meechai srisai m.d. ,ph.d. nigun worapunpong m.d. department of anatomy faculty of medicine
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
Meechai Srisai M.D. ,Ph.D.Meechai Srisai M.D. ,Ph.D.Nigun Worapunpong M.D.Nigun Worapunpong M.D.
Department of AnatomyDepartment of AnatomyFaculty of MedicineFaculty of Medicine
Chulalongkorn UniversityChulalongkorn UniversityAugust 2010August 2010
Liver, Gallbladder,Liver, Gallbladder,Biliary tract and Biliary tract and portal venous portal venous
systemsystem
IntroductionIntroduction
• Digestive system consists of – GI tract – Glands and accessory
organs : Salivary glands, Liver ,Gall bladder, Pancreas
Liver Liver
• Largest organ in body 1200-1600 gm• Surface projection
– จุ�ดบนสุ�ด : Rt. Midinguinal line / Rt. 5th rib– จุ�ดล่�างขวา : Rt. Midaxillary line / Rt. 10th
costal cartilage – จุ�ดล่�างซ้�าย : Lt. Midinguinal line / Lt. 5th I.C.S.
Surface projection Surface projection of liverof liver
Parasagittal section Parasagittal section through liverthrough liver
Showing subphrenic Showing subphrenic recess and recess and
hepatorenal recesshepatorenal recess(Rutherford-Morison pouch)(Rutherford-Morison pouch)
Surfaces of LiverSurfaces of Liver1. Diaphragmatic surface
2. Visceral surface : structures lie like ‘H’
Liver Liver
Visceral surface ‘H’Visceral surface ‘H’1.1. Cross-bar of H Cross-bar of H = Porta hepatisPorta hepatis
– Hepatic artery, Portal vein, Bile ducts, Nerves and Lymphatic vss.
2.2. Lt. superior of H Lt. superior of H = Ligamentum teres hepatis or round ligament of liver (Remnant of umbilical v.)
3.3. Lt. inferior of H Lt. inferior of H = Ligamentum venosum (Remnant of ductus venosus)
4.4. Rt. superior of H Rt. superior of H = Gall bladder
5.5. Rt. inferior of H Rt. inferior of H = Inferior vena cava
Liver Liver
VisceralVisceralSurfaceSurface
‘‘H’H’
VisceralVisceralSurfaceSurface
‘‘H’H’
Peritoneal relationsPeritoneal relations
1.1. Peritoneal ligamentsPeritoneal ligaments– Lesser omentum– Falciform ligament– Coronary ligaments– Triangular ligaments
2.2. Vascular ligamentsVascular ligaments– Round ligament of the liver– Ligamentum venosum
Liver Liver
Parts of stomach and lesser omentum
Liver Liver
Bare areas of the liverBare areas of the liver เป็�นบริ�เวณที่�� ไม่�ม่� เป็�นบริ�เวณที่�� ไม่�ม่� peritoneum peritoneum คล่�ม่คล่�ม่
1. b/t Ant. & Post. Coronary ligaments2. Fossa for gall bladder3. Porta hepatis4. Fissure for round ligament5. Fissure for ligamentum venosum6. Fossa for IVC
Lobes of liverLobes of liver
1.1. Anatomical lobationAnatomical lobation• Right lobe• Left lobe• Caudate lobe• Quadrate lobe
2.2. Functional lobationFunctional lobation• Right lobe• Left lobe• By a line passing the gallbladder and IVC
Liver Liver
Anatomical lobesAnatomical lobes
Anatomical lobesAnatomical lobes
Functional lobesFunctional lobes
Functional lobesFunctional lobes
Blood supply of liverBlood supply of liver
1. Rt. & Lt. hepatic arteries carry oxygenated blood (25%)(25%)
2. Portal vein carries venous blood (75%) (75%) rich in nutrients
3. Hepatic veins drain venous blood to IVC
Liver Liver
Autonomic nervesAutonomic nerves• Symp : Celiac plexus• Parasymp : Ant. and
Post. Vagal trunks
Liver Liver
Celiac plexusCeliac plexus
Anterior vagal trunkAnterior vagal trunk
Lymphatic drainage of liverLymphatic 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
Liver Liver
Lymphatic drainage of liverLymphatic drainage of liver
Lymphatic Lymphatic drainage of drainage of GI GI
tracttract
Topographic anatomy of abdomenTopographic anatomy of abdomen
CT scanCT scanTopographic anatomyTopographic anatomy
Gallbladder & Biliary tractsGallbladder & Biliary tracts
Biliary system consists of
1.1. Gall bladderGall bladder
2.2. Biliary tractsBiliary tractsCystic duct, hepatic ducts, common hepatic duct and common bile duct
Gallbladder & Biliary tractsGallbladder & Biliary tracts
• Length 6-10 mm. • Capacity ~ 45 cm3 • b/t Rt. lobe & Quadrate
lobe of liver• Surface projection
Fundus of gallbladder = Murphy’s pointMurphy’s point
Gallbladder Gallbladder
Gallbladder has 4 portions1. Fundus2. Body3. Neck Infundibulum :
Hartmann’s pouch
Internal surface Internal surface : : folds, spiral folds, spiral folds and crypts of Luschkafolds and crypts of Luschka
Gallbladder Gallbladder
BodyBody
FundusFundus
Hartmann’sHartmann’spouchpouch
NeckNeck
Crypts Crypts of of
LuschkaLuschka
Spiral valveSpiral valve
Blood supply of gallbladderBlood supply of gallbladder
1. Cystic artery from Right Hepatic artery
(in Calot’s triangle → Cholecystectomy)
2. Cystic vein : tributary of Portal vein
Gallbladder Gallbladder GallbladderGallbladder
Cystic arteryCystic artery
Calot’s triangleCalot’s triangle
1.1. Cystic duct Cystic duct : ~ 3 cm
: spiral valve of Heisteri
2.2. Common hepatic ductCommon hepatic duct
: ~ 3-5 cm
: from Rt. & Lt. hepatic
ducts
3.3. Common bile ductCommon bile duct
: ~ 7.5 cm
1+2 → 31+2 → 3
Biliary tractBiliary tract
Common bile duct has 4 parts– Supraduodenal– Retroduodenal– Infraduodenal– Intraduodenal
Biliary tractBiliary tract
Common bile duct + Major pancreatic duct
▼
Hepatopancreatic ampulla (Ampulla of Vater)(Ampulla of Vater)
Opening is Greater duodenal papilla in 2nd
part of duodenum (surrounded by Sphincter of OddiSphincter of Oddi)
Compression of commonCompression of common
bile ductbile duct resulted inresulted in
obstructive jaundiceobstructive jaundice
Icteric scleraIcteric sclera
Biliary tractBiliary tract
Celiac plexusCeliac plexus
Anterior vagal trunkAnterior vagal trunk
Nerves of GallbladderNerves of Gallbladder• Symp : Celiac plexus• Parasymp : Ant. and
Post. vagal trunks
Lymphatic drainage of GallbladderLymphatic drainage of Gallbladder• Drain to Hepatic nodes of cystic nodes
↓ Celiac nodes
Biliary tractBiliary tract
Radiograph of gallbladder Radiograph of gallbladder & biliary tracts& biliary tracts
Radiograph of gallbladder Radiograph of gallbladder & biliary tracts& biliary tracts
• A system of venous blood vessels from GI tract to the liver
• FormationFormation : – Superior mesenteric Superior mesenteric
vein vein + + Splenic vein Splenic vein (behind neck of pancreas)
Portal venous systemPortal venous system
TributariesTributaries1. Cystic vein
2. Paraumbilical vein
3. Right gastric vein
4. Left gastric vein
5. Splenic vein
6. Superior mesenteric vein
Portal venous systemPortal venous system
Portal hypertensionPortal 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 systemPortal venous system
Portal-Caval AnastomosisPortal-Caval AnastomosisAnastomosis among portal vein and systemic vein (Inferior vena cava)
1.1.Left gastric v.Left gastric v.→ Esophageal v.→ Azygos v. → SVC : ‘Esophageal varices’
2.2.Splenic v.Splenic v. → Sup. rectal v. → Rectal venous plexuses → middle & Inf. Rectal v. → → → IVC : Dilated rectal venous plexuses = Internal hemorrhoids
Portal venous systemPortal venous system
Portal-systemicPortal-systemicanastomosisanastomosis
Esophageal Esophageal
varicesvarices
Internal Internal
hemorrhoidshemorrhoids
InternalInternalhemorrhoidhemorrhoid
ExternalExternalhemorrhoidhemorrhoid
Portal venous systemPortal venous system
3.3. Paraumbilical v.Paraumbilical v. → Superficial epigastric v. → External iliac v.→ IVC : ‘Caput Medusae’
4.4. Colic v. Colic v. anastomosis to Retroperitoneal v. → IVC
DilatedDilated
SuperficialSuperficial
Epigastric veinsEpigastric veins
Caput Caput medusaemedusae
• Signs & symptomsSigns & symptoms– Esophageal varices :
Hematemesis– Internal hemorrhoids– Caput Medusae– Splenomegaly– Ascites – etc.
Portal hypertensionPortal hypertension