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SMP - GI > Lecture 7 - Abdominal Viscera II > Flashcards

Lecture 7 - Abdominal Viscera II Flashcards

1
Q

What is the largest internal organ and gland of the body? How much does it weigh?

A

LIVER

Weighs 1.5 kg

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2
Q

What gives stool its color?

A

The break down products of RBCs are eliminated in bile and gives the stool its characteristic dark color

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3
Q

Regions occupied by liver?

A

Right AND LEFT hypochondrium and epigastric regions

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4
Q

What is the bare area of the liver?

A

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

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5
Q

What are the coronary ligaments?

A

Ligaments made of peritoneum forming the borders of the bare area of the liver:

  1. Anterior border: anterior coronary ligament
  2. Posterior border: posterior coronary ligament
  3. Lateral borders: left and right triangular ligaments (where ant and post ligaments come together)
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6
Q

6 structures located inferior to liver aka relating to its visceral surface? List from lateral to medial (right to left).

A
  1. Right colic flexure and right transverse colon
  2. Gallbladder
  3. Lesser omentum
  4. Superior part of duodenum
  5. Esophagus
  6. Right side of the anterior aspect of the stomach
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7
Q

2 structures located posterior to liver aka ALSO relating to its visceral surface?

A
  1. Right kidney and right adrenal gland

2. IVC

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8
Q

What divides the liver into its right and left lobes? Which is larger?

A

Fossae for gallbladder and IVC

Right lobe is larger

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9
Q

What is the right lobe of the liver divided into? Describe each. Which lobe of the liver does it relate to FUNCTIONALLY?

A
  1. 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
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10
Q

What is the hepatic triad?

A

3 most important vessels of liver:

  1. Hepatic artery
  2. Portal vein
  3. Common bile duct
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11
Q

Liver blood supply? % for each? L/min for each? Origin for each? Total % of CO?

A
  1. 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

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12
Q

Pathway of biliary system?

A

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

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13
Q

2 lymph drainage pathways of liver?

A

FIRST WAY:
Anterior diaphragmatic and visceral surface of liver + portal triad => superficial hepatic lymphatics => deep hepatic lymphatics at the
porta hepatis => hepatic lymph nodes => celiac lymph nodes => chyle cistern

SECOND 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

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14
Q

Location of deep hepatic lymphatics?

A

Accompany the hepatic arteries and portal vein to IVC

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15
Q

Location of superficial hepatic lymphatics?

A

Subperitoneal fibrous capsule of the liver = “Glisson’s capsule”

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16
Q

Location of hepatic lymph nodes?

A

Scattered throughout the lesser omentum

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17
Q

Lymphatic drainage of gallbladder? What does it follow?

A

Celiac lymph nodes (following cystic artery)

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18
Q

Diagnosis for hepatomegaly?

A

Measure length of liver at midclavicular line (>10-12 cm) or midsternal line (>6-8 cm) by using percussions

AND also feel liver beyond the diaphragm

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19
Q

5 fluids going in/out of liver?

A
  1. Arterial blood
  2. Portal blood
  3. Venous blood
  4. Bile
  5. Lymph
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20
Q

Does the liver have a mesentery?

A

NOPE

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21
Q

What is Morrison’s pouch? Other name?

A

Part of the peritoneal cavity on the right side between the liver and the right kidney and right suprarenal gland = hepatorenal recess

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22
Q

What are the 2 recesses of the diaphragmatic surface of the liver? Are these continuous?

A
  1. Hepatorenal recess
  2. Subphrenic recess

YES, continuous anteriorly

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23
Q

What is the subphrenic recess?

A

It separates the diaphragmatic surface of the liver from the diaphragm and is divided into right and left areas by the falciform ligament

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24
Q

What is the falciform ligament derived from embryologically?

A

Derived from the ventral mesentery in the embryo

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25
Q

2 surfaces of liver? Describe each.

A
  1. Diaphragmatic surface in the anterior, superior, and posterior directions
  2. Visceral surface in the inferior direction
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26
Q

Where does liquid in the peritoneal cavity collect if the patient is in the supine position?

A
  1. Hepatorenal recess

2. Pelvic cavity

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27
Q

Is the visceral surface of the liver covered by visceral peritoneum?

A

Yes, except for the fossa for the gallbladder and the porta hepatis

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28
Q

What is the porta hepatis?

A

Gateway to the liver (kinda like hilum to lung)

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29
Q

On what side of liver is caudate lobe visible?

A

Posterior portion of visceral surface

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30
Q

On what side of liver is quadrate lobe visible?

A

Anterior portion of visceral surface

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31
Q

What separates functional left and right lobes of the liver?

A

Supply by left or right hepatic artery

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32
Q

What are the segments of the liver? How many?

A

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)

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33
Q

What is the hepatic pedicle?

A

Hepatic triad at the porta hepatis

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34
Q

Which is larger: hepatic artery or portal vein?

A

Portal vein

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35
Q

How to identify portal vein in hepatic triad?

A

Largest and most posterior structure

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36
Q

What 4 structures does the hepatic portal vein drain? Pathway to heart?

A
  1. GIT
  2. Pancreas
  3. Spleen
  4. Gallbladder

Portal vein => liver capillaries => hepatic veins (right, middle, and left) => IVC => RA

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37
Q

Common portal circulation pathology? Causes? 8 complications of this?

A

Portal hypertension

3 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. Ascites
2. Formation of portocaval venous shunts via natural anastomoses
3. Congestive splenomegaly (especially with prehepatic causes)
4. Hepatic encephalopathy
5. 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 varices
7. Internal hemorrhoids due to increased pressure in the superior rectal vein’s anastomosis to middle and inferior rectal veins
8. Caput medusa due to increased pressure in superficial veins of the anterior abdominal wall anastomosis with paraumbilical veins
9. Retroperitoneal veins

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38
Q

What % of initial gastro-esophageal variceal bleeding fatal?

A

30%!!

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39
Q

How to diagnose esophageal varices?

A

Bulges in lumen of esophagus when doing endoscopy

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40
Q

Technique to image the biliary tract?

A

Endoscopic Retrograde Cholangiopancreatography (ERCP)

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41
Q

What % of gallbladder stones radio-opaque? What does this mean?

A

10-15%, pretty rare => only 10-15% of stones will show up on a radiograph

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42
Q

% of kidney stones that are radio-opaque?

A

85%

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43
Q

Best imaging technique to find gallbladder stones?

A

Ultrasound

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44
Q

Long-term consequence of gallbladder stones that are large?

A

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

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45
Q

Pain due to liver?

A
  1. Referred pain in epigastric area since part of foregut
  2. Parietal pain in RUQ
  3. If diaphragm is irritated => pain through phrenic nerve from C3-C5 => referred pain to right upper shoulder
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46
Q

What is the point of the gallbladder storing bile?

A

Bile production by the liver is continuous but the body only needs it a few times a day

47
Q

Volume capacity of gallbladder? What does this correspond to?

A

30-75 mL = 12 hours worth of bile produced by liver

48
Q

Gallbladder surface anatomy?

A

Fundus located at junction of right 9th costal cartilage and midclavicular line, where the lateral border of rectus abdominis is located

49
Q

Pain due to gallbladder?

A
  1. Referred pain in epigastric area since part of foregut
  2. Parietal pain in RUQ at particular surface anatomy area: tenderness
  3. 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
50
Q

Position of gallbladder?

A

Lies on visceral surface in a fossa between the right and quadrate lobes

51
Q

3 parts of the gallbladder? Describe each.

A
  1. 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
52
Q

What is the body of the gallbladder in contact with?

A
  1. Superior part of duodenum

2. Transverse colon

53
Q

Blood supply to gallbladder? Clinical significance?

A

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

54
Q

What is a cholecystectomy? Why is this sometimes conducted? What does this mean?

A

Removal of gallbladder

Because of gallstones

Not essential for life, although certain dietary modifications may be necessary

55
Q

When do gallbladder stones pose a problem?

A

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

56
Q

What is the Ampulla of Vater? Other name?

A

= hepatopancreatic duct = is formed by the union of the pancreatic duct and the common bile duct

57
Q

Position of pancreas? Vertebral levels?

A

Posterior to stomach extending retroperitoneally across the posterior abdominal wall from duodenum on right to spleen on left

T12 to L2

58
Q

5 parts of the pancreas? Describe each.

A
  1. Head: lies within C-shape concavity of duodenum
  2. Uncinate process: projecting from inferior part of the head
  3. Neck
  4. Body: elongate part
  5. Tail: between layers of splenorenal ligament
59
Q

At what part of the pancreas do the pancreatic duct and common bile duct come together?

A

Head of pancreas

60
Q

Other name for pancreatic duct?

A

Duct of Wirsung

61
Q

What are the 2 ducts of the pancreas? How does each secrete into the duodenum?

A
  1. 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 Oddi
  2. Accessory pancreatic duct: empties into minor papilla
62
Q

Part of pancreas where accessory pancreatic duct is?

A

Head with tip in uncinate process

63
Q

Other name for accessory pancreatic duct?

A

Pancreatic duct of Santorini

64
Q

What is located anterior to the uncinate process of the pancreas?

A

Superior mesenteric vessels

65
Q

What is located anterior to the neck of the pancreas?

A

Superior part of duodenum

66
Q

What is located posterior to the neck of the pancreas?

A

Superior mesenteric vein meets the splenic vein to form the portal vein AND SMA branches from abdominal aorta

67
Q

What is located posterior to the body of the pancreas?

A

Left kidney

68
Q

Other name for sphincter of Oddi?

A

Sphincter of ampulla

69
Q

2 branches of the accessory pancreatic duct?

A
  1. One that connects to the pancreatic duct where it turns inferiorly
  2. One that passes anterior to the pancreatic duct and ends in the uncinate process
70
Q

Embryological origins of the 2 ducts of the pancreas?

A

Dorsal and ventral buds from foregut

71
Q

Blood supply of pancreas?

A
  1. Gastroduodenal artery from the common hepatic artery (a branch of the celiac trunk)
  2. HEAD: Anterior superior pancreaticoduodenal artery from the gastroduodenal artery
  3. HEAD: Posterior superior pancreaticoduodenal artery from the gastroduodenal artery
  4. 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)
72
Q

Usual size of the spleen?

A

A fist

73
Q

Surface projection of spleen? Region?

A

Posterior to the mid-axillary line at ribs 9-10

Region: left hypochondrium

74
Q

5 functions of spleen?

A
  1. Is hematopoietic in fetus
  2. Destroys aged (worn-out) RBCs in adulthood
  3. Filters blood
  4. Stores RBCs and platelets
  5. Produces lymphocytes and antibodies
75
Q

Is the spleen covered by visceral peritoneum?

A

Yes, except for the splenic hilum where the splenic vessels enter and sometimes where the tail of the pancreas is

76
Q

Blood supply of spleen?

A

Splenic artery from the celiac trunk

77
Q

What is the largest branch of the celiac trunk?

A

Splenic artery

78
Q

What is the spleen in contact with?

A
  1. Stomach
  2. Splenic flexure of colon
  3. Tail of pancreas
  4. Left kidney
  5. Diaphragm
79
Q

What is the narrowest part of the biliary tract?

A

Hepatopancreatic duct

80
Q

2 most common causes of pancreatitis?

A
  1. Gall stones

2. Alcoholism

81
Q

What % of patients with acute pancreatitis die? How common is this disease?

A

10%

Rare disease

82
Q

Complication of pancreatitis?

A

Chronic calcification of the pancreas

83
Q

What is pancreatic cancer referred to as? Why? In what part of the pancreas do they arise most commonly?

A

The silent killer

Usually in the HEAD of the pancreas

Close 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

84
Q

Where are pancreatic tumors more frequent?

A

Head and neck

85
Q

3 symptoms of pancreatic cancer?

A
  1. Abdominal pain
  2. Loss of appetite
  3. Weight loss
86
Q

Complication of pancreatic cancer?

A

Obstruction of the BILE duct (especially if pancreatic cancer is in the head of the pancreas) => obstructive jaundice

87
Q

Where do pancreatic cancers usually spread?

A
  1. Superior mesenteric vessels
  2. Portal vein
  3. Porta hepatis
88
Q

Largest lymphoid organ of the body?

A

Spleen

89
Q

2 surfaces of the spleen?

A
  1. Diaphragmatic

2. Visceral

90
Q

2 ligaments connected to spleen? What does each contain?

A
  1. Gastrosplenic ligament with gastroepiploic and short gastric vessels
  2. Splenorenal ligament with splenic vessels
91
Q

Other name for splenorenal ligament?

A

Lienorenal ligament

92
Q

Venous drainage of the spleen?

A

Splenic vein => portal vein

93
Q

If a penetrating injury reaches the spleen in the 9th ICS, what else is damaged?

A
  1. Left pleura => pneumothorax
  2. Diaphragm
  3. Peritoneum
94
Q

Is the spleen necessarily penetrated if it is bleeding?

A

NOPE, blunt trauma can cause bleeding

95
Q

If the spleen is palpable below the costal margin, what does this mean? How can you tell?

A

It is at least 3x its normal size = splenomegaly

Notches are palpable

96
Q

What can cause splenomegaly? What comes with it?

A
  1. Leukemia
  2. Lymphoma
  3. Certain infections

WITH generalized lymphadenopathy

  1. Portal HT
97
Q

What is a positive rebound sign?

A

It refers to pain upon removal of pressure rather than application of pressure to the abdomen

98
Q

If there is blunt trauma to the abdomen, what 2 organs are most likely to bleed? List in order.

A
  1. Spleen

2. Liver

99
Q

Can obstruction of the pancreatic duct cause jaundice?

A

NOPE

100
Q

Liver innervation?

A

Celiac plexus and vagus nerve

101
Q

Gallbladder innervation?

A

Celiac plexus

102
Q

Lymph drainage of pancreas?

A
  1. Celiac lymph nodes

2. Superior mesenteric lymph nodes

103
Q

Pancreas innervation?

A

Celiac plexus

104
Q

What % of portal circulation is recovered in hepatic veins in normal individuals?

A

100%

105
Q

Most common portocaval venous shunts via natural anastomoses formed due to portal HT?

A
  1. 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
106
Q

Anterior and posterior surface projections of left and right costodiaphragmatic recesses?

A

Anterior = medial 6th ICS to lateral 8th ICS

Posterior = T10 to T12

107
Q

Describe in painful detail the inferior margin of the parietal pleura.

A

Margin is just above the costal margin

  1. Midclavicular line: rib 8
  2. Midaxillary line: rib 10
  3. More laterally: horizontal margin crossing ribs 11 and 12 to reach T12
108
Q

How does the spiral valve of the gallbladder work?

A

It keeps the lumen of the cystic duct open to allow for bidirectional flow of bile

109
Q

Other name for gallstones?

A

Cholelithiasis

110
Q

What can gallstones cause?

A

Gradual accumulation of the components of bile:

  1. Obstructive jaundice
  2. Cholecystitis
  3. Pancreatitis
  4. Sepsis
111
Q

What is primary sclerosing cholangitis? What does it lead to?

A

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.

112
Q

How to make diagnosis of acute pancreatitis?

A

Increased levels of blood pancreatic enzymes

113
Q

Other name for hemorrhoids?

A

Pyles

114
Q

Treatment for gallstones? Consequence?

A
  1. Surgical removal
  2. Low-fat diet

=> Liver will upregulate bile production to compensate for loss of gallbladder

SMP - GI (21 decks)

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