Liver and gallbladder

Question 1

What are the two key external surfaces of the liver?

Answer 1

Diaphragmatic

Visceral

Question 2

What is the ‘bare area’ of the liver?

Answer 2

Area of the diaphragmatic surface not covered by visceral peritoneum so is in direct contact with the diaphragm

Question 3

What organs is the visceral surface of the liver in contact with?

Answer 3

Right kidney + adrenal gland 
Hepatic flexure of colon 
Transverse colon 
Duodenum (part 1) 
Gallbladder
Oesophagus
Stomach

Question 4

What is the falciform ligament?

Answer 4

Ligament attaching the anterior surface of the liver to the anterior abdominal wall.
Forms natural division between right and left lobes of liver.

Question 5

What is the ligamentum teres?

Answer 5

Remnant of the umbilical vein forming the free edge of the falciform ligament

Question 6

Where are the subphrenic spaces?

Answer 6

Between the diaphragm and anterior/ superior surface of liver.
Divided into right and left by falciform ligament.

Question 7

Where is the subhepatic space?

Answer 7

Peritoneal space between the inferior surface of the liver and the transverse colon.

Question 8

What is Morison’s Pouch?

Answer 8

Potential space between the visceral surface of the liver and the right kidney

Question 9

What is the clinical relevance of Morison’s Pouch?

Answer 9

Deepest part of peritoneal cavity so fluid most likely to collect here in supine patient (e.g. bleeding or ascites)

Question 10

What is the Glisson’s capsule?

Answer 10

Fibrous layer covering the liver

Question 11

What are the lobes of the liver?

Answer 11

Right
Left
Caudate (upper aspect of visceral surface)
Quadrate (lower aspect of visceral surface)

Question 12

What is the porta hepatis?

Answer 12

Transverse fissure that transmits all vessels, nerves, and ducts entering or leaving the liver (with the exception of the hepatic veins)

Question 13

What structures make up the portal triad?

Answer 13

Branch of Hepatic Artery
Branch of Hepatic Portal Vein
Branch of Bile Duct

[Also lymphatic vessels and Vagus nerve]

Question 14

What is the venous drainage of the liver?

Answer 14

Central vein (drains each lobule) - form multiple hepatic veins which drain into IVC

Question 15

What is the blood supply to the liver?

Answer 15

Hepatic artery proper (25%)

Hepatic portal vein (75%)

Question 16

What is the nerve supply to the liver?

Answer 16

Hepatic plexus (containing sympathetic fibres from coeliac plexus and parasympathetic fibres from vagus nerve)

Question 17

What nerve innervates the Glisson’s capsule?

Answer 17

lower intercostal nerves

Question 18

What is the primary function of the gallbladder?

Answer 18

Concentration and storage of bile

Question 19

What is the gallbladder divided into anatomically?

Answer 19

Fundus
Body
Neck (which becomes cystic duct)

Question 20

What is a common area for gallstones to get lodged?

Answer 20

Hartmann’s Pouch (mucosal fold in neck)

Question 21

What makes up the biliary tree?

Answer 21

Common bile duct = Common hepatic duct (formed by amalgamation of collecting ducts) + Cystic duct (from gallbladder)

Common bile duct + Pancreatic duct = Hepatopancreatic ampulla of Vater

Question 22

Where does the biliary tree drain into?

Answer 22

Duodenum via the major duodenal papilla

Question 23

What regulates drainage of bile into the duodenum?

Answer 23

Sphincter of Oddi

Question 24

What is the blood supply to the gallbladder?

Answer 24

Cystic artery (branch of right hepatic artery)

Question 25

What is the venous drainage of the gallbladder?

Answer 25

Cystic veins drain into Portal vein

Question 26

What is the nerve innervation of the gallbladder?

Answer 26

Sympathetic and Sensory - Coeliac plexus

Parasympathetic - Vagus

Question 27

What is the lymph drainage of the gallbladder?

Answer 27

Cystic lymph nodes - Hepatic lymph nodes - Coeliac lymph nodes

Question 28

What is the clinical name for gallstones?

Answer 28

Cholelithiasis

Question 29

What are gallstones?

Answer 29

Small lumps of cholesterol and bile salts

Question 30

What is the surface anatomy of the diaphragm?

Answer 30

Mainly in Right Hypochondrium but extends to the Left Hypochondrium, following the upper limit of the diaphragm (approx. 5th rib, MCL)

Question 31

What is the lesser omentum?

Answer 31

Peritoneum between the stomach and liver

Question 32

What is the Pringle Manouvre?

Answer 32

Clamp free edge of the lesser omentum to cut off blood supply to the liver (e.g. during surgery)

Question 33

What does the free edge of the lesser omentum contain?

Answer 33

Common bile duct, Hepatic artery, Portal vein

Question 34

Where do porto-systemic anastomoses occur?

Answer 34

Inferior oesophagus
Rectum
Umbilicus (Caput Medusae)

Question 35

What is the consequence of increased portal venous pressure?

Answer 35

Dilation of anastomoses (varices) - lower oesophageal, ano-rectal and umblicus
Enlarged spleen

Question 36

What is the surface anatomy of the gallbladder?

Answer 36

Fundus sits around tip of right 9th costal cartilage (transpyloric plane)

Question 37

Where can gallbladder pain refer to?

Answer 37

R Hypochondrium
R Shoulder (e.g. due to diaphragmatic irritation)
Epigastrium

Question 38

What is the clinical name for inflammation of the gallbladder?

Answer 38

Cholecystitis

Question 39

What sign might be elicited in patient’s with acute inflammation of the gallbladder?

Answer 39

Murphy’s Sign (applying pressure under right costal margin at the 9th costal cartilage and asking patient to inspire)
Positive sign = patient ceases to inspire due to pain elicited