Meechai Srisai M.D.,Ph.D. Nigun Worapunpong M.D. Department of Anatomy Faculty of Medicine Chulalongkorn University August 2010 Liver, Gallbladder, Biliary tract and portal venous system

Introduction Digestive system consists of –GI tract –Glands and accessory organs : Salivary glands, Liver,Gall bladder, Pancreas

Liver Largest organ in body gm Surface projection – จุดบนสุด : Rt. Midinguinal line / Rt. 5 th rib – จุดล่างขวา : Rt. Midaxillary line / Rt. 10 th costal cartilage – จุดล่างซ้าย : Lt. Midinguinal line / Lt. 5 th I.C.S.

Surface projection of liver

Parasagittal section through liver Showing subphrenic recess and hepatorenal recess (Rutherford-Morison pouch)

Surfaces of Liver 1.Diaphragmatic surface 2.Visceral surface : structures lie like ‘H’ Liver

Visceral surface ‘H’ 1.Cross-bar of H Porta hepatis 1.Cross-bar of H = Porta hepatis –Hepatic artery, Portal vein, Bile ducts, Nerves and Lymphatic vss. 2.Lt. superior of H 2.Lt. superior of H = Ligamentum teres hepatis or round ligament of liver (Remnant of umbilical v.) 3.Lt. inferior of H 3.Lt. inferior of H = Ligamentum venosum (Remnant of ductus venosus) 4.Rt. superior of H 4.Rt. superior of H = Gall bladder 5.Rt. inferior of H 5.Rt. inferior of H = Inferior vena cava Liver

VisceralSurface‘H’

VisceralSurface‘H’

Peritoneal relations 1.Peritoneal ligaments –Lesser omentum –Falciform ligament –Coronary ligaments –Triangular ligaments 2.Vascular ligaments –Round ligament of the liver –Ligamentum venosum Liver

Parts of stomach and lesser omentum

Liver Bare areas of the liver เป็นบริเวณที่ ไม่มี 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

Lobes of liver 1.Anatomical lobation Right lobe Left lobe Caudate lobe Quadrate lobe 2.Functional lobation Right lobe Left lobe By a line passing the gallbladder and IVC Liver

Anatomical lobes

Functional lobes

Blood supply of liver (25%) 1.Rt. & Lt. hepatic arteries carry oxygenated blood (25%) (75%) 2.Portal vein carries venous blood (75%) rich in nutrients 3.Hepatic veins drain venous blood to IVC Liver

Autonomic nerves Symp : Celiac plexus Parasymp : Ant. and Post. Vagal trunks Liver Celiac plexus Anterior vagal trunk

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 Liver

Lymphatic drainage of liver

Lymphatic drainage of GI tract

Topographic anatomy of abdomen CT scan Topographic anatomy

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 & Biliary tracts

Length 6-10 mm. Capacity ~ 45 cm 3 b/t Rt. lobe & Quadrate lobe of liver Surface projection Murphy’s point Fundus of gallbladder = Murphy’s point Gallbladder

Gallbladder has 4 portions 1.Fundus 2.Body 3.Neck  Infundibulum : Hartmann’s pouch Internal surface : folds, spiral folds and crypts of Luschka Gallbladder Body Fundus Hartmann’spouch Neck CryptsofLuschka Spiral valve

Blood supply of gallbladder 1.Cystic artery from Right Hepatic artery (in Calot’s triangle → Cholecystectomy) 2.Cystic vein : tributary of Portal vein Gallbladder Gallbladder Cystic artery Calot’s triangle

1.Cystic duct 1.Cystic duct : ~ 3 cm : spiral valve of Heisteri 2.Common hepatic duct : ~ 3-5 cm : from Rt. & Lt. hepatic ducts 3.Common bile duct : ~ 7.5 cm 1+2 → 3 Biliary tract

Common bile duct has 4 parts – Supraduodenal – Retroduodenal – Infraduodenal – Intraduodenal Biliary tract Common bile duct + Major pancreatic duct ▼ (Ampulla of Vater) Hepatopancreatic ampulla (Ampulla of Vater) Opening is Greater duodenal papilla in 2 nd Sphincter of Oddi part of duodenum (surrounded by Sphincter of Oddi)

Compression of common bile duct resulted in obstructive jaundice Icteric sclera

Biliary tract Celiac plexus Anterior vagal trunk Nerves of Gallbladder Symp : Celiac plexus Parasymp : Ant. and Post. vagal trunks

Lymphatic drainage of Gallbladder Drain to Hepatic nodes of cystic nodes ↓ Celiac nodes Biliary tract

Radiograph of gallbladder & biliary tracts

A system of venous blood vessels from GI tract to the liver FormationFormation : –Superior mesenteric vein + Splenic vein –Superior mesenteric vein + Splenic vein (behind neck of pancreas) Portal venous system

Tributaries 1.Cystic vein 2.Paraumbilical vein 3.Right gastric vein 4.Left gastric vein 5.Splenic vein 6.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 O 2 supply Normal portal pressure is 5-10 mmHg (7-14 cm H 2 O), 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. 1.Left gastric v.→ Esophageal v.→ Azygos v. → SVC : ‘Esophageal varices’ 2.Splenic v. 2.Splenic v. → Sup. rectal v. → Rectal venous plexuses → middle & Inf. Rectal v. → → → IVC : Dilated rectal venous plexuses = Internal hemorrhoids Portal venous system

Portal-systemicanastomosis

Esophagealvarices

Internalhemorrhoids

Internalhemorrhoid Externalhemorrhoid

3.Paraumbilical v. 3.Paraumbilical v. → Superficial epigastric v. → External iliac v.→ IVC : ‘Caput Medusae’ 4.Colic v. 4.Colic v. anastomosis to Retroperitoneal v. → IVC DilatedSuperficial Epigastric veins

Caput medusae

Signs & symptomsSigns & symptoms –Esophageal varices : Hematemesis –Internal hemorrhoids –Caput Medusae –Splenomegaly –Ascites –etc. Portal hypertension