removed without affecting the rest of the liver 9 segments: (I to VIII with IVa and IVb)
What is the hepatic pedicle?
Hepatic triad at the porta hepatis
Which is larger: hepatic artery or portal vein?
Portal vein
How to identify portal vein in hepatic triad?
Largest and most posterior structure
What 4 structures does the hepatic portal vein drain? Pathway to heart?
- GIT2. Pancreas3. Spleen4. GallbladderPortal vein => liver capillaries => hepatic veins (right, middle, and left) => IVC => RA
Common portal circulation pathology? Causes? 8 complications of this?
Portal hypertension3 possible causes:1. Prehepatic: obstructed blood flow to liver (e.g. portal vein thrombosis or congenital atresia)2. Posthepatic: obstructed blood flow from liver to heart (e.g hepatic vein thrombosis, CHF, pericarditis)3. Intrahepatic: cirrhosis, fibrosis, or Wilson’s disease) Consequences:1. Ascites2. Formation of portocaval venous shunts via natural anastomoses3. Congestive splenomegaly (especially with prehepatic causes)4. Hepatic encephalopathy5. Hypersplenism (with moderate anemia, neurtopenia, thrombocytopenia)Venous enlargements at the anastomosis areas: 6. Esophageal varices (with intrahepatic causes) of the esophageal tributaries of the left gastric veins + gastric varices7. Internal hemorrhoids due to increased pressure in the superior rectal vein’s anastomosis to middle and inferior rectal veins8. Caput medusa due to increased pressure in superficial veins of the anterior abdominal wall anastomosis with paraumbilical veins9. Retroperitoneal veins
What % of initial gastro-esophageal variceal bleeding fatal?
30%!!
How to diagnose esophageal varices?
Bulges in lumen of esophagus when doing endoscopy
Technique to image the biliary tract?
Endoscopic Retrograde Cholangiopancreatography (ERCP)
What % of gallbladder stones radio-opaque? What does this mean?
10-15%, pretty rare => only 10-15% of stones will show up on a radiograph
% of kidney stones that are radio-opaque?
85%
Best imaging technique to find gallbladder stones?
Ultrasound
Long-term consequence of gallbladder stones that are large?
They cannot go through the cystic duct so they stay in the gallbladder and weaken its walls => fistulas form with duodenum (which may block the ileocecal junction) OR transverse colon where the stones can go
Pain due to liver?
- Referred pain in epigastric area since part of foregut2. Parietal pain in RUQ3. If diaphragm is irritated => pain through phrenic nerve from C3-C5 => referred pain to right upper shoulder
What is the point of the gallbladder storing bile?
Bile production by the liver is continuous but the body only needs it a few times a day
Volume capacity of gallbladder? What does this correspond to?
30-75 mL = 12 hours worth of bile produced by liver
Gallbladder surface anatomy?
Fundus located at junction of right 9th costal cartilage and midclavicular line, where the lateral border of rectus abdominis is located
Pain due to gallbladder?
- Referred pain in epigastric area since part of foregut2. Parietal pain in RUQ at particular surface anatomy area: tenderness3. If diaphragm is irritated => pain through phrenic nerve from C3-C5 => referred pain to right upper shoulder to the right of the referred pain of the liver
Position of gallbladder?
Lies on visceral surface in a fossa between the right and quadrate lobes
3 parts of the gallbladder? Describe each.
- Fundus: rounded end projecting from inferior border of liver 2. Body: major part in the fossa 3. Neck: narrow part with mucosal folds forming the spiral fold = spiral valve
What is the body of the gallbladder in contact with?
- Superior part of duodenum2. Transverse colon
Blood supply to gallbladder? Clinical significance?
Cystic artery from right hepatic artery (but may receive blood supply by many others) => arterial supply needs to be ligated during cholecystectomy, but because of wide blood supply it is possible to accidentally severe the artery
What is a cholecystectomy? Why is this sometimes conducted? What does this mean?
Removal of gallbladder Because of gallstonesNot essential for life, although certain dietary modifications may be necessary
When do gallbladder stones pose a problem?
When they get lodged in the Ampulla of Vater, causing the pancreatic juices from exiting, increasing the risk for pancreatitis in which the pancreatic enzymes start destroying the pancreas
What is the Ampulla of Vater? Other name?
= hepatopancreatic duct = is formed by the union of the pancreatic duct and the common bile duct
Position of pancreas? Vertebral levels?
Posterior to stomach extending retroperitoneally across the posterior abdominal wall from duodenum on right to spleen on left T12 to L2
5 parts of the pancreas? Describe each.
- Head: lies within C-shape concavity of duodenum 2. Uncinate process: projecting from inferior part of the head 3. Neck4. Body: elongate part 5. Tail: between layers of splenorenal ligament
At what part of the pancreas do the pancreatic duct and common bile duct come together?
Head of pancreas
Other name for pancreatic duct?
Duct of Wirsung
What are the 2 ducts of the pancreas? How does each secrete into the duodenum?
- Pancreatic duct: tail to body to head, turns inferiorly to meet the common bile duct to form the hepatopancreatic duct, which empties in the major papilla of the duodenum after passing by the sphincter of Oddi2. Accessory pancreatic duct: empties into minor papilla
Part of pancreas where accessory pancreatic duct is?
Head with tip in uncinate process
Other name for accessory pancreatic duct?
Pancreatic duct of Santorini
What is located anterior to the uncinate process of the pancreas?
Superior mesenteric vessels
What is located anterior to the neck of the pancreas?
Superior part of duodenum
What is located posterior to the neck of the pancreas?
Superior mesenteric vein meets the splenic vein to form the portal vein AND SMA branches from abdominal aorta
What is located posterior to the body of the pancreas?
Left kidney
Other name for sphincter of Oddi?
Sphincter of ampulla
2 branches of the accessory pancreatic duct?
- One that connects to the pancreatic duct where it turns inferiorly2. One that passes anterior to the pancreatic duct and ends in the uncinate process
Embryological origins of the 2 ducts of the pancreas?
Dorsal and ventral buds from foregut
Blood supply of pancreas?
- Gastroduodenal artery from the common hepatic artery (a branch of the celiac trunk)2. HEAD: Anterior superior pancreaticoduodenal artery from the gastroduodenal artery3. HEAD: Posterior superior pancreaticoduodenal artery from the gastroduodenal artery4. HEAD: Anterior inferior pancreaticoduodenal artery from the inferior pancreaticoduodenal artery (a branch of the SMA)5. HEAD: Posterior inferior pancreaticoduodenal artery from the inferior pancreaticoduodenal artery (a branch of the SMA)6. Dorsal pancreatic artery from the inferior pancreatic artery (a branch of the splenic artery)7. Great pancreatic artery from the inferior pancreatic artery (a branch of the splenic artery)
Usual size of the spleen?
A fist
Surface projection of spleen? Region?
Posterior to the mid-axillary line at ribs 9-10 Region: left hypochondrium
5 functions of spleen?
- Is hematopoietic in fetus 2. Destroys aged (worn-out) RBCs in adulthood3. Filters blood4. Stores RBCs and platelets5. Produces lymphocytes and antibodies
Is the spleen covered by visceral peritoneum?
Yes, except for the splenic hilum where the splenic vessels enter and sometimes where the tail of the pancreas is
Blood supply of spleen?
Splenic artery from the celiac trunk
What is the largest branch of the celiac trunk?
Splenic artery
What is the spleen in contact with?
- Stomach2. Splenic flexure of colon3. Tail of pancreas4. Left kidney 5. Diaphragm
What is the narrowest part of the biliary tract?
Hepatopancreatic duct
2 most common causes of pancreatitis?
- Gall stones2. Alcoholism
What % of patients with acute pancreatitis die? How common is this disease?
10%Rare disease
Complication of pancreatitis?
Chronic calcification of the pancreas
What is pancreatic cancer referred to as? Why? In what part of the pancreas do they arise most commonly?
The silent killer Usually in the HEAD of the pancreasClose association of the pancreas with large blood vessels, extensive drainage to lymph nodes, and frequent spread to the liver via the portal venous system => ineffectiveness of surgical removal (or cure) of pancreatic tumors
Where are pancreatic tumors more frequent?
Head and neck
3 symptoms of pancreatic cancer?
- Abdominal pain2. Loss of appetite3. Weight loss
Complication of pancreatic cancer?
Obstruction of the BILE duct (especially if pancreatic cancer is in the head of the pancreas) => obstructive jaundice
Where do pancreatic cancers usually spread?
- Superior mesenteric vessels2. Portal vein3. Porta hepatis
Largest lymphoid organ of the body?
Spleen
2 surfaces of the spleen?
- Diaphragmatic2. Visceral
2 ligaments connected to spleen? What does each contain?
- Gastrosplenic ligament with gastroepiploic and short gastric vessels2. Splenorenal ligament with splenic vessels
Other name for splenorenal ligament?
Lienorenal ligament
Venous drainage of the spleen?
Splenic vein => portal vein
If a penetrating injury reaches the spleen in the 9th ICS, what else is damaged?
- Left pleura => pneumothorax 2. Diaphragm 3. Peritoneum
Is the spleen necessarily penetrated if it is bleeding?
NOPE, blunt trauma can cause bleeding
If the spleen is palpable below the costal margin, what does this mean? How can you tell?
It is at least 3x its normal size = splenomegaly Notches are palpable
What can cause splenomegaly? What comes with it?
- Leukemia2. Lymphoma3. Certain infections WITH generalized lymphadenopathy 4. Portal HT
What is a positive rebound sign?
It refers to pain upon removal of pressure rather than application of pressure to the abdomen
If there is blunt trauma to the abdomen, what 2 organs are most likely to bleed? List in order.
- Spleen2. Liver
Can obstruction of the pancreatic duct cause jaundice?
NOPE
Liver innervation?
Celiac plexus and vagus nerve
Gallbladder innervation?
Celiac plexus
Lymph drainage of pancreas?
- Celiac lymph nodes2. Superior mesenteric lymph nodes
Pancreas innervation?
Celiac plexus
What % of portal circulation is recovered in hepatic veins in normal individuals?
100%
Most common portocaval venous shunts via natural anastomoses formed due to portal HT?
- Left gastric vein anastomoses with azygos system of veins 2. Superior rectal vein anastomoses with middle and inferior rectal veins (these are systemic)3. Paraumbilical veins anastomose with superficial veins of the anterior abdominal wall
Anterior and posterior surface projections of left and right costodiaphragmatic recesses?
Anterior = medial 6th ICS to lateral 8th ICSPosterior = T10 to T12
Describe in painful detail the inferior margin of the parietal pleura.
Margin is just above the costal margin1. Midclavicular line: rib 82. Midaxillary line: rib 103. More laterally: horizontal margin crossing ribs 11 and 12 to reach T12
How does the spiral valve of the gallbladder work?
It keeps the lumen of the cystic duct open to allow for bidirectional flow of bile
Other name for gallstones?
Cholelithiasis
What can gallstones cause?
Gradual accumulation of the components of bile:1. Obstructive jaundice2. Cholecystitis3. Pancreatitis4. Sepsis
What is primary sclerosing cholangitis? What does it lead to?
Disease of uncertain cause that involves ongoing inflammation, destruction, and fibrosis (“onionskin” appearance) of intrahepatic and extrahepatic bile ducts. It leads to cirrhosis, portal hypertension, and liver failure.
How to make diagnosis of acute pancreatitis?
Increased levels of blood pancreatic enzymes
Other name for hemorrhoids?
Pyles
Treatment for gallstones? Consequence?
- Surgical removal2. Low-fat diet=> Liver will upregulate bile production to compensate for loss of gallbladder
