Unit 8: Liver and pancreas and portal system

Question 1

What are the different surfaces of the liver and Saha structures do they border with?

Answer 1

The anterosuperior surface = diaphragm
The posteriorinferior surface = visceral surface

Question 2

What ligaments can be found on the anterior surface of the liver?

Answer 2

The right and left coronary ligament
THe falciform ligament
The ligamentum teres

Question 3

What is the function of the right and left coronary ligamen of the liver?

Answer 3

Form part of the peritoneum reflection that attaches the superior surface of the liver to the diaphragm

Question 4

What is the function of the falciform ligament of the liver?

Answer 4

Attaches the liver to the anterior abdominal wall

Question 5

WHat is the function of the ligamentum teres in the liver?

Answer 5

In an embryological remanant of the umbilical vein that exists on the free edge of falciform ligament

Question 6

What are some ligaments on the posterior liver surface?

Answer 6

The posterior folds of the left and right coronary ligament
Triangular ligaments x2
Ligamentum venosum
Ligamentum teres

Question 7

What is the function of the posterior folds of the left and right coronary ligament in relation to the liver?

Answer 7

Help hold the liver to the posterior abdominal wall

Question 8

What is the triangular ligament made from? And what is its function in relation to the liver?

Answer 8

Made from the joining of the anterior and posterior folds of the coronary ligaments
Help anchor to the posterior abdominal wall

Question 9

What is the bare area of the liver?
What does it attach to?

Answer 9

Area on the superior surface of the liver that attaches directly to the diaphragm
Is margined by the anterior/posterior left/right coronary ligaments and the triangular ligaments.

Question 10

What is the function and location of the ligamentum venosum of the liver?

Answer 10

Is found on the posterior surface between the left lobe and the caudate lobe
Is a remnant of the ductus venous from the embryo

Question 11

What two ligaments form the lesser omentum?

Answer 11

The heptogastric
The heptoduodenal

Question 12

Describe the lobes of the liver

Answer 12

Large left and large right - seen anteriorly
Two additional lobes on the posterior surface - caudate (superior) and quadrate (inferior)

Question 13

Why and how is the liver split into segments?

Answer 13

Split into 8 segments
Each segment is supplied by its own portal traid
This is important to identify the location of liver problems or if parts of the liver are being operated on, will try to only damage the necessary segments

Question 14

How are the segments of the liver numbered?

Answer 14

The caudate lobe in lobe number one (only seen on the posterior surface)
When looking at the posterior sruface the lobes can then be numbered in an anticlockwise fashion
When looking at the anterior surface the lobes should be numbered in a clockwise fashion (remember caudate not seen) so start at most left and superior.
Lobe 4 is split into a (superiorly) and b (inferiorly)

Question 15

How is the liver split into the left and right lobes?

Answer 15

Semgnet 1 to 4 are on the left
This division from the right is by an invisible strucutre called the cantlie line - this is where the middle hepatic vein will run internally
This division is NOT by the falciform ligament

Question 16

What are the inwards sources of blood to the liver?

Answer 16

The portal vein
The proper hepatic artery (a branch of the coeliac trunk)

Question 17

What is the venous drainage of the liver?

Answer 17

Each lobule contains a central vein which will eventually drain into the right, middle or left hepatic vein which eventually drains in the ascending IVC.

Question 18

What is the billiary system?

Answer 18

Organs that synthesise, store and secrete bile.

Question 19

What are the main componenets of bile?

Answer 19

Bilirubin
Biliverdin
Products of rbc breakdown
This gives bile its green colour

Question 20

What vessels does bile drain into when leaving the liver?

Answer 20

Bile canaliculi
Right/left hepatic ducts
Common hepatic ducts

Question 21

How does bile enter the gallbladder?

Answer 21

The common hepatic duct branches into the cystic duct.

Question 22

How does bile enter the duodenum?

Answer 22

By the common bile duct
This is made from the combining of the common hepatic duct and the cystic duct.
This will combine with the pancreatic duct to form the ampulla a vatar which enters the duodenum at the major duodenal papilla.

Question 23

What sphincter control the flow of bile into the duodenum?

Answer 23

Sphincter of the bile duct - at the start of the common bile duct, allows bile to flow from the common hepatic duct into the cystic duct
Pancreatic sphincter - controls release of pancreatic juices
Sphincter of oddi - release into duodenum

Question 24

What comonly blocks bile flow?

Answer 24

Bile stones
pancreatic tumour

Question 25

What is billiary colic?

Answer 25

When blockage of the passage of bile out of the gall bladder, gall bladder contracts painfully to try and get bile past the blockage. Often causes pain after eating.

Question 26

What is cholecsystitis?

Answer 26

When the gallbladder becomes inflammed and sore because the passage of bile into the duodenum is blocked.

Question 27

What causes jaundice?

Answer 27

Blocked flow of bile from the liver Increased levels of bilirubin

Question 28

What are the consequences if bile can not mix with the food?

Answer 28

Fat is not digested Stools are greasy and pale More acidic contents of the intestines - as not neutralised

Question 29

What is pancreatis?

Answer 29

When digestive enzymes are unable to leave the pancreatic duct, so begin the digest the pancreas itself, resulting in pain and inflammation

Question 30

What is the general location of the pancreas?

Answer 30

L1 or transpyloric plane level retroperitoneal - except the tail Epigastrum and left hypochondriac regions

Question 31

How does the position of the pancrea relate to the stomach?

Answer 31

Stomach is anterior, seperated by the lesser sac

Question 32

How is the position of the pancreas related to the duodenum?

Answer 32

C-shpaed part of duodenum curves around the pancreas head

Question 33

How is the position of the transverse mesocolon realted to pancreas?

Answer 33

transverse mesocolon fused with the anterior surface of the pancreas

Question 34

How does the position of the common bile duct relate to the pancreas?

Answer 34

Common bile duct descends just behind the head of the pancreas before joing the major pacnreatic duct through the major duodenal papilla

Question 35

How is the position of the spleen related to the position of the pancreas?

Answer 35

Tail of the pancreas is anterior and medial to the spleen Connected by the lienorenal ligament

Question 36

How is key vasculature orientated around the pancreas?

Answer 36

IVC and AA are posterior to the head of the pancreas SMA is posterior to the neck of the pancreas The splenic vein and SMV unite to form the hepatic portal vein posterior to the neck of the pancrease The splenic artery travels along the superior border ot the pancreas.

Question 37

How is the pancreas divided into different segments?

Answer 37

Tail - near hilum of spleen body - until duodenum surrounds pancreas Neck - where the duodenum originally makes contact with the pancreas Head- within the C-shape curve of the duodenum Ucinate process - the terminal part of the pencreas, inferior to the neck

Question 38

What is the arterial supply of the pancreas?

Answer 38

Pancreatic branches from the splenic artery THe superiorpancreaticoduodenal from the gastroduodenal The inferior pancreaticoduodenal from the SMA Both of which have anterior and posterior branches

Question 39

What is the venous drainage of the pancreas?

Answer 39

Into the superior mesenteric branches of the hepatic portal vein This rest of the pancreatic venous branches are from the splenic vein

Question 40

What lymphatic vessels drain the pancreas?

Answer 40

Follow the arterial supply Empty into pancreaticosplenal nodes and the pyloric nodes Which then empty into the superior mesenteric and the coeliac lymph nodes.

Question 41

Draw a diagram to represent the bile tree structures

Answer 41

Question 42

Draw a diagram to represent the sphincters in the bile tree

Answer 42

Question 43

What are the boundaries of the caudate lobe?

Answer 43

The left lobe indentation for the ligamentum venosum and the IVC

Question 44

What are the boundaries of the quadrate lobe?

Answer 44

The left lobe indentation for the ligamentum teres and the gall bladder.

Question 45

How do the ligaments of the liver relate to the foetal blood supply?

Answer 45

The ligamentum venosum (posterior) is a remanant of the ducuts venosus The ligamentum teres or the round ligament of the liver - is a remanant of the umbilical veins

Question 46

What are the different impressions on the visceral surface of the liver and where can they be found?

Answer 46

The right lobe - the renal impression and the colic impression The left lobe - the gastric impressions The impression for the vena cava - prominent and central on the posterior surface, anterior of the visceral sruface

Question 47

How many hepatic veins drain directly into the inferior vena cava?

Answer 47

3 - left, right and intermediate

Question 48

What structure is in direct contact with the bare area of the liver?

Answer 48

The diaphragm

Question 49

What are the surface marking of the liver?

Answer 49

The fitfh intercostal space on the left midclavicular line The fifth intercostal space on the right midclvavicular line Midline at the transpyloric plane Tip of the eights costal cartilage on the right The lowest point of the costal margin on the right CHECK THIS ANSWER

Question 50

How can you describe the boundaries of the liver using the ribs?

Answer 50

Right - between ribs five and rib ten Left - rib five and lower border passess over the costal cartilage of rib seven

Question 51

What two veins unite to form the hepatic portal vein?

Answer 51

The splenic and the superior mesenteric vein

Question 52

What two vessels unify to form the common bile duct?

Answer 52

The cystic duct and the common hepatic duct

Question 53

The liver forms eight functional segments, what differentiates these eight different segments?

Answer 53

Individual branch of the portal triad (portal vein, hepatic artery and the bile duct)

Question 54

How are bilirubin and bile related?

Answer 54

Bilirubin is a component of bile

Question 55

Is the pancrease intra or retro peritoneal?

Answer 55

Retroperitoneal expect from the tail which is intraperitoneal

Question 56

Pancreatic cancer is very aggressive, suggest some reasons why?

Answer 56

Retroperitoneal - difficult to palplate/image so slow to diagnose Quick to metastasise - rapidly into the liver or the duodenum by the pnacreatic duct and billary tree.

Question 57

What blood vessel supplying the pancreas has anterior and posterior branches?

Answer 57

The inferior pancreaticoduodenal from the SMA The superior pancreaticoduodenal from the gastroduodenal

Question 58

What is the portal hepatus?

Answer 58

The hilum of the liver where the portal triad enter

Question 59

What does the uncinate part of the pancreas surround?

Answer 59

The superior mesenteric vessels

Question 60

Where are the portosystemic anastamoses found? Why are these important clincally?

Answer 60

Umbilical vein - round ligament of liver, is re canalised and connects the vein in the anterior abdominal wall, veins appear in a radial pattern around the umbilicus Oesophagus - anatamoses between systemic and hepatic circulation. Internal veins become variococed, swallow so black poo or cough up red blood Superior rectal artery - variococity Identify signs of hepatic hypertension

Question 61

What are all the branches from the hepatic portal vein?

Answer 61

The left and right gastric veins The superior mesenteric vein The spleninc vein (drained into by the inferior mesenteric vein)

Question 62

What is hepatic portal hypertension? Causes/

Answer 62

Cause within liver Cirrhosis - fibrosis of connective tissue, stiffer so more difficult for blood to flow through, backflow creates hypertension Hepatitis - inflammation, impedes blood flow through the liver.

Question 63

What is pre hepatic portal hypertension? Causes?

Answer 63

Thrombus in veins that drain into hepatic portal vein Tumour in the GIT that push on the veins into the portal vein

Question 64

What is post hepatic portal hypertension? Causes?

Answer 64

Slows down flow of blood from IVC from the liver Examples include heart failure

Question 65

What is the consequences of portal hypertension?

Answer 65

Increases resistance in the liver More difficult for blood to drain into the liver.

Question 66

Why might the abdomen be distended in a patient with hepatic hypertension?

Answer 66

Back flow of blood in the vessels that supply the hepatic portal vein Accumulation of ECF around the vessels

Question 67

Describe two routes of venous drainage from the umbilicus, one into systemic circulation one into portal circulation

Answer 67

para-umbilical veins - direct tributary into the portal vein Epigastric vein - pubic and obturator branch of the inferior epigastric vein, will drain into the external iliac and into the IVC via the common iliac.