Liver, Gall Bladder and Stomach Flashcards
What is the largest gland in the body?
Liver
T/F
The liver is the third largest single organ.
F
The liver is the SECOND largest single organ (next to the skin).
The liver is ___ % of an adult’s body weight, ___ % of the total fetal weight.
2.5 %, 5 %
During fetal development, what is the function of the liver?
It is a hematopoetic organ.
The liver can be found in which quadrant and region of the body?
RUQ of the abdomen;
R Hypochondrium, Epigastric, and L Hypochondrium
T/F
The liver is enclosed by peritoneum.
F
The liver is surrounded by peritoneum except on the BARE AREA of the liver.
Where can one find the bare area of the liver?
Posterosuperior aspect of the liver;
Closely related to the diaphragm
What is the tight fibrous capsule that encloses the liver?
Glisson’s Capsule
What is the location of the liver with respect to the ribs and surface anatomy?
It is deep to the 7th-11th ribs and crosses the midline towards the left nipple.
What structures protect the liver?
Anteriorly: Lower rib cage
Posteriorly: muscles and bones of the abdominal cavity
Identify the functions of the liver.
(1) Glycogen storage
(2) Bile secretion
(3) other metabolic actities
T/F All nutrients (except fat) absorbed from the digestive tract are initially conveyed to the liver by the portal venous system.
T
Path of Bile (from liver)
Liver (via biliary ducts/ R and L hepatic ducts) -> Common Hepatic Duct -> (+ cystic duct) -> Common Bile Duct
What are the five ligaments of the liver?
(1) Falciform Ligament
(2) Coronary Ligament
(3) R Triangular Ligament
(4) L Triangular Ligament
(5) Round Ligament
The falciform can be divided into:
R and L leaflet
Location of the falciform
from the umbilical notch on the inferior surface of the liver portal hepatis
Function of the falciform ligament:
(1) subdivided the subphrenic spac
T/F
The R leaflet becomes the R triangular ligament while the L leaflet becomes the coronary ligament
The R leaflet becomes the coronary, while the L leaflet becomes the L triangular ligament.
Function of the Right Triangular Ligament
It attaches the liver to the undersurface of the right leaflet of the diaphragm.
Location of the round ligament
found at the base of the falciform from the umbilicus
The round ligament is continuous with what structure?
Ligamentum Venosum
Embryonic Function of the ligamentum venosum
fibrous remnant of the fetal ducts venosus;
Shunts blood from the umbilical vein to the IVC
Enumerate the “H” Fissures of the liver
Right Limb:
Anterior Right - Fossa for the Gall Bladder
Posterior Right - Groove for the IVC
Left Limb:
Anterior Left - fissure for ligamentum teres
Posterior Left - fissure for ligamentum venosum
Crossbar of "H": Porta Hepatis, which contains: Common Hepatic Duct Hepatic Artery Hepatic Portal Vein Hepatic Nerve Plexus Lymphatic vessels
What is the significance of the “H” fissure?
It divides the liver into four lobes (R, L, caudal, quadrate).
T/F
The liver is divided into four anatomical lobes.
F
The liver is divided into two anatomical lobes and two accessory lobes.
T/F
The R and L lobes do not communicate.
T
Each lobe has own arterial supply, venous drainage, and biliary drainage.
T/F
The caudate lobe is not located in the caudal position.
T
The caudate lobe is not positioned caudally. It is named as such because of the “tail” or the ELONGATED PAPILLARY PROCESS.
What is the function of the elongated papillary process?
It connects the caudate and right lobes of the liver.
T/F
The right and left livers are functionally dependent with one another.
F
The two lobes of the liver are functionally independent.
What are the vessels that supply and drain the liver? What drains the liver contents?
Hepatic artery and Hepatic Portal Vein
Hepatic Duct
What vessels drain and supply the caudate lobe?
The caudate receives blood from branches of both hepatic arteries and is drained by two or three small hepatic veins that enter directly to the IVC.
The liver can be divided into four divisions and into eight surgically resectable hepatic segments. Clinical Significance?
minimize bleeding during hepatic lobectomies and segmentectomies
What encloses the portal triad?
Lesser Omentum
Enumerate and differentiate the the two ligaments of the lesser omentum
Hepatogastric Ligament: connects stomach to liver
Hepatoduodenal Ligament: connects the liver to the duodenum
What are the three main hepatic veins?
Right, Central and Peripheral Hepatic Veins
Aside from the venous drainage, what is the importance of the hepatic veins? (Hint: related to the pathway of the veins)
The connection of the hepatic veins with the IVC helps hold the liver in position.
T/F
The liver is a major lymph-producing organ.
T
How much of the lymph entering the thoracic duct comes from the liver?
1/4 to 1/2
Where does most of the lymph form in the liver and where does it drain?
Most of the lymph form in the perisinusoidal spaces of Disse and it drain to the DEEP LYMPHATICS in the surrounding intralobular portal triads.
T/F
The liver only receives sympathetic fibers.
F
The liver receives both sympathetic and parasympathetic fibers via the CELIAC PLEXUS.
What nerves contribute fibers for the innervation of the liver?
L and R vagus and R phrenic nerve
What are the spaces between the diaphragm, transverse colon and transverse mesocolon?
Perihepatic Spaces
What are the two divisions of the perihepatic spaces?
Infrahepatic space
Suprahepatic space
Where is the suprahepatic space located?
between the diaphragm and the liver;
anterosuperior surface of the liver
Where is the infrahepatic space located?
between the visceral surface of the liver and the transverse colon;
inferior surface of the liver
During liver biopsy, through which ICS is the needle inserted in?
right 10th ICS in the midaxillary line
T/F
Before liver biopsy, the patient is asked to hold his/her breathe in .
F
Before liver biopsy, the patient is asked to hold his/her breath in full expiration to reduce the costodiaphragmatic recess.
What is one cause of the hepatomegaly?
Congestive heart failure tumor and bacterial/viral disease (e.g hepatitis)
What is a proposed underlying cause of “runner’s stitch”?
Enlargement of the liver + sustained/increased diaphragmatic activity
What is the progressive destruction of hepatocytes and replacement by fat?
Cirrhosis of the liver
What can cause cirrhosis of the liver?
Chronic Alcoholism, Industrial Solvents (e.g. carbon tetrachloride)
Treatment for cirrhosis of the liver?
Surgical creation of a portosytemic or,portocaval shunt, anastomosing the portal and systemic systems
What can be used as a guide during hepatic segmentectomies?
The right, immediate, and the left hepatic arteries can be used as guides to the fissures between the divisions.
T/F
The liver is easily ruptures because it is a large, fixed in position and friable.
T
Liver lacerations can often cause considerable hemorrhage and RUQ pain.
T/F
The liver is the most common site of metatastic carinoma.
T
Enumerate the four surfaces of the liver
(1) Anterosuperior
(2) Posterosuperior
(3) Right Lateral
(4) Inferior
What structure is closely related to the anterosuperior surface of the liver?
This surface snugly fits into the cupola of the diaphragm.
What structures can be found/associated with the posterosuperior surface of the liver?
IVC (found on the posterior surface of the caudate lobe)
Suprarenal Impression
Bare Area of the liver
What is the significance of the inferior surface?
Separates the diaphragmatic and visceral surfaces
What organs come in contact with the inferior surface of the liver?
Stomach, Colon, Kidney, Duodenum, Esophagus, Right Suprarenal Gland
Another name for the hepatorenal recess
Hepatorenal pouch, Morrison’s pouch
Where is the hepatorenal pouch located?
posterosuperior extension of the subhepatic space;
between the right part of the visceral surface of the liver, the right kidney and the suprarenal gland
What is the gravity-dependent part of the peritoneal cavity wherein fluid drains into when in the supine position?
Morrison’s Pouch
What is carried by the hepatic artery? by the hepatic portal vein?
Artery: Oxygenated Blood
Vein: Venous Blood
Where does the renal, phrenic, lumbar and intercostal veins receive blood from?
mesenteric, pancreatic and other veins
T/F
The tertiary branches of the hepatic artery is able to supply independently the eight lobes of the liver.
F
Only seven of the eight lobes are supplied independently by the tertiary branches of the hepatic artery.
Hepatic artery -> Divide into R and L -> Secondary Branches (to supply medial and lateral) -> Tertiary branches (7 of 8 hepatic segments)
What joins to form the hepatic portal vein?
The union of the superior mesenteric and splenic veins
What is the normal size of a gall bladder (in cm)?
7-10 cm long
Where is the gall bladder located (vis-à-vis liver)?
in the fossa of the gall bladder, on the visceral surface of the liver
Where is the gall bladder located (vis-à-vis small intestines)?
It naturally lies anterior to the superior part of the duodenum.
Where does the neck and cystic duck connect?
to the superior part of the duodenum
How much bile can the gall bladder hold?
50 ml
What are the four parts of the gall bladder?
(1) Fundus
(2) Body
(3) Infundibulum
(4) Neck
What is formed by the angle made by the lateral border of the rectus abdominis and the 9th costal cartilage?
Tip of the fundus (of the gall bladder)
The fundus of the gall bladder is associated with which part of the duodenum?
descending part of the duodenum
What is in contact with the body of the gall bladder?
Inferior surface of the liver, right part of the transverse and superior part of the duodenum
What is the tapering transitional area between the body and the neck?
Infundibulum
What attaches the first part of the duodenum to the infundibulum? What is its significance?
Cholecystoduodenal ligament (significance in the operative search for major vascular and ductal structures)
What is the bulging inferior surface of the infundibulum of the gall bladder? What is its significance?
Hartman’s pouch
significance: used to mark the positions of the neck and cystic duct of the gall bladder
What connects the gall bladder to the common hepatic duct?
Cystic Duct
Course of the Cystic Duct
Cystic Duct -> Common Hepatic Duct -> common bile duct
What is the function of the spiral valve of Heister?
(1) helps keep the cystic duct open
(2) offers additional resistance to sudden dumping of bile
What is the clinical significance of the relationship between the gall bladder and the right colon?
The biliary stones can pass directly to the colon;
it allows for the early spread of carcinoma
What is the arterial supply of the gall bladder?
Cystic Artery
Where may the cystic artery arise from?
R hepatic artery
L hepatic artery
Common hepatic artery
superior mesenteric artery
What does the cystic artery supply?
Gall Bladder and the Cystic Duct
Where does the cystic artery commonly arise from?
R hepatic artery
Describe the venous drainage of the gall bladder?
There is no major cystic vein. Cystic Vein (go in the liver ) -> Portal Capillary System
Where does the lymphatics of the gall bladder drain into?
Cystic Lymph Nodes -> Hepatic Lymph Nodes
Efferent Lymphatic vessels pass to the celiac lymph nodes
Referred Pain:
Irritation in the liver can manifest as…
pain in the ipsilateral neck and shoulder region
Referred Pain:
Irritation in the gall bladder can manifest as…
pain in the T7 and T9 (until posterior) and infrascapular area
Abdominal pain while in the crouching position may suggest…
appendicitis.
Term for gall bladder inflammation
Cholecystitis
What is the most dilated part of the alimentary canal between the esophagus and the small intestines?
Stomach
In what region does the stomach lie in?
Epigastric, Umbilicus, and left hypochondriac region
T/F
The stomach is retroperitoneal.
F
The stomach in intraperitoneal and is covered by visceral peritoneum except where the blood vessels run along.
Identify the organs related to the anterior surface of the stomach
diaphragm, left lobe of the liver, anterior abdominal wall
Identify the organs related to the posterior surface of the stomach
omental bursa and pancreas
What are the three parts of the stomach?
(1) Fundus
(2) Body
(3) Pyloric Region
*The cardia was not considered as a “part” of the stomach by the lecturer.
What part of the stomach is related to the left dome of the diaphragm
Fundus of the Stomach
What structure lies on the horizontal plane which determines the inferior boundary of the fundus?
Cardiac Orifice
Where is the cardiac notch located?
between the esophagus and the fundus
What is the major portion of the stomach?
Body of the stomach
The body of the stomach lies in contact with…
the left costal margin and upper anterior abdominal wall on the left side
What is the funnel-shaped outflow region of the stomach?
Pyloric Region of the stomach
What is the widest part of the pyloric region?
Pyloric Antrum (More promixal to the stomach proper)
What groove divides the pyloric region?
Sulcus Intermedius
What is the narrow part of the pyloric region?
Pyloric Canal (More distal to the stomach proper)
What determines the level of the transpyloric plane?
It traverses the pyloric canal and sphincter
Identify the two curvatures of the stomach
(1) Greater Curvature
(2) Lesser Curvature
Identify the two orifices of the stomach
(1) Cardiac Orifice
(2) Pyloric Orifice
Temporary Longitudinal folds; formed when gastric mucosa is contracted
Rugae
T/F
One has more prominent gastric folds as you eat.
F
It diminishes and obliterates as the stomach is distended.
What is temporarily formed during swallowing between the rugae of the mucosa along the lesser curvature?
Gastric Canal
What are the two surfaces of the stomach?
(1) Anteriosuperior surface
(2) Posteroinferior surface
The stomach bed is composed of the…
Left suprarenal gland Upper part of the alimentary canal Splenic Artery Anterior surface of the the pancreas Diaphragm Transverse colon Left colic flexure
What are the three primary branches of the celiac trunk?
(1) Splenic Artery
(2) L Gastric Artery
(3) Common Hepatic Artery
Where does the arterial supply of the stomach come from?
(1) R & L Gastroepiploic Arteries
(2) R & L Gastric Arteries
(3) Short Gastric Arteries
(4) Inferior Gastric Arteries
What supplies blood to the greater curvature of the stomach?
R & L Gastroepiploic Arteries
What supplies blood to the lesser curvature of the stomach?
R & L Gastric Arteries
What supplies blood to the fundus and upper body of the stomach?
Short Gastric Arteries and Inferior Gastric Arteries
Describe the venous drainage o the stomach vis-à-vis the arterial supply.
The gastric veins are parallel to the arteries in positions and course
What is the main draining vein?
Portal Vein
What are the veins that drain the stomach? Which parts do they specifically drain?
(1) R and L Gastric Veins
(2) Splenic Veins - receives from short gastric and L gastroepiploic veins
(3) Superior Mesenteric Vein - receives from L gastroepiploic veins
(4) Prepyloric Vein - to the R gastric artery
What is the clinical significance of the Prepyloric vein?
It is used to identify the pylorus
Where are the lymphatic vessels of the stomach located?
(1) Along the left part of the lesser curvature
(2) Along the greater curvature and most of the pyloric region
(3) Along the left of the greater curvature
(4) Along a small part of the pyloric region
Describe the parasympathetic nerve supply of the stomach
Anterior Vagal Trunk: derived from L vagus nerve and runs along the lesser curvature
AVT -> hepatic, duodenal, and anterior gastric branches
Posterior Vagal Trunk: derived from R vagus nerve and runs along the lesser curvature; supplies the anterior and posterior surface of the stomach
PVT -> celiac branch -> posterior gastric branches
Describe the sympathetic nerve supply of the stomach
From T6-T9 segments -> celiac plexus -> distributed around the gastric and gastroepiploic arteries
