Hepatopancreatic System Flashcards
Function of liver
Storage, metabolism and release of nutrients and some vitamins.
Detoxification and elimination of toxins, drugs and metabolites.
Synthesis of proteins: albumin, clotting factors.
Synthesis and secretion of bile, important for lipid digestion and absorption.
Role in immune function and clearance of intestinally absorbed bacteria.
Removal of red blood cells. Kupfer cells – specialised macrophages in liver.
Location of liver
Right hypochondrium and extends out to epigastrium
(Sometimes lobes of liver can be seen in left hypochondrium)
Inferior to diaphragm- moves with it in respiration
INTRAPERITONEAL
Blood from GI tract goes where?
Blood from digestive system first goes to liver to be processed then circulated around rest of body
Which ribs protect the liver?
Ribs 7-11
Which ribs protect the liver?
Ribs 7-11
Lobes of the liver
Left
Right
Cordate (tail)
Quadrate
Caudate vs Quadrate lobes
Caudate lobe is an independent lobe. (arises from right lobe)
Quadrate lobe to be considered part of left lobe (though it arises from right lobe)
Functional Anatomical Divisions / segments of liver
8 functional segments
Based on distribution of portal venous branches- each segment has own individual blood supply, so can remove one segment and will not affect rest of functioning units of liver (eg can remove cancerous part of liver)
Important for surgical resection surgery
Falciform ligament
Double fold of peritoneum connecting liver to anterior abdominal wall.
Divides left lobe into right lobe
Diaphragmatic surface vs Visceral surface of liver
Ligaments of the lung
Falciform ligament:
- Double fold of peritoneum connecting liver to anterior abdominal wall.
Fissure for ligamentum venosum:
- Remnant of ductus venosus
- Shuts umbilical blood directly into IVC
Round ligament / ligamentum teres:
- Remnant of umbilical vein
- Carries oxygenated blood from placenta
- Small paraumbilical veins may remain in substance of ligament
How is bile transported to duodenum?
Via common bile duct- receives it from cystic duct or from liver via common hepatic duct (right and left hepatic duct come together to form common hepatic duct)
Round ligament of liver
Embryological remnant of umbilical vein
Continuous with ligament venosum
Umbilical vein goes to ductus venosus, inters IVC to right atrium of heart -> blood pumped through fossa ovale into left ventricle and up into aorta to main circulation
Ductus venosus becomes ligament venosum post birth
Bare area of liver
No peritoneum on top surface of liver.
Fenced by ant. and post. coronary which meet as the left and right triangular ligament.
Results from massive embryonic growth of liver within ventral mesogastrium.
Recesses of liver
Sites where peritoneal fluid or metastases can localise.
Recesses important for pooling of fluid and indication of pathological process
Peritoneal folds: lesser omentum
Double ford of peritoneum that connects the inferior surface of the liver to the lesser curvature of the stomach and first part of duodenum
Hepatogastric ligament
Hepatoduodenal ligament
What part of the liver is not covered in peritoneum?
Superior surface
Coronary ligaments of liver
Falciform ligament split into two going over superior surface of liver
Fuse with as triangular ligaments - fenced off area they create is the Bare area
From where does the common hepatic artery arise?
Coeliac trunk
Subphrenic space
Gap between diaphragm and liver
Hepatorenal pouch of Morrison
Gap between kidney and liver
If patient supine, this is where fluid is likely to accumulate
Subhepatic space
Gap under liver
What runs in the free edge of the lesser omentum?
Portal triad:
- Common bile duct
- Proper hepatic artery
- Hepatic portal vein
- Vagus nerve
- Lymphatics
What acts as the opening into the lesser sac (omental bursa)?
Lesser omentum
Boundaries of lesser sac
Superior: Caudate process of liver
Inferior: 1st part of duodenum
Posterior: Inferior vena cava and right crus of diaphragm
Anterior: Portal triad (in free edge of lesser omentum)
Pringle’s manoeuvre
Haemostat used to clamp hepatoduodenal ligament.
Stops blood flow through hepatic duodenal artery and portal vein
Blood supply of liver
Dual system
25% from Hepatic artery proper
75% from Hepatic portal vein (GI tract)
Then processed in sinusoids -> hepatic veins x3 -> IVC -> right atrium
Hepatic portal system
What vessels make up the hepatic portal vein?
Superior mesenteric vein - brings blood from midgut
Splenic vein - unites with superior mesenteric to form hepatic portal vein
Inferior mesenteric vein - brings blood from hindgut, usually enters into splenic vein (in 1/3 of people also enters in hepatic portal vein)
Portal hypertension
Obstruction in liver increases pressure in hepatic portal vein (eg. Cirrhosis).
–> May cause enlargement of spleen bc blood can’t flow back out of spleen due to HBP in liver
Collateral (alternative) pathways open up between portal and systemic venous systems = Portosystemic anastomoses.
Caput medusa of para-umbilical veins.
Portosystemic Anastomoses
Collateral circulation between systemic and portal circulation
Occurs in:
Oesophageal veins
Peri-umbilical region
Anal canal
Oesophageal vein portosystemic anastomoses
Portal via left gastric vein
Systemic via azygos veins
Anal canal portosystemic anastomoses
Portal via Inferior mesenteric vein
Systemic via inferior and middle rectal veins
Peri-umbilical region portosystemic anastomoses
Portal via paraumbilical veins
Systemic via epigastric veins
Sites of gallstone obstruction
Sites of obstruction:
Hepatopancreatic ampulla
Cystic duct
Hartmann’s pouch (infundibulum)
Jaundice occurs when bile cannot leave the gallbladder and enters the blood.
Referred gallbladder pain
Back of shoulder due to right phrenic nerves C3 C4 C5 corresponding to dermatomes of shoulder region
Where does the inferior mesenteric vein normally drain?
Splenic vein
Location of pancreas
Posterior to stomach.
Transpyloric plane passes through neck (L1).
Secondary retroperitoneal apart from tail (splenorenal ligament).
Function of pancreas
Exocrine:
Pancreatic juice: acinar cells.
Enters duodenum through main and accessory ducts.
Endocrine:
Produces Glucagon and insulin: Pancreatic islets of Langerhans.
Enters blood.
Ampulla of Vater
formed by the union of the pancreatic duct and the common bile duct. The ampulla is specifically located at the major duodenal papilla.
The ampulla of Vater is an important landmark halfway along the second part of the duodenum that marks the anatomical transition from foregut to midgut, and hence the point where the celiac trunk stops supplying the gut and the superior mesenteric artery takes over.
What opens cystic duct to release bile?
Spiral valve (spiral folds)
Function of duodenum
Receives:
Chyme from pyloric part of stomach.
Bile from liver and gallbladder via common bile duct.
Enzymes from pancreas via main and accessory pancreatic duct.
Duodenum structure
First part of small intestine.
‘C’-shaped structure.
Widest lumen of small intestine.
First 2-3 cm: intraperitoneal (hepatoduodenal ligament).
Remaining portion is retroperitoneal.
First/superior part of duodenum
Referred to as ampulla or duodenal cap
Smooth wall
Common site of duodenal ulcers
Clinical consequence, as gastroduodenal artery runs posteriorly.
What is the most common site for diverticula?
Second / Descending Part of duodenum
Second/descending part of duodenum
Opening of:
Hepatopancreatic ampulla –> major duodenal papilla (of vater).
- Marks division of foregut and midgut
- Consequence for neurovasculature.
Opening of:
Accessory pancreatic duct –> minor duodenal papilla
What part of the duodenum is intraperitoneal?
First part only
What can haemorrhage if a duodenal ulcer rips through duodenal wall?
Gastroduodenal artery
What artery crosses the third/horizontal/inferior part of the duodenum?
Superior mesenteric artery (and vein)
Where does the ascending part of the duodenum join the jejunum?
Duodenojejunal flexure
What holds the ascending part of the duodenum in place?
Ligament of Treitz
Lymphatics of duodenum
Follows arteries superiorly from superior pancreaticoduodenal to gastroduodenal to coeliac nodes.
Follows arteries inferiorly from inferior pancreaticoduodenal to superior mesenteric nodes.
Whipple’s procedure
Pancreaticoduodenectomy
Cancer in head of pancreas Remove: Head of pancreas Duodenum Gallbladder Bile duct
Annular pancreas
Congenital condition
Ventral pancreatic bud consists two components.
During development two parts migrate in different directions around the duodenum.
Constrict the duodenum and may result sin complete obstruction.
Causes reflux and vomiting
Spleen structure
Lymphatic organ.
Protected by 9th – 11th ribs.
Left upper quadrant / left hypochondrium.
Intraperitoneal organ
Size of it depends on blood flow- can get bigger
Spleen function
White cell proliferation.
Immune surveillance.
Filters and stores red blood cells and platelets.
Recycles iron and globin
Where are the splenic artery and vein?
Hilum of spleen
Run in splenorenal ligament
Splenomegaly
May be caused by portal hypertension
10Xs normal size!
May be palpable in right iliac fossa
Can treat with splenectomy.
What structure is this
Quadrate lobe
Identify this structure
Falciform Ligament
attaches to anterior abdominal wall
Identify this structure
Ligamentum teres
was umbilical vein during embryo
What structure is this
Caudate lobe
What is this line
Round ligament
What is this line
Fissure for ligamentum venosum
What is the clinical relevance of the fissure for ligamentum venosum?
Embryological remnant of ductus venosus
What is the entry point into liver?
Porta hepatis
Identify the vessel
Common bile duct
Identify the vessel
Hepatic portal vein
Identify the vessel
Proper hepatic artery (brings blood from coeliac trunk)
What nerves go into liver?
Vagus nerve branches
Identify the vessel
Proper hepatic artery
What 3 structures run in the lesser omentum?
Proper hepatic artery
Hepatic portal vein
Common bile duct
Where does hepatic portal vein arise from?
Superior mesenteric vein and splenic vein form hepatic portal vein
(posterior to pancreas)
Name the peritoneal reflection
Anterior coronary ligament
Name the peritoneal reflection
Posterior coronary ligament
What do the anterior and posterior coronary ligaments come together to form
Triangular ligament
Identify the vessel
Inferior vena cava
What is the space between the diaphragm and liver?
Subphrenic space
Space between kidney and liver
Pouch of Morrison / hepatorenal pouch
Why are peritoneal recesses clinically significant?
Peritoneal fluid can fill these areas
Identify the structure
Hartman’s Pouch/infundibulum
How is common bile duct formed?
Cystic duct of gallbladder unites with common hepatic duct (formed by L and R hepatic ducts)
Where in pancreas does common bile duct enter?
Head of pancreas
What duct does common bile duct fuse with in pancreas?
Main pancreatic duct
What forms the hepatopancreatic ampulla?
Common bile duct
Main pancreatic duct
Where does bile enter into duodenum?
Major duodenal papilla
Endocrine function of pancreas
Insulin production
Exocrine function
Digestive juices travel through duct to enter digestive system
Which part of the pancreas is not retroperitoneal?
Tail- intraperitoneal
What runs behind neck of pancreas?
Superior mesenteric vein and artery
What vessel runs along body of pancreas?
Splenic vein
splenic artery from coeliac trunk on superior surface
What leads directly into duodenum?
Pylorus of stomach
What part of duodenum is not retroperitoneal?
Superior part- intraperitoneal
What part of duodenum is this?
Duodenal cap/ampulla
What vessel is this
Gastroduodenal artery (can rupture in ulcer)
Identify the structure
Major duodenal papilla
opening of common bile duct and main pancreatic duct
What marks the division between the foregut and midgut?
Major duodenal papilla
What are the vessels running in the mesentery?
Superior mesenteric artery and vein
At what point does the duodenum become the jejunum?
Duodenojejunal junction (ascending part of duodenum)
What hold duodenaljejunal junction in place?
Ligament of treitiz
What is the largest lymphatic organ and is intraperitoneal?
Spleen
Spleen blood supply
Coeliac trunk and splenic artery
Splenic vein
What is spleen closely related to?
Kidney
What is this large area
Greater sac
What is greater sac of peritoneal cavity divided into?
Supracolic compartment (above transverse colon)
Infracolic compartment (below transverse colon)
What allows surgeons to go in behind stomach?
Lesser omentum through lesser sac/omental bursa
What is this area
Epiploic foramen
What attaches the transverse colon to the greater omentum?
Transverse mesocolon
What runs down from duodenal jejunal junction to sacroiliac joint?
Root of mesentery
What is this structure>
Round ligament (remnant of umbilical vein)
What are these two points?
Paracolic gutters
Rectovesical pouch
Between superior surface of bladder and rectum
What is this space?
Vesico uterine pouch
What is this space?
Recto uterine pouch of Douglas
