Liver and Biliary Tree Anatomy

Question 1

What is the falciform ligament?

Answer 1

The falciform ligament provides an attachment to the liver with the anterior abdominal wall. It is a fold of the peritoneum (internal lining of abdominal.

Question 2

What is the lesser omentum?

Answer 2

The double layer of peritoneum that extends from the liver to the lesser curvature of the stomach (hepatogastric ligament) and the first part of the duodenum (hepatoduodenal ligament).

Question 3

What is the greater omentum?

Answer 3

The greater omentum is a prominent peritoneal fold that hangs down from the stomach anterior to the transverse colon, to which it is attached. The greater omentum is a double fold that connects the stomach to the posterior abdominal wall

Question 4

What is the portal triad?

Answer 4

The three main structures that enter the liver: hepatic artery proper, hepatic portal vein and the bile duct (in addition to a branch of the vagus nerve and the lymphatics)

Question 5

What is the porta hepatis?

Answer 5

This region of the liver functions similarly to a hilum and acts as the ‘liver root’. This region contains the portal triad (hepatic artery proper, bile duct and portal vein), lymph nodes and autonomic nerve fibres.

Question 6

What is the ligament venosum?

Answer 6

The ligamentum venosum is the fibrous remnant of the ductus venosus of the fetal circulation. Usually, it is attached to the left branch of the portal vein within the porta hepatis and it may be continuous with the round ligament of liver

It is invested by the peritoneal folds of the lesser omentum within a fissure on the visceral/posterior surface of the liver between the caudate and main parts of the left lobe.

Question 7

Name the lobes of the liver

Answer 7

Left, right, quadrate and caudate

Question 8

What three structure pass into the liver at the porta hepatis?

Answer 8

Hepatic artery proper, bile duct and hepatic portal vein

Question 9

Name the ligaments of the liver

Answer 9

Right/left coronary ligaments, right/left triangular ligaments, falciform ligament, round ligament, ligamentum venosum

Question 10

Where are the coronary ligaments of the liver found?

Answer 10

The convex diaphragmatic surface of the liver (anterior, superior and a little posterior) is connected to the concavity of the inferior surface of the diaphragm by reflections of peritoneum. The coronary ligament is the largest of these, having an anterior (frontal) and posterior (back) layers.

Question 11

Where are the triangular ligaments of the liver found?

Answer 11

The anterior and posterior coronary ligament layers converge on the right and left sides of the liver to form the right triangular ligament and the left triangular ligament, respectively.

Question 12

What is the omental bursa and where is it found?

Answer 12

This is also known as the lesser sac; the cavity in the abdomen that is formed by the lesser and greater omentum.

Question 13

What and where is the epiploic/omental foramen?

Answer 13

The passage of communication, or foramen, between the greater sac (general cavity (of the abdomen)), and the lesser sac.

Question 14

What structures make up the lesser omentum?

Answer 14

Hepatoduodenal and hepatogastric ligaments

Question 15

What two arteries supply the liver?

Answer 15

Hepatic portal vein (75% of blood supply) and coeliac trunk (25% of blood supply)

Question 16

What two veins make up the hepatic portal vein?

Answer 16

Splenic and superior mesenteric vein; these meet at the posterior head of the pancreas to form the portal vein

Question 17

What is liver cirrhosis?

Answer 17

Liver cirrhosis is a consequence of chronic liver disease that is grossly characterised b the replacement of liver tissue by fibrosis, scar tissue and regenerative nodules which eventually leads to the loss of liver function

Question 18

What are regenerative nodules?

Answer 18

Lumps that occur as a result of damaged tissue being regenerated

Question 19

What is normal portal pressure?

Answer 19

9mmHg

Question 20

What is normal inferior vena cava pressure?

Answer 20

2-6mmHg

Question 21

How is portal hypertension defined?

Answer 21

Portal pressure gradient (portal pressure - IVC pressure) that is greater than 10mmHg

Question 22

Name the different porto-systemic anastomoses in the body, and why is this clinically relevant?

Answer 22

Oesophageal, rectal, anterior abdominal wall and retroperitoneal; these can all be sites affected by increased portal pressure that can lead to the production of varices

Question 23

Describe the porto-systemic anastomosis in the oesophagus

Answer 23

Systemic drainage: The superior oesophagus is drained by the oesophageal veins to the azygos vein

Portal drainage: the inferior oesophagus drains into the left gastric veins

Question 24

Describe the cause of oesophageal varices

Answer 24

At the gastro-oesophageal junction there is anastamosis between the left gastric veins (portal) and oesophageal veins (systemic to azygos); if there is an increase in portal pressure there is blood pooling in the liver so portal drainage is impeded, and therefore the oesophageal blood will preferably drain into the systemic drainage (oesophageal veins) and increase the pressure in these veins which can cause the veins to lengthen and dilate (oesophageal varices)

Question 25

What is ascites?

Answer 25

Fluid in the peritoneal space

Question 26

What are the common causes of ascites?

Answer 26

Portal hypertension (increased hydrostatic capillary pressure), hypoalbuminaemia (decreased colloid osmotic pressure) and aldosterone-related renal sodium retention –> increased blood volume

Question 27

What is caput medusae?

Answer 27

This is where the round ligament (ligamentum teres hepatis), which is the remnant of the umbilical vein, found within the falciform ligament, becomes re-vascularised due to increased portal pressure and this umbilical vein then starts to drain into the paraumbilical veins into the systemic circulation

Question 28

Describe the blood supply of the ano-rectal junction

Answer 28

Systemic:
The middle rectal and inferior rectal veins which give rise to the internal and external venous plexi respectively drain up into the internal iliac vein

Portal:
The superior rectal vein drains into the inferior mesenteric vein

Question 29

What is the portal and systemic venous drainage of the oesophagus?

Answer 29

Portal: left gastric vein into the IVC

Systemic: oesophageal veins into the azygos

Question 30

What is the portal and systemic venous drainage of the rectum?

Answer 30

Portal: superior rectal vein to the internal iliac vein

Systemic: superior rectal vein to the inferior mesenteric vein

Question 31

What is the portal and systemic venous drainage of the anterior abdominal wall?

Answer 31

Portal: umbilical vein (if the round ligament is revascularised in portal hypertension) which drains into the paraumbilical veins

Systemic: the intercostal and inferior epigastric veins

Question 32

What is the portal and systemic venous drainage of the retro-peritoneal wall?

Answer 32

Portal: duodenal, pancreatic, right and left colic veins

Systemic: lumbar veins

Question 33

What is the major duodenal papilla?

Answer 33

It’s the main entry of the bile duct into the duodenum, and this structure is surrounded by the sphincter of Oddi

Question 34

What is the hepatopancreatic ampulla/ampulla of Vader?

Answer 34

Where the material collects prior to flowing to the major duodenal papilla

Question 35

Where is the common hepatic duct found?

Answer 35

In the free margin of the lesser omentum

Question 36

Where is the bile duct found?

Answer 36

In the free margin of the lesser momentum anterior to the hepatic portal vein and to the right of the hepatic artery

Question 37

Why may gall bladder inflammation (cholecystitis) lead to pain in the upper right quadrant that can be referred to the right flank or scapula?

Answer 37

The gall bladder is related to the hepatic flexure of the colon and duodenum and therefore an inflamed gall bladder (cholecystitis) may herniate into these structures and lead to pain in the upper right quadrant that can be referred to the right flank or scapula, relevant to the innervation of the structures impeded.

Question 38

What is Calot’s triangle?

Answer 38

An anatomic space bordered by the cystic duct inferiorly, common hepatic duct medially and the inferior (visceral) surface of the liver superiorly.

Question 39

What’s the blood supply to the gall bladder?

Answer 39

The cystic artery which is branch off of the right hepatic artery

Question 40

What is the round ligament (ligamentum teres hepatis) of the liver?

Answer 40

Is a degenerative string of tissue that exists in the free edge of the falciform ligament of the liver