Sem 1 - L - Foregut 2 - Liver/Biliary Tree/Gallbladder/Pancreas/Spleen - Blood vessels/lymph/nerves&surface anatomy - Gallstones

Question 1

What are the four lobes of the liver?

Answer 1

Four lobes of the liver - right lobe, left lobe, caudate lobe (superior aspect of posterior), quadrate lobe (inferior aspect of posterior)

Question 2

Where does the gallbladder sit in relation to the lobes of the liver? What costal level is the gallbladder at? What structure sits between the caudate lobe and the right love of the liver?

Answer 2

The gallbladder sits between the quadrate and the right lobe of the liver at the level of the 9th costal cartilage The inferior vena cava sits between the right lobe and caudate lobe of the liver

Question 3

The hilum of the liver sits posteriorly and the free edge of the lesser omentum attaches here * What is the free edge of the lesser omentum also known as? * What structures are carried within the free edge of the lesser omentum? * What is the hilum of the liver better known as? - it sits transversely just above the gall bladder attachment to the liver

Answer 3

Free edge of the lesser omentum aka hepatoduodenal ligament Carries the bile duct, hepatic artery and hepatic portal vein The hilum of the liver is better known as the porta hepatis

Question 4

What structures are present in the porta hepatis? What lobes does the porta hepatis lie between? Where do the hepatic veins exit the liver?

Answer 4

Porta hepatis carries the R+L hepatic ducts, hepatic arteries, porta vein, ANS fibres and lymph nodes It separates the caudate and quadrate lobes of the liver The HEPATIC VEINS are NOT AT the PORTAL HEPATIS - they drain directly from liver into the IVC

Question 5

What is the orientation of the R+L hepatic ducts, hepatic arteries and portal vein in the porta hepatis?

Answer 5

Portal vein is the most superior structure Hepatic arteries lie on the left R+L hepatic ducts lie on the right and join to form the common hepatic duct

Question 6

What is most of the anterior and superior surface of the liver covered by?

Answer 6

Most of the anterior surface of the liver is covered by the ribs and their costal cartilages The superior surface of the liver is covered by the diaphragm

Question 7

What regions of the abdomen does the liver extend into? Similar to the stomach, which ribs does the superior aspect of the liver normally lie?

Answer 7

The liver fills most if not all of the right hypochondrium and the left lobe extends into epigastric region Superiorly the ribs will meet roughly the 5th - 6th rib

Question 8

How can the gallbladder be located roughly, using a line drawn vertically?

Answer 8

If a line is drawn vertically from the mid-clavicle on the right hand side, this will intercept the 9th costal cartilage where the gallbladder is roughly located

Question 9

Most of the anterior surface covered by ribs, costal cartilages Superior surface covered by diaphragm What structures are located at the posterior surface of the liver?

Answer 9

Posterior surface Gallbladder, right kidney and adrenal gland, oesophagus, stomach, duodenum and right colic flexure - aka the hepatic flexure

Question 10

The liver is an intraperitoneal organ as it is almost completely covered by peritoneum What part of the liver is not covered by peritoneum?

Answer 10

The area attached to diaphragm on the right lobe of the liver - known as the bare area - is not covered by peritoneum - apart form this the liver is completely covered in visceral peritoneum

Question 11

When the peritoneum is reflected off the abdomen, it folds back onto itself to create a double layer of peritoneum which separates the right and left lobes of the liver, what is this known as?

Answer 11

This double layer of peritoneum is named the falciform ligament

Question 12

The falciform ligament passes to the umbilicus and contains a remnant of what? What is this remnant known as?

Answer 12

The ligamentum teres (or round ligament of the liver) is a degenerative string of tissue that exists in the free edge of the falciform ligament. It is a remnant of the umbilical vein. The umbilical vein/round ligament inserts around the umbilicus and is an important landmark of the inner surface of the anterior abdominal wall.

Question 13

In the foetus, blood would travel from the placenta to the umbilical vein and then bypass the liver using the ductus venosus What is the remnant of the ductus venosus known as and where is it found?

Answer 13

The remnant of the ductus venosus is known as the ligamentum venosum- it is found between caudate and the left lobe of the liver

Question 14

The falciform ligament remember is a double layer of folded peritoenum Where does the peritoneum fold to form the falciform ligament? What does the right and left layer of the falciform ligament create?

Answer 14

The right layer creates the coronary ligament - this attaches the bare area of the liver to the diaphragm The coronary ligament extends to become the right triangular ligament The left layer creates the left riangular ligament The peritoneum folds at the porta hepatis to form the falciform ligament

Question 15

The liver has a dual blood supply, what is this blood supply? What percentage of blood comes from each supply

Answer 15

30% blood comes from the hepatic artery 70% blood comes from the hepatic portal vein

Question 16

* Does the liver gets its oxygenated blood from the hepatic artery or the hepatic portal vein? * Does the liver get the nutrients in the blood from the hepatic artery or the hepatic portal vein? How is the arterial and venous blood of the liver conducted to the central vein of each of the liver lobules?

Answer 16

* The liver gets its oxygenated blood from the hepatic artery * The liver gets its nutrient rich blood from the hepatic portal vein The arterial and venous blood of the liver connects to the central vein of each liver via the liver sinusoids

Question 17

The central veins of the lobules of the liver drain the blood into the hepatic veins How many hepatic veins are there? Where do they drain blood to?

Answer 17

There are normally 4 hepatic veins which drain blood directly into the inferior vena cava

Question 18

How much of the lymph from the liver accounts for the total body lymph? Where does the lymph from the liver drain?

Answer 18

Approximately 1/3rd to 1/2 of all total body lymph is from the liver The lymph from liver drains to the nodes at the porta hepatis and from there to the coeilac nodes at T12 A small amount of lymph will pass through the diaphragm to the posterior mediastinum

Question 19

What is the nerve innervation of the liver? Where is pain felt?

Answer 19

Nerve innervation to the liver is ANS from the coeliac plexus Pain radiates to the epigastric region although pain may also be referred to the right shoulder due to the livers close relation with the diaphragm which is supplied by the phrenic nerve - roots C3,4,5 and therefore pain may felt in these dermatomes

Question 20

Where is bile produced and where is it stored? What forms the bile duct (properly known as the common bile duct)?

Answer 20

Bile is produced in the liver and exits via the right and left hepatic ducts Bile is stored and concentrated in the gallbladder The union of the right and left hepatic ducts forms the common hepatic duct which joins with the cystic duct from the gallbladder to form the COMMON BILE DUCT

Question 21

How long is the common bile duct and where does it end?

Answer 21

The CBD is approximately 8cm long and ends by piercing the medial wall of the 2nd part of the duodenum

Question 22

What does the CBD join with to form what before opening into the dudodneum via what? What is the sphincter circling the opening into the duodenum?

Answer 22

The common bile duct joins with the main pancreatic duct to form the hepatopancreatic ampulla (ampulla of vater) - this empties into the 2nd part of the duodenum via the major duodenal papilla which has the sphincter of oddi (hepatopancreatic sphincter) enclosing it

Question 23

If the hepatopancreatic sphincter closes on the major duodenal papilla, what will happen to the bile?

Answer 23

The bile will travel along the common bile duct into the cystic duct to the gallbladder where it is stored and concentrated

Question 24

What are the three parts of the gallbladder? What is the gallbladder covered in?

Answer 24

The fundus - which hangs out below the liver The body - which is in contact with the visceral peritoneum of the liver The neck - which is continous with the cystic duct Gallbladder sits in space between the quadrate and right lobe of the liverr

Question 25

Gallblader function- Store and concentrate bile – folds and microvilli When there is fat in the duodenum, what is released and from where to cause the gallbladder to contract?

Answer 25

When there is fat in the duodneum cholecystokinin (released form the small intestine mucosa) causes the gallbladder to contract releasing bile into the cystic duct and CBD

Question 26

The smooth muscle at the distal end of the bile duct (sphincter of oddi) and the ampulla of vater then relax allowing the bile to enter the duodenum What does the bile do to the fat?

Answer 26

The bile when then emuslify the fat The bile from the gallbladder contains salts which emulsify large fat droplets into much smaller units.

Question 27

What is the blood supply/drainage of the gallbladder? What is the lymph drainage of the gallbladder? What is the nerve supply and where is pain felt?

Answer 27

Blood supply - cystic artery - branch of the right hepatic artery Blood drainage - cystic vein into portal vein Lymph drainage -cystic nodes then portal hepatis then pre-aortic coeliac nodes Nerve supply from coeliac plexus - pain felt in epigastric region

Question 28

Gallstones are crystalline bodies made from bile components - size of gallstones greatly differs Gallstones are different colours depending on what forms them * Cholesterol? * Pigment stones?

Answer 28

Gallstones from cholesterol are usually green or yellow/white Pigment gallstones are formed from bilirubin and calcium and are usually small and dark

Question 29

The pancreas is both an endocrine and exocrine organ What are the different regions of the pancreas?

Answer 29

The pancreas has the head, neck, body, tail and uncinate process (on posterior aspect)

Question 30

The pancreas is normally a white colour and is glandular tissue so is lumpy Where do each of the regions of the pancreas lie?

Answer 30

The head lies in the concavity of the duodenum with the uncinate process lying posterior to superior mesenteric vessels The neck connects head to body and lies anterior to the origin of the SMA The body moves across laterally and superiorly The tail passes in the lienorenal ligament, into contact with the hilus of the spleen

Question 31

What is the lienorenal ligament? (also known as the splenorenal ligament) What does it contain?

Answer 31

This is a small remnant of the dorsal mesentery of the stomach which encircles the tail of the pancreas and splenic vessels

Question 32

Where does the pancreatic ducts secrete?

Answer 32

The main pancreatic duct joins with the common bile duct into the ampulla of vater There may be accessory pancreatic ducts which drain superiorly into the duodenum through minor duodenal papilla

Question 33

Where does the main pancreatic duct originate? Where do accessory pancreatic ducts originate?

Answer 33

The main pancreatic duct originates in the tail of the pancreas Accessory pancreatic ducts arise in the head of the pancreas and drain into the duodenum at sites other than the ampulla of vater

Question 34

Is the pancreas intraperitoneal or retroperitoneal? What is on its anterior surface? What is on its posterior surface?

Answer 34

The pancreas is a retroperitoneal organ Anterior have the transverse colon and stomach Posteriorly - bile duct, portal vein, splenic vein, IVC, aorta, SMA, Left psasos major, Left adrenal and kidney, spleen

Question 35

Pancreas is both and endocrine and exocrine organ The endocrine part is composed of hormonal tissue distributed along the pancreas in discrete units called the Islets of Langerhans. The exocrine part has two main ducts, the main pancreatic duct and the accessory pancreatic duct. Duodneum and pancreas are halfway between foregut and midgut and therefore both have blood supply from both What is the arterial supply to the pancreas?

Answer 35

Pancreas blood Supply:

• Superior pancreaticoduodenal artery - a branch of the gastroduodenal from the common hepatic artery
• Inferior pancreaticoduodenal artery - branch of the SMA
• Dorsal pancreatic artery and its branches from the splenic artery

Question 36

What is the venous and lymph drainage of the pancreas?

Answer 36

Drainage

• Superior pancreaticoduodenal vein - hepatic portal vein
• Inferior pancreaticoduodenal vein - SMV
• Dorsal pancreatic vein - Splenic vein
• Lymph drains to preaortic coeliac and superior mesenteric nodes

Question 37

What is the nerve supply to the pancreas? Where is pain referred?

Answer 37

Nerve supply - from coeliac and superior mesenteric plexuses (pain referred to epigastric region)

Question 38

What is the largest single mass of lymphoid tissue in the body? Where does this mass lie?

Answer 38

This would be the spleen It lies inferior to ribs 9-11 in the left hypochondrium - posterior to the stomach

Question 39

The vessels arising to the spleen are contained within two ligaments which are derived form peritoneum, what is the name of these ligaments?

Answer 39

These are the gastrosplenic and splenorenal (lineorenal) ligament

Question 40

The two ligaments, gastrosplenic and splenorenal, are remnants of the dosrsal mesentery of the stomach What do both the ligaments carry?

Answer 40

The gastrosplenic ligament carrys the short gastric and left gastric epiploic arteries which branch from the splenic artery

The lienorenal ligaments carries the tail of the pancreas and splenic vessels to the hilum of the spleen

Question 41

Need to be able to tell apart spleen and kidney for the purpose of the exam How is this able to be done?

Answer 41

The spleen will only have vessels coming from the hilum whereas the kidneys will also have a ureter extending inferiorly

Question 42

What is the largest branch of the coeliac trunk? What is the arterial supply and venous drainage of the spleen? Where does the midgut and hindgut drain into? What forms the hepatic portal vein?

Answer 42

The largest branch of the coeliac trunk is the splenic artery which runs on the superior surface of the pancreas Spleen supplied by splenic artery and drained by splenic vein Hindgut drains into IMV which drains into splenic vein Midgut drains into SMV Superior mesenteric vein and splenic vein join to form the hepatic portal vein

Question 43

Where does lymph from the spleen drain to? Where does the nerve supply to the spleen come form?

Answer 43

Lymph drains to the pancreaticosplenic lymph nodes before going to the coeliac nodes Nerves are derived from the coeliac plexus