Liver

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Liver, Gallbladder,
Biliary tract and
portal venous
system
Meechai Srisai M.D. ,Ph.D.
Nigun Worapunpong M.D.
Department of Anatomy
Faculty of Medicine
Chulalongkorn University
August 2010
Introduction
• Digestive system
consists of
– GI tract
– Glands and accessory
organs : Salivary glands,
Liver ,Gall bladder,
Pancreas
Liver
• Largest organ in body 1200-1600 gm
• Surface projection
– จุดบนสุด
: Rt. Midinguinal line / Rt. 5th rib
– จุดลางขวา
: Rt. Midaxillary line / Rt. 10th
่
costal cartilage
th
– จุดลางซ
่
้าย : Lt. Midinguinal line / Lt. 5
I.C.S.
Surface projection
of liver
Parasagittal section
through liver
Showing subphrenic
recess and
hepatorenal recess
(Rutherford-Morison pouch)
Liver
Surfaces of Liver
1.
2.
Diaphragmatic surface
Visceral surface : structures lie like ‘H’
Liver
Visceral surface ‘H’
1.
2.
3.
4.
5.
Cross-bar of H = Porta hepatis
– Hepatic artery, Portal vein, Bile
ducts, Nerves and Lymphatic vss.
Lt. superior of H = Ligamentum teres
hepatis or round ligament of liver
(Remnant of umbilical v.)
Lt. inferior of H = Ligamentum venosum
(Remnant of ductus venosus)
Rt. superior of H = Gall bladder
Rt. inferior of H = Inferior vena cava
Visceral
Surface
‘H’
Visceral
Surface
‘H’
Liver
Peritoneal relations
1.
Peritoneal ligaments
–
–
–
–
2.
Lesser omentum
Falciform ligament
Coronary ligaments
Triangular ligaments
Vascular ligaments
–
–
Round ligament of the liver
Ligamentum venosum
Parts of stomach and lesser omentum
Liver
Bare areas of the liver
เป็ นบริเวณที่ ไมมี
่ peritoneum คลุม
1. b/t Ant. & Post. Coronary ligaments
2. Fossa for gall bladder
3. Porta hepatis
4. Fissure for round ligament
5. Fissure for ligamentum venosum
6. Fossa for IVC
Liver
Lobes of liver
1.
Anatomical lobation
•
•
•
•
2.
Right lobe
Left lobe
Caudate lobe
Quadrate lobe
Functional lobation
•
•
•
Right lobe
Left lobe
By a line passing the gallbladder and IVC
Anatomical lobes
Anatomical lobes
Functional lobes
Functional lobes
Liver
Blood supply of liver
1.
2.
3.
Rt. & Lt. hepatic arteries carry
oxygenated blood (25%)
Portal vein carries venous blood
(75%) rich in nutrients
Hepatic veins drain venous blood
to IVC
Liver
Anterior vagal trunk
Autonomic nerves
• Symp : Celiac plexus
• Parasymp : Ant. and
Post. Vagal trunks
Celiac plexus
Liver
Lymphatic drainage of liver
Liver is a major lymph-producing organ
(1/4 -1/2 of lymph → Thoracic duct)
•
Diaphragmatic surface of liver drains
to Phrenic nodes
•
Visceral surface and deep lymphatics
along portal triads drains to Porta
Hepatis → Hepatic nodes → Coeliac
nodes → Cisterna chyli → Thoracic
duct
Lymphatic drainage of liver
Lymphatic
drainage of GI
tract
Topographic anatomy of abdomen
Topographic anatomy
CT scan
Gallbladder & Biliary tracts
Gallbladder & Biliary tracts
Biliary system consists of
1. Gall bladder
2. Biliary tracts
Cystic duct, hepatic ducts,
common hepatic duct and
common bile duct
Gallbladder
• Length 6-10 mm.
• Capacity ~ 45 cm3
• b/t Rt. lobe & Quadrate
lobe of liver
• Surface projection
Fundus of gallbladder =
Murphy’s point
Gallbladder
Spiral valve
Neck
Body
Gallbladder has 4 portions
1.
2.
3.
Fundus
Body
Neck  Infundibulum :
Hartmann’s pouch
Hartmann’s
pouch
Internal surface : folds, spiral
folds and crypts of Luschka
Fundus
Crypts
of
Luschka
Gallbladder
Gallbladder
Blood supply of gallbladder
1.
Cystic artery from
Right Hepatic artery
(in Calot’s triangle
→ Cholecystectomy)
2.
Cystic vein : tributary of
Portal vein
Calot’s triangle
Cystic artery
Biliary tract
1.
2.
3.
Cystic duct : ~ 3 cm
: spiral valve of Heisteri
Common hepatic duct
: ~ 3-5 cm
: from Rt. & Lt. hepatic
ducts
Common bile duct
: ~ 7.5 cm
1+2 → 3
Biliary tract
Common bile duct has 4 parts
–
–
–
–
Supraduodenal
Retroduodenal
Infraduodenal
Intraduodenal
Common bile duct + Major pancreatic duct
▼
Hepatopancreatic ampulla (Ampulla of Vater)
Opening is Greater duodenal papilla in 2nd
part of duodenum (surrounded by Sphincter of Oddi)
Icteric sclera
Compression of common
bile duct resulted in
obstructive jaundice
Biliary tract
Anterior vagal trunk
Nerves of Gallbladder
• Symp : Celiac plexus
• Parasymp : Ant. and
Post. vagal trunks
Celiac plexus
Biliary tract
Lymphatic drainage of Gallbladder
• Drain to Hepatic nodes of cystic nodes
↓
Celiac nodes
Radiograph of gallbladder
& biliary tracts
Radiograph of gallbladder
& biliary tracts
Portal venous system
• A system of venous blood
vessels from GI tract to
the liver
• Formation :
– Superior mesenteric
vein + Splenic vein
(behind neck of
pancreas)
Portal venous system
Tributaries
1.
2.
3.
4.
5.
6.
Cystic vein
Paraumbilical vein
Right gastric vein
Left gastric vein
Splenic vein
Superior mesenteric
vein
Portal venous system
Portal hypertension
•
•
•
The portal vein provides about 75% of the liver's
blood flow and about 60% of its O2 supply
Normal portal pressure is 5-10 mmHg (7-14 cm
H2O), which exceeds inferior vena caval pressure
by 4-5 mm Hg (the portal venous gradient)
Higher values are defined as portal hypertension
Portal venous system
Portal-Caval Anastomosis
Anastomosis among portal vein and systemic vein
(Inferior vena cava)
1. Left gastric v.→ Esophageal v.→ Azygos v. → SVC :
‘Esophageal varices’
2. Splenic v. → Sup. rectal v. → Rectal venous
plexuses → middle & Inf. Rectal v. → → → IVC :
Dilated rectal venous plexuses = Internal
hemorrhoids
Portal-systemic
anastomosis
Esophageal
varices
Internal
hemorrhoids
Internal
hemorrhoid
External
hemorrhoid
Portal venous system
3.
4.
Paraumbilical v. → Superficial epigastric v. →
External iliac v.→ IVC : ‘Caput Medusae’
Colic v. anastomosis to Retroperitoneal v. → IVC
Dilated
Superficial
Epigastric veins
Caput
medusae
Portal hypertension
• Signs & symptoms
– Esophageal varices
: Hematemesis
– Internal hemorrhoids
– Caput Medusae
– Splenomegaly
– Ascites
– etc.
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