Gastrointestinal System IV Liver, Pancreas And Spleen

Question 1

Where is the liver?

Answer 1

Right hypochondrium and epigastric region

Question 2

What can cause liver trauma?

Answer 2

Liver trauma can be caused by: Fractures of lower ribs.

Penetrating wounds of the thorax or upper abdomen. Blunt trauma. All can be associated with severe hemorrhage

Question 3

What is liver cirrhosis?

Answer 3

Cirrhosis of liver – progressive destruction of hepatocytes [replaced by fibrous tissue], which makes the liver firm, impedes blood circulation [most frequent cause of portal hypertension]

Question 4

How is a percutaneous liver biopsy performed?

Answer 4

Percutaneous Liver biopsy : Patient asked to hold breath in full expiration to prevent damage to pleura / lung. Needle is inserted through the 9th / 10th right intercostal space in the mid axillary line.

Question 5

What are the two surfaces of the liver?

Answer 5

Diaphragmatic: anterior, superior, posterior

Visceral surface: inferior and covered with visceral peritoneum (except the fossa for gallbladder+ porta hepatis)

Question 6

What us the subphrenic space?

Answer 6

Between diaphragm and liver

Question 7

What is the hepatorenal recess?

Answer 7

[between right kidney & liver] is the gravity dependent part of
the peritoneal cavity in supine position

Question 8

What is the importance of liver lobes?

Answer 8

Caudate & quadrate lobes – functionally belong to left lobe [left branches of the hepatic artery, portal vein & bile duct]

Right & left lobes; Right lobe larger
with caudate & quadrate lobes

Porta hepatis – structures enter / leave the liver (except hepatic veins)

Question 9

What are the segments of the liver?

Answer 9

liver is divided into 8 segments based on the main branches of right & left hepatic arteries, portal vein & hepatic ducts [hepatic veins → intersegmental]

Branches of the right & left hepatic arteries, ducts and
portal vein do not communicate significantly. [hepatic
lobectomy / segmentectomy can be performed]

Question 10

What is the anatomical importance of lobes in the liver?

Answer 10

• Anatomically the liver can be divided into four lobes : right ,left, caudate and quadrate . In this classification the quadrate and caudate lobes are considered part of the right liver.
• Functionally it can be divided into independent right and left livers i.e. portal lobes. This functional division is produced by the sagittal plane passing through the gall bladder fossa and the fossa of the IVC on the visceral surface of the liver and an imaginary line over the diaphragmatic surface that runs from the surface of the gall bladder to the IVC. The left liver now includes anatomic quadrate and caudate lobes.

This functional division results in the liver having a slightly larger right lobe. These “portal lobes” will have its own blood supply from the hepatic artery, portal veins, its own venous (hepatic veins) and biliary drainage.

• The portal lobes of the liver are further divided into 8 segments. The segmentation is based on the principal branches of the right and left hepatic arteries, hepatic portal veins and hepatic ducts . Each segment is supplied by the corresponding branch of the right or left hepatic artery, portal vein and drained by a branch of the left or right hepatic duct

Question 11

What is the falciform ligament?

Answer 11

Falciform – liver is attached to the anterior abdominal wall. Posterior
free margin is the ligamentum teres → obliterated umbilical vein

Question 12

What is the bare area?

Answer 12

Bare area – triangular area devoid of peritoneal covering, related to the diaphragm

Question 13

What is the ligamentum venosum a remnant of?

Answer 13

Ductus venosus

Question 14

What is the lesser omentum?

Answer 14

Lesser omentum – connected to stomach
[hepatogastric] & duodenum [hepatoduodenal part]

Right free margin of the lesser omentun contains portal vein, proper hepatic artery & bile duct

Question 15

What is the pringle maneuver?

Answer 15

Pringle maneuver is clamping hepatoduodenal ligament to

prevent bleeding from proper hepatic artery

Question 16

What is the blood supply of the liver?

Answer 16

Arterial supply – hepatic artery
Veins – hepatic & portal
Hepatic artery [30%] & portal vein [70%] to the liver; hepatic veins open in to IVC

Liver produces large amount of lymph → mainly to celiac nodes

Question 17

Summarize structure of the gall bladder

Answer 17

Receives bile from the liver (stores & concentrates it)

Pear shaped, in the fossa [inferior surface of liver]

Parts – fundus [projects beyond the inferior
margin of liver→ located at the tip of the SOM.1aii.BPM2.1.DM.1.ANAT.DG.4449 right 9th costal cartilage mid-clavicular line], Body, neck→leads to cystic duct

Question 18

What is the biliary apparatus?

Answer 18

Right & left hepatic ducts join to form the common hepatic duct; joined by the cystic duct to form the [common] bile duct

BD passes posterior to the I part of duodenum, joins the
pancreatic duct to open into the major duodenal papilla

Question 19

Can gall stones be asymptomatic?

Answer 19

Gall stones may be asymptomatic [common in fat, fertile, female of forty]; can produce colic or acute cholecystitis

Question 20

What is biliary colic?

Answer 20

Biliary colic – usually caused by spasm of the smooth muscle of the gall bladder in an attempt to expel the gall stones

Question 21

What is acute cholecystitis?

Answer 21

Acute cholecystits – pain in the right upper quadrant→may cause subdiaphragmatic parietal peritoneum irritation, which is supplied by the phrenic nerve [referred pain → right shoulder]

Question 22

What is the significabce of an obstruction of biliary tree by gall stones?

Answer 22

Obstruction of biliary tree by gall stone or compression by pancreatic growth→obstructive jaundice. Impaction of stone in the ampulla can cause passage of infecte bile into the pancreatic duct leading to pancreatitis

Question 23

What is an ERCP?

Answer 23

ERCP (endoscopic retrograde cholangiopancreatography) is a diagnostic procedure used to evaluate the biliary and pancreatic ducts. A tube is passed via the esophagus stomach 2nd part of the duodenum. Dye is injected into the major papilla under fluoroscopy

Question 24

Where is the spleen located?

Answer 24

Spleen mainly in the left hypochondrium, surrounded by visceral peritoneum

Question 25

Describe splenic rupture

Answer 25

though well protected it is the most frequently injured organ in the abdomen, bleeds profusely when ruptured → intra- peritoneal hemorrhage & shock. If repair is difficult→Splenectomy

Question 26

What is splenomegaly?

Answer 26

diseases affecting the reticulo- endothelial system, portal hypertension may cause splenic enlargement

Question 27

Describe the function of portal vein

Answer 27

Collects venous blood with products of digestion from the abdominal part of GIT + gallbladder, spleen & pancreas

Passes through the lesser omentum, enters the liver through porta hepatis, divides into right & left and then segmental branches→ends in venous sinusoids of liver

Question 28

Describe the formation if the portal vein

Answer 28

Formation – behind the neck of pancreas; joining of splenic vein & superior mesenteric vein

Question 29

Describe portal systemic [porto-caval] anastomoses

Answer 29

Portal vein tributaries communicate with caval tributaries

1. Lower end of the esophagus

Esophageal tributaries of the left gastric vein with esophageal tributaries of azygos & hemiazygos veins [Esophageal varices → Hematemesis]

2. Lower end of the anal canal

Superior rectal vein [drains into inferior mesenteric vein] with Inferior & middle rectal veins (→internal iliac vein). Varicosity leads to hemorrhoids [piles]

3. Umbilicus [Anterior abdominal wall]

Veins along the ligamentum teres – para-umbilical veins with tributaries of the superior and inferior epigastric veins specifically the superficial epigastric veins. These dilated tortuous superficial epigastric veins radiating from the umbilicus are called Caput Medusa

4. Retro-peritoneal organs: Veins of colon, duodenum, pancreas, spleen etc. with Renal, lumbar, azygos veins etc.→Dilated veins around the posterior abdominal wal
5. Bare area of the Liver: Venous sinusoids of liver with Diaphragmatic veins [intercostal & phrenic]

Question 30

Describe portal hypotension

Answer 30

Any pathology which obstructs the hepatic portal vein increases pressure in this vein and its tributaries. A common method for reducing portal hypertension is to divert blood from the portal venous system to the systemic venous system by creating a shunt (communication) between the portal vein and the inferior vena cava.

Question 31

How is the pancreas special?

Answer 31

Mixed gland – exocrine & endocrine; with age exocrine part & connective tissue decline – progressive thinning atrophy

Question 32

Describe the structure of the pancreas

Answer 32

Extends across [12 - 15cm] posterior abdominal wall [retroperitoneal] from the duodenum on the right to spleen on the left. Mostly posterior to the stomach

Parts – head with uncinate process, neck, body & tail [mobile within the splenorenal ligament]

Question 33

Where is the minor pancreatic duct located?

Answer 33

Minor pancreatic duct – opens above the major duodenal papilla, usually communicates with the major duct

Question 34

What is the major pancreatic duct?

Answer 34

passes from the tail towards the head; joins the bile duct to form hepatopancreatic ampulla, which enters the major
duodenal papilla [II part of duodenum]

Question 35

Describe the arteries of the pancreas

Answer 35

1. Anterior & posterior superior pancreaticoduodenal arteries – branch of gastroduodenal artery (Celiac artery)
2. Anterior & posterior inferior pancreatic duodenal artery – branch of SMA
3. Pancreatic branches – numerous from the splenic arter

Question 36

Describe the veinous drainage of the pancreas

Answer 36

To portal vein. Head & neck to superior mesenteric vein ; body & tail – to splenic vein

Question 37

Describe pancreatic lymph drainage

Answer 37

The pancreatic lymph vessels follow the arteries and will therefore drain into :

• Celiac nodes
• Superior mesenteric nodes

Question 38

Describe the clinical correkation of pancreatic rupture

Answer 38

Rupture of the pancreas – may result from sudden, forceful compression of the abdomen

Question 39

Describe the pancreatic cancer clinical signuficance

Answer 39

Pancreatic cancer – of the head may cause obstructive jaundice →retention of bile pigments, enlargement of the gall bladder. Growth may compress the portal vein leading to portal hypertension