The Liver and Gallbladder Flashcards
Describe the position of the liver
Right upper quadrant
Epigastrium, right hypochondrium
Which digestion products are carried to the liver and how?
All products apart from lipids
Transported by hepatic portal vein
Describe the surfaces of the liver
Diaphragmatic surface
Anterosuperior and is related to the inferior surface of the diaphragm
Visceral surface
Lies posteroinferior and is related to other organs
Which areas of the liver are not covered by visceral peritoneum?
bare area of the liver - region on posterior surface in contact with the diaphragm
region of contact with the gallbladder
porta hepatis - where hepatic and ducts of the biliary system enter/exit
What are the liver’s two anatomical lobes separated by?
Large left lobe separated from small left lobe by falciform ligament.
Also connects it to the internal aspect of the anterior abdominal wall
What are the two accessory lobes of the liver and where are they found?
Caudate and quadrate lobes
Posteroinferior surface
How many functional segments is the liver arranged into internally?
Eight
How are the eight functional segments of the liver separate?
Each segment is served by its own branch of the hepatic artery and portal vein
And by its own hepatic duct
How is the liver connected to the diaphragm?
By coronary and triangular ligaments
How is the liver connected to the anterior abdominal wall?
By the falciform ligament
How is the liver connected to the stomach and the duodenum?
The lesser omentum
What ligaments connect the liver to things?
Coronary and triangular ligaments - diaphragm
Falciform ligament - anterior abdominal wall
Lesser omentum - stomach and duodenum
What is the portal triad on the free edge of the lesser omentum?
Hepatic artery
Hepatic portal vein
Bile duct
What do the portal triad and the free edge of the lesser omentum form?
The anterior boundary of the epiploic foramen (entrance to the lesser sac)
What is the epiploic foramen?
entrance to the lesser sac
What are the two recesses related to the liver?
hepatorenal recess - between right kidney and posterior surface of right side of liver
in supine position fluid flows into this space
L/R subphrenic recesses - either side of the falciform ligament. Between anterosuperior surface of liver and the diaphragm
Where does the liver develop from embryologically?
the foregut - from a bud that develops in the ventral mesentery
What is the ventral mesentery?
Embryological structure
Peritoneal fold in the upper abdomen - connects the stomach to the anterior abdominal wall
Its remains form the lesser omentum and the falciform ligament
Where is the round ligament of the liver found? (/ligamentum teres)
the free edge of the falciform ligament
What is the round ligament of the liver a remnant of?
Umbilical vein - carries oxygenated blood from placenta to fetus
What is the ligamentum venosum?
Embryological remnant of ductus venosus - diverted blood from umbilical vein to the IVC, shunting oxygenated blood to bypass the liver
Posterior surface of the liver - groove between caudate lobe and left lobe
What vessels are the liver supplied by?
right and left hepatic arteries - derived from coeliac trunk
What does the coeliac trunk give rise to?
The left gastric, splenic and common hepatic arteries
What does the common hepatic artery give rise to?
gastroduodenal artery, then it is called the hepatic artery proper (HAP)
Where do the L/R arteries enter the liver?
at the porta hepatis
How does venous blood leave the liver?
By two or three large hepatic veins within the liver - not visible external to the liver
Unite with the inferior vena cava
What is the difference between the hepatic veins and the hepatic portal vein?
Hepatic portal vein is nutrient rich blood from gut tube
venous blood leaves the liver by hepatic veins
Describe the nervous supply of the liver
Hepatic plexus
Parasympathetic fibres from the vagus nerve
Sympathetic fibres
Fibres follow the path of the hepatic vessels and ducts of the biliary tree
Where is pain arising from the liver referred to?
Epigastric region - derived from the foregut
Which cranial nerve supplies parasympathetic fibres to the hepatic plexus?
the vagus
Where is the gallbladder?
Posteroinferior (visceral) surface of the liver, close to the duodenum
In the glandular fossa
What are the three parts of the gallbladder?
The fundus
the body
the neck
What is the fundus of the gallbladder?
the rounded end of the gallbladder
surface marking is at the tip of the 9th costal cartilage where right midclavicular line intersects right costal margin
What is the neck of the gallbladder?
Communicates with the cystic duct (from gallbladder)
Where is bile produced and first excreted?
Produced by hepatocytes, secreted into small channels called bile canaliculi
What are the bile canaliculi?
small channels where bile is excreted into from the hepatocytes
Where do the canaliculi drain into?
Drain into bile ducts of increasing calibre - ultimately converge into left and right hepatic ducts that exit the liver at the porta hepatis
What do the left and right hepatic ducts converge into?
Common hepatic duct
What does the common hepatic duct receive from the gallbladder?
the cystic duct
What is the common bile duct?
The common hepatic duct distal to the cystic duct joining it is called the common bile duct.
Where does the common bile duct run?
Where does the common bile duct descend?
In the free edge of the lesser omentum
Descends posterior to superior part of the duodenum, posterior to the head of the pancreas
What happens when bile produced by the liver is not needed for digestion?
It enters the gallbladder via the cystic duct
The spiral fold/spiral valve lies at the junction between the gallbladder neck and the cystic duct.
What and where is the spiral fold?
Between the gallbladder neck and the cystic duct
Valve lies at the junction here
Describe the blood supply of the gallbladder
Via cystic artery - typically arises from the right hepatic artery
What veins drain the gallbladder?
Cystic veins - pass directly into the liver or hepatic portal vein
Describe nervous supply of the gallbladder
Innervated by parasympathetic and sympathetic fibres
Visceral afferents return to CNS with the sympathetic fibres
Where is referred pain from the gallbladder felt? [3 things]
In the epigastrum (enters spinal cord levels T5-T9)
May also be referred to the right shoulder if the pathology affects the diaphragm
If it irritates the parietal peritoneum - innervated by somatic nerves - well localised pain in right hypochondrium
What is hepatomegaly?
Enlargement of the liver
causes include hepatitis, malignancy, heart failure
When enlarged inferior border becomes palpable inferior to the right costal margin
What are liver metastases?
Most cancers of the liver are metastases from cancer elsewhere.
Often bowel cancers due to the venous blood travelling from there
What is cirrhosis of the liver?
‘scarring’ of the liver
Chronic excess alcohol consumption, chronic infection with hep B or C, build up of fat in the liver
Hepatocytes are destroyed and replaced with fibrous tissue
Liver becomes shrunken, hard, nodular
Loss of hepatocytes impairs liver function, may result in liver failure
What is portal hypertension?
High blood pressure in the portal venous system
Occurs when blood flow through liver and portal vein is obstructed
What are portosystemic anastomoses? And oesophageal varices?
Oesophageal varices caused by potal hypertension at portosystemic anastomoses
Gallstons
Biliary colic
Cholecystitis
What are the three major branches of the coeliac trunk?
left gastric artery
common hepatic artery
splenic artery
What does the left gastric artery supply?
Distal oesophagus
lesser curvature of the stomach
What does the common hepatic artery supply?
liver
stomach
duodenum
What does the splenic artery /branches/ supply?
Stomach
Pancreas
Spleen
What is the duodenum continuous with?
proximally with the pylorus of the stomach
distally with the jejunum
What are the four parts of the duodenum?
1st - superior part
2nd - descending part
3rd - inferior part
4th - ascending part
Where do the common bile duct, gastroduodenal artery and hepatic portal vein lie in relation to the duodenum?
Posterior to the first part (superior part)
Which part of the duodenum does the mesentery lie anterior to?
Third part (inferior or horizontal part)
Where does the fourth part meet the jejunum?
Duodenojejunal flexure
What is the major duodenal papilla?
Halfway along duodenum
Small elevation where bile and pancreatic secretions enter the duodenum
Describe the blood supply of the duodenum
First half derived from foregut - supplied by coeliac trunk branches
Gastroduodenal artery from common hepatic artery from coeliac trunk
Second half derived from midgut - supplied by branches of superior mesenteric artery
Inferior pancreaticoduodenal arteries from mesenteric artery
Where is the pancreas?
Lies horizontally on posterior abdominal wall
Level of L1
Head is cupped by C of duodenum
Tail extends to hilum of the spleen
Is the pancreas retroperitoneal or intraperitoneal?
Retroperitoneal
What is the pancreas formed from during development?
Dorsal and ventral pancreatic buds - fuse during development
What are the four parts of the pancreas?
Head
Neck
Body
Tail
What is the uncinate process on the pancreas?
hook-like projection of the head of the pancreas
Which part of the lesser sac does the pancreas form?
Part of the posterior wall
How are the splenic artery and vein related to the pancreas?
Artery - runs towards the upper border of the pancreas
Vein - lies posterior to the pancreas
2 big ducts of the pancreas?
Main duct
Accessory duct
They don’t usually communicate with each other
What is the function of the pancreas?
Endocrine and exocrine functions
Produces pancreatic juice that contains digestive enzymes - transported through both ducts to the duodenum
What is the relationship between the main pancreatic duct and the bile duct?
bile enters duodenum by common bile duct
pancreatic juice enters duodenum by pancreatic ducts
Main pancreatic duct and bile duct merge at the hepatopancreatic ampulla
What is the hepatopancreatic ampulla?
convergence of main pancreatic duct and common gall bladder
Opens into the major duodenal papilla
Surrounded by smooth muscle, hepatopancreatic sphincter - prevents reflux of duodenal contents
Where does the accessory pancreatic duct open into the duodenum?
The minor duodenal papilla
just proximal to major duodenal papilla
What arteries supply the pancreas?
Branches of the coeliac trunk and superior mesenteric artery
Coeliac trunk
- splenic artery runs on upper border of the pancreas; gives rise to pancreatic arteries
- gastroduodenal artery gives rise to the superior pancreaticoduodenal
Superior mesenteric
- inferior pancreaticoduodenal arteries
What veins drain the pancreas?
Veins follow the arteries
Splenic vein drains the pancreas and unites with the superior mesenteric vein - forms hepatic portal vein posterior to the neck of the pancreas
What are the functions of the spleen?
Haematopoietic and lymphoid
Includes breakdown of old RBC, storage of RBC and platelets
Various immune responses including IgG production
What are the 2 surfaces of the spleen?
-diaphragmatic surface
-visceral surface - stomach etc - where hilum is
What are the four borders of the spleen?
Anterior and superior - typically notched
Posterior and inferior - smooth
Describe the position of the spleen
Upper left quadrant
Protected by ribs 9-11
Is the spleen intraperitoneal or retroperitoneal?
intraperitoneal - covered by visceral peritoneum
Describe the arterial supply of the spleen
supplied by the splenic artery, branch from the coeliac trunk
divides into approximately 5 branches at the hilum
What is a duodenal ulcer?
most common in the first part of the duodenum
It may erode the duodenal wall and gastroduodenal artery which results in severe intra-abdominal bleeding
What is pancreatitis?
inflammation of the pancreas - may be chronic or acute
Acute pancreatitis is life threatening
Most commonly due to excess alcohol intake or impaction of gallstone at hepatopancreatic ampulla
Gallstone pancreatitis pancreatic juice is prevented from leaving the pancreas and it starts to break down the pancreas(autolysis) - pain typically radiates towards the back
Pancreatic cancer
typically causes pain that radiates to the back
If it affects the head of the pancreas, bile flow can be obstructed in bile duct - leads to accumulation of bile pigments - leads to jaundice
What is diabetes mellitus?
insulin-secreting cells in the pancreas no longer produce insulin/produce inadequate amounts
sustained high blood glucose levels
detrimental to tissues, fatal if not controlled
some patients develop diabetes secondary to pancreatitis
What is a splenomegaly?
Enlargement of the spleen
can be caused by infection, haematological malignancy, portal hypertension
Spleen enlarges down to the midline/right iliac fossa because phrenicocolic ligament prevents descent towards left iliac fossa
What is a splenic rupture?
Blunt abdominal trauma or rib fractures may puncture the spleen
Splenic haemorrhage is life threatening and managed by splenectomy (removal)
Spleen is not essential for life
