lec16

Question 1

I. Liver
A) Surfaces
1. _________—located just below the dome of the diaphragm and is covered by peritoneum except at the bare area, where the liver is in direct contact with the diaphragm.

2. _________—faces posteriorly, caudally, and to the left. It is covered by peritoneum except at gall bladder and porta hepatis.

Answer 1

1. Diaphragmatic

2. Visceral

Question 2

I.LIVER
B. Lobes
a. In gross anatomical appearance, the liver is divided into ________ lobes.

b. The fissures of the ligamentum venosum and ligamentum teres hepatis divide the liver into a ______left lobe and a _____ right lobe.
c. The ________ (portal fissure), fossae for the gall bladder and groove for the inferior vena cava further divide the right lobe of the liver into a caudate lobe and quadrate lobe.

Answer 2

a. 4
b. smaller, bigger
c. porta hepatis

d.

Question 3

I.Liver
C. ______________—folds of peritoneum

1. _______—attaches the liver to the stomach (hepatogastric ligament) and duodenum (hepatoduodenal ligament). The free margin of the lesser omentum contains the portal triad (hepatic artery, bile duct, and portal vein). These structures pass into the liver in a region called the porta hepatis.
2. _________—attaches the liver to the diaphragm and anterior abdominal wall
3. {_________—remnant of the umbilical vein; located in the inferior free margin of the falciform ligament. Oxygenated and nutrient-rich blood is brought from the placenta to the fetal liver via the umbilical vein.
4. ________—remnant of the ductus venosus. The ductus venosus shunts blood from the umbilical vein to the IVC, bypassing the fetal liver.

Answer 3

C. peritoneal ligament

1. lesser omentum
2. falciform ligament
3. ligamentum teres (hepatis)
4. ligamentum venosum

Question 4

I.LIVER
D. Surface Anatomy

1. _________—the liver lies mostly under cover of the thoracic cage just below the dome of the diaphragm on the right, and extends a variable distance to the left past the median plane. 2. Normally, the liver is not palpable below the right costal margin

Answer 4

1. Normal position

Question 5

I.LIVER
E.Function

1. Synthesis of proteins and clotting factors; storage of iron, copper, vitamins, and glycogen; secretion of bile.
2. Important blood forming organ in the fetus.
3. Chemical modification of macromolecules, toxins, and drugs.

Question 6

I.LIVER

F. Blood Supply

1. ___________—a branch of the common hepatic artery (from the celiac trunk) that brings oxygenated blood to the liver. Near the porta hepatis, the proper hepatic artery divides into right and left hepatic arteries. These supply 30% of the blood flow to the liver.
2. __________—collects blood from the capillary beds of the entire GI tract and brings venous blood, rich in products of digestion, to the liver. This supplies 70% of the blood flow to the liver.
   a. ________—valves are insignificant or absent. The system begins as a capillary plexus in the organs of the GI tract, gall bladder, pancreas, and spleen, and ends by emptying its blood into sinusoids within the liver. The portal vein receives blood from the superior and inferior mesenteric veins, and the splenic vein.
   b. The portal venous system communicates with the systemic venous system in several locations. These are called________________anastomoses.
   i. superior rectal vein <==> middle and inferior rectal veins to internal iliac veins
   ii. left gastric vein <==> esophageal veins to azygos vein
   iii. paraumbilical veins epigastric veins to external iliac veins
3. ________ leave the posterior surface of the liver to open directly into the inferior vena cava, just below the diaphragm.

Answer 6

1. Proper hepatic artery
2. (Hepatic) Portal vein
   a. Portal system
   b. portal-systemic (portacaval)
3. Hepatic vein

Question 7

I.LIVER

g. Nerve Supply—derived from the sympathetic and parasympathetic nerves via the __________

Answer 7

celiac plexus.

Question 8

Clinical Considerations
1. __________—obstruction of normal blood flow through the hepatic circulation, often resulting from cirrhosis. When this occurs, venous blood from the GI tract bypasses the hepatic circulation by flowing through sites of venous anastomoses between the portal vein and the inferior or superior vena cava. These are known as portacaval anastomoses and are possible because these vessels lack valves. Three major sites of anastomoses develop: esophageal, umbilical, and rectal venous plexuses

2. _________—is due to atrophy or destruction of the liver cells and hypertrophy of the connective tissue. This tissue surrounds the intrahepatic blood vessels and biliary ducts, impeding circulation of blood flow through the liver.
3. Because of its great vascularity, the liver is a common site for metastasis from cancers in many other body sites.
4. _________—is a yellow appearance of the skin due to an accumulation of bile pigment frequently as a result of obstruction of the intrahepatic or extrahepatic bile duct system.

Answer 8

1. Portal hypertension
2. Cirrhosis
3. metastasis from cancers
4. jaundice

Question 9

II. GALL BLADDER

A. _______—lies along the right edge of the quadrate lobe of the liver in a depression, the gallbladder fossa.

1. Parts: fundus, body, and neck
2. On the visceral surface of the liver; covered by peritoneum causally.

B. _________—gallbladder is located at the intersection of the linea semilunaris (lateral margin of rectus abdominis muscle) and the right costal margin.

Answer 9

A. Gall Bladder

B. Surface Anatomy

Question 10

II.Gall Bladder

C. Ducts

i. The liver develops as a bud from the developing _______, and in the adult, it retains this connection via the bile duct.
ii. ________ is secreted by the liver into many intrahepatic ducts, which coalesce into the right and left hepatic ducts, from the right and left lobes of the liver. These fuse to form the common hepatic duct.

iii. The __________ from the gall bladder merges with the common hepatic
duct to form the bile duct.

iv. The bile duct runs in the
free edge of the hepatoduodenal ligament to terminate in duodenum.

v. Just before the bile duct enters the second part of the duodenum, it is joined by the main pancreatic duct to form the ________.
The walls are thickened by smooth muscle forming the sphincter of the ampulla (the hepatopancreatic sphincter). The ampulla opens into the duodenum at the apex of the greater duodenal papilla.

Answer 10

i. duodenum
ii. Bile
iii. cystic duct
iv. hepatopancreatic ampulla.
v.

Question 11

II.Gallbladder

1. Functions
   i. The gall bladder stores ______.
   ii. The bile is produced in the liver and flows into the duodenum. When the sphincter muscle at the duodenal papilla is constricted, bile is forced back into the _____ and gall bladder.
   iii. There, the bile is stored, concentrated, and acidified. At meal time, the sphincter relaxes, the gall bladder contracts in response to gastrointestinal hormones and the vagus nerves, and bile is directed to the duodenum. The bile renders the ingested fats more soluble in water where the digestive enzymes can function.

E. Blood Supply—cystic artery (usually a branch from the right hepatic artery). Cystic vein drains directly into the portal vein.

F. Innervation—Nerves pass along the cystic artery from the celiac plexus (sympathetic), the vagus nerve (parasympathetic), and the right phrenic nerve (sensory).

G. Clinical Considerations—Obstruction of the biliary ducts with a gallstone results in pain, as well as backup of bile in the ducts. Inflamed gall bladder (cholecystitis) is another common occurrence. This also causes pain. If the bile cannot leave the gallbladder, it will enter the blood and cause jaundice

Answer 11

i. bile
ii. cystic duct
iii.

Question 12

III. PANCREAS

A. An exocrine and endocrine (islets of Langerhans) gland consisting of a head, body, neck, and tail.

B. The pancreas is a retroperitoneal structure that lies just deep to the stomach. The head lies in the “C” of the duodenum and the tail touches the spleen. The pancreas has an extensive pancreatic duct which enters the ___________ in company with the bile duct at the hepatopancreatic ampulla. The exocrine glands secrete an alkaline mixture of enzymes that aid in the digestion of proteins, fats, and carbohydrates. Pancreatic secretion is regulated by hormones and the vagus nerves.

C. Blood supply—branches from the splenic artery, gastroduodenal artery (superior pancreaticoduodenal artery) and superior mesenteric artery (inferior pancreaticoduodenal artery). Pancreatic veins drain into the portal, splenic, and superior mesenteric veins.

D. Innervation—sympathetic and parasympathetic fibers reach the gland by passing along arteries from the celiac and superior mesenteric plexuses.

E. Clinical Conditions

1. Pancreatitis—a serious inflammatory condition of the exocrine pancreas. This may be caused by a blocked duct or reflux of bile from the hepatopancreatic ampulla into the pancreatic duct.
2. Cancer of the pancreas—usually involves its head and accounts for most cases of extrahepatic obstruction of the biliary system. Because of its deep retroperitoneal locations, pancreatic cancer is difficult to diagnose early.
3. Cystic Fibrosis—a genetic disease causing secretion of abnormally thick mucus in the lungs and pancreas. This leads to serious lung infections, and the inability to digest nutrients.

Answer 12

B. major duodenal papilla

Question 13

IV.SPLEEN

A. The spleen is an organ of the lymphatic system consisting of organized masses of lymphatic tissue intimately associated with blood vessels.

i. In effect, the spleen filters blood. The spleen is also the site for lymphocyte and monocyte production and is very active in immune response to antigens. Its macrophages remove debris from the blood and specifically break down aged red blood cells. The heme portion of the hemoglobin molecule is converted indirectly into bilirubin, which is conducted to the liver by way of the hepatic portal vein and incorporated into bile. Accumulation of bilirubin in the blood results in jaundice and is generally indicative of liver or gall bladder disease. The storage function of red blood cells in the spleen is minimal.

B. Anatomical position—the spleen is located on the left, at the level of ribs ______in the abdomen. Two ligaments connect to it: the gastrosplenic (gastrolienal) ligament connects the spleen to the stomach, and the splenorenal (lienorenal) ligament attaches the spleen to the posterior abdominal wall in the region of the left kidney. It has a diaphragmatic and visceral surface. The spleen varies in size and shape and usually fits into a cupped hand.

C. Surface anatomy—parallel to ribs 9,10 and 11 behind the midaxillary line (MAL).

D. Blood supply—splenic artery (from the celiac trunk) and splenic vein, which joins the superior mesenteric vein to form the portal vein.

E. Clinical Conditions 1. Splenomegaly—enlargement of the spleen, which is abnormal and associated with many diseases. The notched border is helpful when palpating an enlarged spleen because when the patient takes a deep breath these notches can often be palpated as it moves inferoanteriorly, below the left costal margin. 2. The spleen is the most frequently injured organ in the abdomen. Rupture of the spleen causes severe intraperitoneal hemorrhage and shock.

Answer 13

B. 9-11

Question 14

V. BLOOD SUPPLY OF THE ABDOMEN

A. _______—begins at the T12 vertebra and ends at the L4 vertebra by dividing into the right and left common iliac arteries

1. ______ a. lumbar—small segmental branches b. common iliac
2. _____ a. suprarenal b. renal c. gonadal (testicular or ovarian) d. celiac trunk
   i. _____—supplies the lesser curvature of the stomach and the abdominal part of the esophagus.
   ii. _____—supplies the spleen, body and tail of the pancreas, and greater curvature of the stomach via the left gastroomental (gastroepiploic) branches.
   iii. ________—supplies the liver via the proper, right and left hepatic arteries, lesser curvature of the stomach via the right gastric artery, duodenum via the gastroduodenal artery, head of the pancreas via the superior pancreaticoduodenal branches, the gall bladder via the cystic artery, and the greater curvature of the stomach via the right gastroomental (gastroepiploic) branches.
   e. ____________—supplies blood to the head of the pancreas (via inferior pancreaticoduodenal branches), the distal half of the duodenum, the small intestine, the ascending colon, and the right half of the transverse colon. The 6-12 branches from the superior mesenteric artery to the small intestine are collectively called the intestinal arteries. The large artery from the superior mesenteric to the cecum is called the ileocolic artery. The right colic and middle colic arteries supply the ascending and hepatic flexure portions of the colon, respectively.
   f. _____________—supplies blood to the left half of the transverse colon, the descending colon, the sigmoid colon, and the rectum. The left colic, sigmoid, and superior rectal arteries are all branches of the inferior mesenteric artery and anastomose by way of the marginal artery near the colon. This artery provides an anastomotic channel for branches of the inferior and superior mesenteric arteries.

B. _________ 1. Principal blood supply to the pelvic viscera, perineum, medial thigh, and gluteal region (See PELVIS II: PELVIC VISCERA)

C. _________1. Become the fermoral arteries after passing deep to the inguinal ligament 2. Principal blood supply to the lower limb (See LOWER LIMB II: THIGH

Answer 14

A.  Abdominal aorta
1. Parietal branches 
2. Visceral branches 
 i. left  gastric  artery
ii. splenic  artery
iii.  common  hepatic  artery
e. superior  mesenteric artery
f.inferior  mesenteric artery
B. internal iliac arteries 
C. external iliac arteries