Liverspleen

Question 1

What is meant by the bare area of the liver

Answer 1

Superior surface of liver has direct contact with the inferior surface of the diaphragm
No intervening peritoneum
Visceral peritoneum reflects at bare area.

Question 2

Describe the boundaries of the bare area of the liver

Answer 2

Anterior boundary- reflection of the peritoneum- anterior coronary ligament
Posterior boundary- reflection of peritoneum- posterior coronary ligament
Where the two coronary ligaments come together laterally they form the right and left triangular ligaments

Question 3

Describe the Mesenteries in Relation to the Stomach, Liver, and Spleen

Answer 3

Liver is attached to stomach and duodenum via folds of peritoneum (lesser omentum- hepatogastric and hepatoduodenal ligaments respectively)
Stomach is attached to spleen via gastrosplenic ligament
Spleen attached to left kidney via splenorenal ligament
They are folds in peritoneum

Question 4

Describe the liver mesenteries and bare areas

Answer 4

Liver develops in the ventral foregut mesentery
Connected to anterior abdominal wall by Falciform Ligament- derived from ventral mesentery in the embryo
Connected to stomach by Lesser Omentum
Direct contact with part of Diaphragm (Bare Area of Liver)

Question 5

Describe the location of the liver

Answer 5

Largest visceral organ in the body- primarily in the right hypochondrium and epigastric region, extending into the left hypochondrium (RUQ and LUQ)

Question 6

Describe the surface anatomy of the liver

Answer 6

Deep to: ribs 7 -11

Mostly under the cover of ribs

Epigastrium- covered by rectus abdominis muscle- can’t palpate here
palpate under ribs

Question 7

Describe the two surfaces of the Liver

Answer 7

Diaphragmatic- anterior, superior and posterior directions

visceral- inferiorly

Question 8

Describe the recesses of the diaphragmatic surfaces of the liver

Answer 8

Diaphragmatic surface is smooth and domed
Subphrenic recess- separates diaphragmatic surface of the liver from the diaphragm- and is divided into right and left areas by the falciform ligament- a structure derived from the ventral mesentery
hepatorenal recess- part of the peritoneal cavity on the right side between the liver and right kidney and right suprarenal gland
Both recesses are continuously anteriorly

Question 9

Describe the anatomical lobes of the liver

Answer 9

The liver is divided into right and left lobes by fossae for the gallbladder and IVC. The right lobe is the largest
The quadrate and caudate lobe arise from the right lobe and are functionally distinct.

Question 10

Describe the ligaments of the Liver

Answer 10

Visceral peritoneum reflects off the liver in the form of the falciform ligament and the coronary ligaments which reflect off the right and left lobes of the liver
Superior surface of left lobe- left triangular ligament
Superior surface of right lobe- coronary ligament
All these ligaments attach the liver to the diaphragm (anterior abdominal wall)

Question 11

What is attached to the falciform ligament

Answer 11

Ligamentum teres (round ligament of liver)- remnant of the obliterated left umbilical vein
This joins the ligamentum venosum- now a fissure on the visceral surface (fissure of ligamentum venosum)

Question 12

Essentially, what forms the lobes

Answer 12

The peritoneal reflections divide the liver externally into two main lobes and 2 accessory lobes

Question 13

Summarise the visceral surface of the liver

Answer 13

Covered in visceral peritoneum except in the fossa for the gallbladder and at the porta hepatis
Porta hepatis serves as a point of entry into the liver for the hepatic arteries, and portal veins, and an exit point for the hepatic ducts

Question 14

Describe the right anatomical lobe of the liver and its posterior relations

Answer 14

Inferior to posterior coronary ligament- renal impression
Inferior to this colic impression
Medial to colic impression- gall bladder
medial to this- quadrate lobe
Gall bladder moves superiorly (fundus, body, neck) into porta hepatis
IVC superiorly
Caudate lobe just medial to falciform ligament in the middle
See diagram!

Question 15

Describe the left anatomical lobe of the liver and its relations

Answer 15

Gastric impression just inferior to the left triangular ligament
Esophageal impression medial to this

Question 16

Describe the quadrate lobe

Answer 16

Visible on the anterior part of the visceral surface- bounded on the left by the fissure of ligamentum teres and on the right the fossa of the gall bladder
Functionally- it is related to the left lobe but anatomically to the right

Question 17

Describe the caudate lobe

Answer 17

Visible on the posterior part of the liver
bounded on the left by the fissure of ligamentum venosum and on the right by the groove for the IVC
Functionally distinct from the right and left lobes

Question 18

Describe the functional lobes of the liver

Answer 18

Divided into right and left functional lobes by fossae for the IVC and gallbladder

Question 19

Describe the arterial supply to the liver

Answer 19

Right hepatic artery from hepatic artery proper ( a branch of the common hepatic artery from the celiac trunk)
The left hepatic artery from hepatic artery proper ( a branch from common hepatic artery from the celiac trunk)

Question 20

Describe blood supply to the quadrate and caudate lobes

Answer 20

caudate- both

quadrate- left hepatic

Question 21

Outline the key points regarding the visceral surface of the liver

Answer 21

Gall bladder and inferior vena cava mark the separation into functional R and L lobes

Grooves for foetal veins mark out minor parts of functional L lobe (quadrate and caudate Lobes)

Porta of the liver separates quadrate and caudate lobes.
Porta carries the 1) Hepatic Artery 2) Portal Vein 3) Common bile duct, and lymphatics

Question 22

Summarise the visceral relations of the liver

Answer 22

Covered by costal margin except in upper epigastrium
Convex diaphragmatic surface
Complex visceral surface in contact with stomach, duodenum, right kidney and colon

Question 23

bDescribe the key branches of the common hepatic artery

Answer 23

Runs to the right and divides into its two terminal branches- the hepatic artery proper and the gastroduodenal artery
the hepatic artery proper ascends towards the liver in the free edge of the lesser omentum- runs to the left of the bile duct and anterior to the portal vein, and divides into the right and left hepatic arteries near the porta hepatis
as the right hepatic nears the liver it gives off the cystic artery to the gallbladder

Question 24

Describe the branches of the gastroduodenal artery

Answer 24

May give off supraduodenal artery and does give off posterior superior pancreaticoduodenal artery near the upper part of the superior duodenum
after these branches the gastroduodenal artery continues descending posterior to the superior part of the duodenum
reaches the lower body and divides into its terminal branches- right gastro-omental branch and anterior superior pancreaticoduodenal artery

Question 25

What do the posterior and anterior superior pancreaticoduodenal arteries anastomose with

Answer 25

Superior pancreaticoduodenal arteries – anastomose with inferior pancreaticoduodenal arteries from the superior mesenteric artery

Question 26

Describe venous drainage from the liver

Answer 26

IVC: drains blood from liver via three hepatic veins

Question 27

Summarise blood supply of the liver

Answer 27

Hepatic artery, derived from the coeliac axis, supplies arterial blood to the liver Portal vein drains, venous blood from the GI tract and spleen, into the liver Venous blood from the liver drains directly into the inferior vena cava via 3 short hepatic veins

Question 28

List some important sites for porto-systemic anastomoses

Answer 28

Site A Oesophageal v - Sys Lt gastric v - port Site B Inferior rectal v - Sys Superior rectal v – port Site C Epigastric v - Sys Paraumbilical v – port Site D Retroperitoneal v - Sys Visceral v – port

Question 29

Describe the general important areas for portacaval anastomoses

Answer 29

esophagus para-umbilical region where liver is in contact with diaphragm where wall of G.I tract is in direct contact with posterior abdominal wall (retroperitoneal structures)

Question 30

Describe the importance of these anatamoses

Answer 30

blockage of hepatic portal vein or vascular channels in the liver can affect patterns of venous return from abdominal parts of the G.I system vessels that interconnect the portal and caval systems can become greatly enlarged and tortuous and rupture the anastomoses allow blood in the tributaries of the portal system to bypass the liver, enter the caval system and thereby return to the heart. likewise if IVC is partially compressed or obstructed

Question 31

Describe the consequences of portal hypertension

Answer 31

can result in esophageal and rectal varicies and in caput medusae in which systemic vessels that radiate from the para-umbilical veins enlarge and become visible on the abdominal wall

Question 32

Summarise the portal systemic anastomoses

Answer 32

May become dilated if portal blood flow through the liver is obstructed in liver disease. Important sites of PSA are lower oesophagus, rectum, and para-umbilical veins Haemorrhage is common from the first two sites

Question 33

Summarise the biliary tree

Answer 33

left and right hepatic ducts form the common hepatic duct, and the cystic duct from the gall bladder then joins the common hepatic duct to form the common bile duct, passing behind the 1st part of the duodenum and head of pancreas, entering the duodenum at the major papilla

Question 34

Describe the structure of the gall bladder

Answer 34

pear-shaped sac on visceral surface of right lobe of liver consist of: a rounded end (fundus)- projects from inferior border a major part in the fossa (body)- which may be against the transverse colon and the superior part of the duodenum narrow part (neck)- with mucosal folds forming spiral fold

Question 35

Describe the relations of the gall bladder

Answer 35

inferior to the liver, anterior to the duodenum and superior to the transverse colon

Question 36

What are the consequences of neoplasms in the head of the pancreas

Answer 36

Neoplasms of head of pancreas can obstruct the ducts here | jaundice- excess bile in the blood

Question 37

How can large gall stones enter the duodenum

Answer 37

large gall stones may enter duodenum directly if a cholecystoenteric fistula forms

Question 38

Where can small gallstones pass

Answer 38

Into the bile duct- and are trapped in the region of the sphincter of the ampulla- obstructing the flow of bile into the duodenum this in turn, produces jaundice

Question 39

Describe the basic characteristics of the spleen

Answer 39

Develops as part of the vascular system in the part of the dorsal mesentery that suspends the developing stomach from the body wall In the adult, the spleen lies against the diaphragm in the area of rib 9- 10 In the LUQ and left hypochondrium

Question 40

Summarise the spleen

Answer 40

Largest lymphoid organ in the body Fist -sized, suspended in dorsal foregut mesentery (gastro-splenic and spleno-renal ligaments) Lies posteriorly on L side under ribs 9-11 Relations with stomach, L kidney, L (splenic) flexure of colon, tail of pancreas Traumatic rupture causes severe haemorrhage

Question 41

Describe the connections of the spleen

Answer 41

greater curvature of the stomach- gastrosplenic ligament (contains the short gastro and gastro-omental vessels) left kindey- splenorenal ligament (contains splenic vessels) both these ligaments are part of the greater omentum

Question 42

Describe the splenic hilum

Answer 42

entry point for splenic vessels, and occasionally the tail of the pancreas reaches this area on medial surface not covered in visceral peritoneum unlike the rest of the spleen

Question 43

Describe the relations of the spleen

Answer 43

Postero-inferior- kidney superior- stomach anterior- colon

Question 44

Describe splenic rupture

Answer 44

tends to occur when there is localised trauma to the LUQ. Associated with lower left rib fractures as the spleen has a thin capsule- susceptible to injury even in the absence of damage to other structures as the spleen is highly vascular- when ruptured- it bleeds profusely into the peritoneal cavity should always be suspected with blunt abdominal injury

Question 45

Describe splenic enlargement

Answer 45

The spleen is an organ of the reticulo-endothelial system (e,g leukaemia, lymphoma and certain infection) may produce lymphadenopathy and enlargement of the spleen (splenomegaly)

Question 46

What is the eight segment model of the spleen based on

Answer 46

hepatic arterial, portal and biliary drainage of each segment

Question 47

what is key to remember about the spleen

Answer 47

don't need it in adult life | spleen cannot repair itself- splenectomy if damaged