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Anatomy Liver ,Gall Bladder.Pptx UNIVERSITY OF BABYLON HAMMURABI MEDICAL COLLEGE GASTROINTESTINAL TRACT S4 - PHASE 1 2018-2019 SESSION 6 /LECT.1 ANATOMY LIVER, GALL BLADDER, PANCREASE DR.SUHAD KAHDUM AL-SADOON F.I.B.M.S.(SURG.),M.B.CH.B. [email protected] OBJECTIVES • gross anatomy of the liver, gall bladder and pancreas and relate it to their respective functions • outline relevant anatomical and physiological information that enables you to understand the symptoms associated with pancreatic and gall bladder disease • identify and describe the position of : vfalciform ligament and ligamentumteres, the coronary, right and left triangular ligaments & the bare area of the liver vleft, right, caudate and quadrate lobes of the liver vstructures (such as the hepatic portal vein, hepatic artery and bile duct) in the porta hepatis vrelation between the liver and the inferior vena cava ,gall bladder and the cystic duct vhepatic portal vein & its main tributaries vpancreas, the spleen and its vasculature • LIVER the liver is the largest gland in the body, and after the skin, all nutrients absorbed from the digestive tract are initially conveyed to the liver by the portal venous system. liver occupies most of the right hypochondriumand upper epigastrium and extends into the left hypochondrium. where it is protected by the rib cage and diaphragm. the normal liver lies deep to ribs 7-11 on the right side and cross the midline towards the left nipple the liver moves with the excursions of the diaphragm and is located more inferiorly when standing due to gravity. the liver has: convex diaphragmatic surface (anterior, superior and some posterior) concave visceral surface (posteroinferior), where are separated anteriorly by its sharp inferior border that follows the right costal margin inferior to the diaphragM VISCERAL SURFACE is flat or relatively concave contains the porta hepatis – for structures entering & leaving the liver ❖not palpable in normal position; lower edge palpable in deep inspiration ❖ the of the liver is covered with visceral peritOneum, except posteriorly in the bare area Of the Liver, where it lies in direct contact with the diaphragm. there is a deep groove in the bare area, where the inferior vena cava traveLs subphrenic recesses are separated into right and left recesses by the faLciform ligament, which extends between the liver and the anterior abdominal wall. subhepatic space portion of the supracolic compartment of the peritoneal cavity immediately inferior to the liver. round Ligament, or ligamentum teres is contained within the falciform ligament. it is the embryonic remnant of the umbiLicaL vein. hepatorenaL recess is the posterior extension of the subhepatic space and fluid from lesser sac flows into this recess. diaphragmatic surface convex surface (anterior, superior and some posterior). the smooth and domed shape and contains a few specific areas: subphrenic recesses are between the diaphragm and the liver, which are superior extensions of the greater sac. in contrast to the smooth diaphragmatic surface, the visceral surface bears multiples fissures and impressions from contact with other organs The bare are is marked out by the reflection of the peritoneum from the diaphragm to it as the anterior (upper) and poster (lower) layers of the Coronary Ligament. These layers met on the right to form the Right TrianguLar Ligament and diverge towards the left to enclose the triangular bare area. Near the apex of the wedge-shaped liver, the layers meet on the left to form the Left Triangular Ligament. the liver is split into 2 anatomical and 2 accessory lobes by the reflections of peritoneum from its surface, the fissures formed in relation to those reflections and the vessels serving the liver and the gallbladder. • the attachment of the falciform ligament divides the right lobe from the much smaller left lobe • on the visceral surface, the right and left sagittal fissures split the right lobe with the porta hepatis into the quadrate lobe anterior and inferiorly and the caudate lobe posteriorly and superiorly HEPATIC BLOOD SUPPLY the arterial blood supply to the liver comes from: common hepatic artery (20 - 30%) &hepatic portal vein (70 - 80%). the hepatic artery, whereby the left and right hepatic arteries branch off the proper hepatic artery (which is a branch of the common hepatic artery). • the hepatic portal vein is the main vein of the portal venous system. it is formed by union of the superior mesenteric and the splenic veins, posterior to the stomach. the hepatic portal veins also divide into left and right branches as it approaches the porta hepatis. • the venous drainage of the liver comes from the hepatic veins. the hepatic veins, which also suspend the liver, drain into the ivc. CLINICAL CONSIDERATIONS SUBPHRENIC ABSCESSES COMMONLY RESULT FROM PERITONITIS. PERITONITIS MAY RESULT IN THE FORMATION OF COLLECTIONS OF PUS OR ABSCESSES IN THE PERITONEAL CAVITY AND ARE COMMON IN THE RIGHT SUBPHRENIC RECESSES DUE TO RUPTURED APPENDICES OR PERFORATED DUODENAL ULCERS. THESE CAN SPREAD TO THE HEPATORENAL RECESSES, ESPECIALLY WHEN THE PATIENTS ARE SUPINE VIA THE PARACOLIC GUTTERS . HEPATIC LOBECTOMIES AND SEGMENTECTOMIES CAN BE PERFORMED DUE TO THE VASCULARISATION OF THE LIVER. AS THE RIGHT AND LEFT HEPATIC ARTERIES AND PORTAL VEINS SUPPLY ONLY THE RIGHT OR LEFT SIDE OF THE LIVER RESPECTIVELY, REMOVAL OF A LOBE OR SEGMENT OF THE LIVER FOLLOWING METASTASIS IS POSSIBLE IN AN ATTEMPT TO CLEAR THE PROBLEM HEPATOMEGALY (ENLARGED LIVER) CAUSED BY BLOOD ENGORGEMENT MAY BE DUE TO RISE IN CENTRAL VENOUS PRESSURE (LACK OF VALVES IN IVC & HEPATIC VEINS), CONGESTIVE HEART FAILURE, BACTERIAL & VIRAL DISEASES (HEPATITIS), TUMOURS & METASTATIC CARCINOMA - 2° FROM ORGANS DRAINED BY THEHEPATIC PORTAL SYSTEM / ALCOHOLIC CIRRHOSIS & PORTAL HYPERTENSION LIVER VULNERABLE TO CELLULAR DAMAGE &CONSEQUENT SCARRING ;REPLACED BY FIBROUS TISSUE FIBROUS TISSUE SURROUNDS INTRA-HEPATIC VESSELS & BILE DUCT > RESTRICTION OF BLOOD FLOW > ↑PRESSURE IN HPV > PORTAL HYPERTENSION. BLOOD FLOW INTO SYSTEMIC CIRCULATION VIA VENOUS SITES (PORTO-SYSTEMIC ANASTOMOSES) ; VESSELS BECOME VARICOSED AND MAY RUPTURE (HAEMORRHAGE). PORTO-SYSTEMIC ANASTOMOSES • A – OESOPHAGEAL VEINS & LEFT GASTRIC VEINS > VIA THE AZYGOS VEIN (OESOPHAGEAL VARICES) • B – SUPERIOR RECTAL VEIN AND MIDDLE & INFERIOR RECTAL VEIN > VIA THE ILIAC VEINS TO IVC (ANO-RECTAL VARICES) • C – PARAUMBILICAL VEINS & EPIGASTRIC VEINS OF ANTERIOR ABDOMINAL WALL (CAPUT MEDUSAE) • D- RETROCOLIC GALLBLADDER • THE GALLBLADDER IS 7-10CM LONG AND LIES IN THE FOSSA FOR THE GALLBLADDER ON THE VISCERAL SURFACE OF THE LIVER. THIS FOSSA LIES AT THE JUNCTION OF THE RIGHT AND LEFT LOBES OF THE LIVER. • THE GALLBLADDER IS PEAR-SHAPED AND CAN HOLD UP TO 50ML OF BILE. PERITONEUM COMPLETELY SURROUNDS IT’S FUNDUS AND BINDS IT’S BODY AND NECK TO THE LIVER. THE HEPATIC SURFACE OF THE GALLBLADDER IS ATTACHED TO THE LIVER BY CONNECTIVE TISSUE OF THE FIBROUS CAPSULE OF THE LIVER THE GALLBLADDER HAS THREE PARTS: • FUNDUS • BODY • NECK • THE NECK OF THE GALLBLADDER JOINS THE CYSTIC DUCT. BILIARY TREE • THE BILIARY DUCTS CONVEY BILE FROM THE LIVER TO THE DUODENUM. HEPATOCYTES PRODUCE BILE CONTINUOUSLY, SECRETING IT INTO CANALICULI • THE CANALICULI DRAIN INTO THE SMALL INTERLOBULAR BILIARY DUCTS AND THEN INTO THE LARGE COLLECTING BILE DUCTS, WHICH IN TURN MERGE TO FORM THE RIGHT AND LEFT HEPATIC DUCTS. • SHORTLY AFTER LEAVING THE PORTA HEPATIS, THESE HEPATIC DUCTS UNITE TO FORM THE COMMON HEPATIC DUCT, WHICH IS JOINED ON THE RIGHT SIDE BY THE CYSTIC DUCT TO FORM THE BILE DUCT, WHICH CONVEYS THE BILE TO THE DUODENUM, THROUGH THE AMPULLA OF VATER. SHORTLY BEFORE THIS, THE PANCREATIC DUCT JOIN THE BILE DUCT SHORTLY AFTER LEAVING THE PORTA HEPATIS, THESE HEPATIC DUCTS UNITE TO FORM THE COMMON HEPATIC DUCT, WHICH IS JOINED ON THE RIGHT SIDE BY THE CYSTIC DUCT TO FORM THE BILE DUCT, WHICH CONVEYS THE BILE TO THE DUODENUM, THROUGH THE AMPULLA OF VATER. SHORTLY BEFORE THIS, THE PANCREATIC DUCT JOIN THE BILE DUCT GALL STONES Gallstones can be divided into three main types: cholesterol, pigment (brown/black) or mixed stone In Gall Bladder -Asymptomatc Cystic Duct – Acute Cholecystitis Common Bile Duct – Biliary Obstruction Terminal Duct – Pancreatitis Cholecystitis (inflammation of gall bladder) due to bile accumulation. pain in the epigastrium or the right hypochondrium; gall bladder derivative of the foregut (sympathetic innervation from T5 – T9 & pain fibres return to T7 – T9 segments of the spinal cord; pain felt along 7th – 9th intercostal spaces (from inf. angle of scapula to epigastrium) Pain referred to the tip of the right shoulder (C3 & C4) because of irritation of the peritoneum on the undersurface of the diaphragm. Cholecystectomy (removal of the gall bladder) presents surgical challenges because of variation of the anatomy & blood supply of the biliary system VASCULATURE OF THE GALLBLADDER AND BILIARY TREE THE ARTERIAL SUPPLY OF THE GALLBLADDER AND CYSTIC DUCT IS FROM THE CYSTIC ARTERY, WHICH COMMONLY ARISES IN THE TRIANGLE BETWEEN THE COMMON HEPATIC DUCT, CYSTIC DUCT AND VISCERAL SURFACE OF THE LIVER, THE CYSTOHEPATIC TRIANGLE (OF CALOT). COELIAC TRUNK à COMMON HEPATIC à RIGHT HEPATIC à CYSTIC THE VENOUS DRAINAGE FROM THE NECK OF THE GALLBLADDER AND CYSTIC DUCT FLOWS VIA THE CYSTIC VEINS. THESE SMALL AND USUALLY MULTIPLE VEINS ENTER THE LIVER DIRECTLY OR DRAIN THROUGH THE HEPATIC PORTAL VEIN. THE VENOUS DRAINAGE FROM THE FUNDUS AND BODY OF THE GALLBLADDER PASS DIRECTLY INTO THE VISCERAL SURFACE OF THE LIVER AND DRAIN INTO THE HEPATIC SINUSOIDS.
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