liver & portal vein
TRANSCRIPT
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Anatomy of
Liver, Biliary system
&Portal vein
Dr Mohamad Aris Mohd Moklas (PhD)Department of Human AnatomyFPSK [email protected] 8947 2330/2331/2783
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected] -
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LIVER
It is the largest gland in
the body. Liver is a soft, dark
brown highly vascularorgan. It is readily torn inabdominal injur ies
causing severe intra-abdominal bleeding.
In adult it is
approximately 2% of the
body weight.
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LIVER
LocationMainly
present in right
hypochondriac region . It
also extends to epigastricregion.
Weight-
1400
1800 gms in males.12001400 gms in females.
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Lobes of liver Liver is divided into a large right lobe and a
small left lobe by the attachment of falciformligament , which extends from liver to theanterior abdominal wall.
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Lobes of liver
Right lobe is further divided into quadratelobe and caudate lobe.
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Surfaces of l iver
Five surfaces,anterior, posterior,superior, inferior and
right surfaces.
A sharp inferior
border separates theanterior from the
inferior surface.
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Relations of l iver:
Per itoneal relations
&
Visceral relations
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Relations of l iver :
Peritoneal relations
Liver is covered by the visceral layer of peritoneumexcept the bare area of liver.
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Relations of liver:
Visceral relations
Superiorly the liver is related to the diaphragm.
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Relations of liver:
Visceral relations
Posteroinferiorsurface: (Posteriorand inferior)
It is related toabdominal part ofoesophagus, the
stomach, the
duodenum, theright colic flexure,the right kidney,right suprarenaland the gallbladder.
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Relations of liver:
Visceral relations
Posteroinferiorsurface: (Posteriorand inferior)
Groove for Inferiorvena cava lodgesthe upper part of
I.V.C.
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Abdominal part of oesophagus is related to theposterior surface of the left lobe.
Bare area is related to the posterior surface of rightlobe .
Stomach is related to the inferior surface of the left
lobe.
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Right kidney and right colic flexure are related to theinferior surface of the right lobe .
Gall bladder fossa lodges the gall bladder on theinferior surface .
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Gastric
Colic
Renal
Left triangular ligament
Ligamentum teres
Bare area
Coronary ligamentsHepatic vein
Quadratelobe
Porta hepatis
Fissure for
ligamentum
venosum
Fissure for
ligamentumteres hepatis
Falciform ligament
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Porta hepatis of l iver (H ilum)
It is present on theposteroinferior surface andlies inbetween caudate and quadrate lobes.
Free edge of the lesser omentum is attached to its
margins.
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Porta hepatis of
liver (H ilum)
Right and lefthepatic ducts, right
and left branches ofhepatic artery andportal vein are passing
throughthe porta
hepatis.
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Vascular segments of Liver
On the basis of blood supply and biliary drainagethere are four main hepatic segments.
Left lateral (left lobe) Left medial (Left lobe) Right anterior (right lobe) Right posterior (right lobe)
Each of these main segments are furthersubdivided into upper and lower parts.
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Peritoneal l igaments of l iver
1. Falciform ligamentIt is a two- layered fold ofperitoneum.
It extends from the anterior abdominal wall to theanterior surface of liver.
I t contains the l igamentum teres, which is theremains of the umbilical vein.
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The right layer of falciform ligament forms theupper layer of the coronary ligament and its left layer
forms the upper layer of the left triangular ligament.
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Peritoneal ligaments of
liver
2. The lesser omentum -
It extends from theedges of theportahepatis and passes to
the lessercurvature ofstomach.
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Lesser omentum
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Bare areaof liver
This is the area of l iver which is devoid ofperitoneum.
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Bare areaof liver
To the right of the I.V.C the posterior part of thediaphragmatic surface is broad and a large part of itbetween the superior and inferior layers of the coronary
ligament is not covered by peritoneum
This is the bare area. Groove for I.V.C and the fossa for gall bladder are
also devoid of peritoneum.
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Blood supply
Hepatic artery, abranch of celiacartery. It divides intoright and left
terminal branchesthat enter the portahepatis.
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VeinsPortal vein divides into right and left
branches that enter the porta hepatis.
The hepatic veins emerge from the posteriorsurface of liver and drain into the I.V.C.
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Blood vessels of liver
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Nerve supplySympathetic and
parasympatheticfrom the celiac plexus.
Lymphatic drainageThe efferent vessels pass
to the celiac nodes.
A few vessels from the bare area pass to the
posterior mediastinal nodes.
Bil i t
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Bil iary system
It consists of thefollowing structures.
Right and left hepaticducts.
Common hepatic duct.
Gall bladder.
Cystic duct.
Common bile duct (bileduct).
Bil i t
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Bil iary system
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Right and left hepatic ducts
Emerge from the right and left lobes of the liver inthe porta hepatis.
The hepatic ducts unite to form the common hepatic
duct.
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Common hepatic duct
It is about 4 cm long. It descends within the freemargin of the lesser omentum. It is joined on the rightside by the cystic duct from the gall bladderto form
the bile duct.
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Gall bladder
It is a pear-shaped sac.
Lies on the undersurface of liver.
Capacity 3050 ml.
It has three partsFundus, bodyand neck. .
Fundus usually projects below the
inferior margin of liver and comesin contact with the anteriorabdominal wall .
E t h ti t f th bil i t
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Extr ahepatic parts of the bil iary system
The bile ducts and the Gall bladder
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Sur face marking of fundus of gal l bladder:
Fundus can be surface marked on the anteriorabdominal wall at the level of the tip of the r ight 9th
costal carti lage.
The body of gall bladder lies in contact with the
visceral surface of liver.
The neck is continuous with the cystic duct.
Theperitoneum completely surrounds the fundus ofgall bladder.
Blood supply Cystic artery a branch of right hepatic artery
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Blood supplyCystic artery a branch of right hepaticartery.
VeinsCystic vein which drains into portal vein.
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Lymphatic drainageDrains into cystic lymph node. From
here the lymph vessels pass to hepatic nodes and then tocel iac nodes.
Nerve supplySympathetic and parasympathetic.
Parasympathetic is the vagus nerve. Sympathetic and parasympathetic form the celiac plexus.
Thepain fibres from the gall bladder and bile ducts ascendthrough the celiac plexus
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Cystic duct
It is about 4 cm long.
It connects the neck ofgall bladder to commonhepatic duct to form the bileduct.
It descends in the freemargin of lesser omentum.
Extrahepatic biliary apparatus
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Bile duct (Common bile
duct)
It is about 8 cm long.
It lies in the right free
margin of lesser omentum.
Here it lies in front of the
portal vein and on the right of
hepatic artery.
Bile duct (Common bile
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Bile duct (Common bile
duct)
Itpasses behind the firstpart of the duodenum .
In the lower part of itscourse i t is poster ior tohead of pancreas.
The bile duct is joined by the main pancreatic duct
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The bile duct is joined by the main pancreatic ductto form hepatopancreatic ampul la(ampulla ofVater).
The ampulla opens in the second part of the
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The ampulla opens in the second part of theduodenum halfway down its length by means of asmall papilla major duodenal papilla.
The terminal parts of both ducts and ampulla aresurrounded by asphincter of Oddi.
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CLINICAL FEATURES
1.Errors in gall bladder surgery is due to the failure to
appreciate the variations in the anatomy of biliarysystem.
It is therefore important to identify all the threebiliary ducts together with the cystic and hepaticarteries before dividing any structures and removing
the gall bladder.
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2.Haemorrhage during cholecystectomy can
be controlled by compressing the hepaticartery between the finger and thumb when itlies in the anterior wall of the foramen of
Winslow (epiploic foramen).
3 St i th bil d t can s all be
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3.Stones in the common bile ductcan usually beremoved through an incision in the supraduodenal
part of the common bile duct.
4. Bi liary colicSpasmodic pain in abdomen
relating to bile passage. Biliary colic is mostintense when the calculus (stone) is impactedeither at the cystic duct or at the lower end of thebile duct.
Biliary colic referred pain is felt in the right
upper quadrant or the epigastrium.
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5.Liver biopsyHepatic tissue may be
obtained for diagnostic purposes by liverbiopsy.
6.Rupture of liverLiver may be torn by afractured rib.
7.HepatomegalyMany diseases cause liverenlargement, orhepatomegaly.
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8.Cirrhosis of liverDestruction of hepatocytes and
replacement of them by fibrous tissue.
9.Liver transplantationA person with end stage
liver disease may opt to have his liver removed to be
replaced with a normal liver.
10. Imaging of the biliary tractGall bladder and
biliary tract can be demonstrated by ultrasound.
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Portal vein
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Portal vein
Portal vein drains blood from abdominal part ofthe gastrointestinal tract, from the lower third of
oesophagus to half way down the anal canal.
It also drains blood from thespleen, pancreas and
gall bladder.
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The portal circulationbegins as capillary plexusand ends by emptying blood into the sinusoids ofliver.
Theportal vein enters the liver through the portahepatis.
Bloodfrom liver is collected by hepatic veins. Hepatic veins join the I.V.C.
Fig 20 The composition of the Portal system
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Fig.20 The composition of the Portal system
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Formation
By the joining ofsuperiormesenter ic and splenicveins.
Site of formationPosterior to neck ofpancreas.
Length - 6 to 8 cm.
Formation of portal Vein
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Formation of portal Vein
Relation of portal vein at its formation
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Relations
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At its formation, portal vein isposterior to neck ofpancreas.
It passes upwards poster ior to first part of duodenum
and enters the lesser omentum.
In lesser omentum it is related anter ior ly to bi le
duct (r ight), and hepatic artery (left). At the porta hepatis it divides into right and left
branches.
Relations of portal Vein
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Portal Vein relations (In lesser omentum)
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Portal Vein Tr ibutaries:
i.Splenic vein It receives the inferiormesenteric vein.
ii. Superior mesenteric vein
iii. Left gastric veiniv. Right gastric vein
v. Cystic vein.
Tributaries of portal vein.
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Portal - systemic anastomosis
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Portal systemic anastomosis
Smaller communications exist between the portal
and systemic veins and they become importantwhen the direct route becomes blocked.
These sites are,
1. At the lower end of oesophagusThe
oesophageal tributaries of the left gastric vein
(Portal tributary) anastomose with oesophagealveins (systemic tributary).
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2. Super ior rectal veinsdraining the upper part
of the anal canal (Portal tributary)anastomose with middle and inferior rectalveins (systemic tributaries).
3. Paraumbil ical veinsconnect the left branch
of portal vein with superficial veins of
anterior abdominal wall (systemictributaries).
Portal-systemic anastomosis
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CLINICAL FEATURES
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CLINICAL FEATURES
1. Portal hypertension
Liver cirrhosis obstruct the portal vein resulting in
increased pressure in portal vein causing portalhypertension.
At the sites of portal caval anastomosis portal
hypertension produces varicose veins. The veinsmay become so dilated that their walls ruptureresul ting in haemorrhage.
Bleeding from oesophageal varices, extremelydilated submucosal veins in oesophagus (at
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d ated sub ucosa ve s oesop agus (atthe distal end of the oesophagus) is often
severe and may be fatal .Oesophageal varices
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3. Paraumbil ical veinsmay become varicose
and look like small snakes radiating underthe skin around the umbilicus.
This condition is referred to as Caput
medusae.
Caput medusae
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4.Collateral circulation through the portal-
systemic communications formshaemorrhoids(piles) in the anal canal.
It may be responsible forrepeated
bleeding per rectum.
Haemorrhoids in anal canal
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