Cbl liver &hepatobiliary apparatus

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CBL- LIVER &HEPATOBILIARY APPARATUS BY DR. ABDUL WAHEED ANSARI CHAIRPERSON & PROF. ANATOMY RAK COLLEGE OF MEDICAL SCIENCES RAK MEDICAL & HEALTH SCIENCES UNIVERSITY U.A.E. Thursday, December 18, 2014 1

Transcript of Cbl liver &hepatobiliary apparatus

Page 1: Cbl  liver &hepatobiliary apparatus

CBL- LIVER &HEPATOBILIARY APPARATUS

BY DR. ABDUL WAHEED ANSARI

CHAIRPERSON & PROF. ANATOMY

RAK COLLEGE OF MEDICAL SCIENCES

RAK MEDICAL & HEALTH SCIENCES UNIVERSITY

U.A.E.

Thursday, December 18, 2014

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Learning outcomes for the CBL-Hepatobiliary apparatus

• Describe the gross anatomical features of Liver & Gall bladder.

• Their blood supply and relations to surrounding structures, nerve supply and lymphatic drainage.

• Histological features of liver and gall bladder.

• Anatomical explanation for cholelethiasis and portal hypertension.

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A clinical case of cirrhosis of liver and hepatic encephalopathy

Mr. N.N. 56 yrs. old male with 1 month H/0 of abdominal distention, confusion, inability to concentrate and dyspnea.

Social History: Excessive alcohol use for approx. 20 yrs.

On Examination:B.P= 130/70 Pulse 80, Apyrexial, Jaundice, Clubbing,Foetor hepaticus present.

No circulatory changes - palmer erythema, spider, telangiectasia, cyanosis.

No endocrine changes - gynecomastia, testicular atrophy.

No bleeding tendency- bruises, purpura, epistaxis.

Abdomen: Abdominal distention, marked ascites present, unable to detect visceromegaly.

Neuro: Apathetic, confused, disorientated, drowsy, slurred speech. Flapping tremor present.

Diagnosed as alcohol- induced liver cirrhosis

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The liver is located in the upper part of the abdominal cavity just beneath the diaphragm

• The greater part of the liver is situated under cover of the right costal margin and also extends to the left to reach the left hemi-diaphragm.

• The diaphragm separates liver from pleura, lungs, pericardium and heart.

• Thus it occupies most of the right hypochondrium and epigastrium and also a small portion extends into the left hypochondrium.

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Superior surface is the largest surface, convex in shape and is molded to the undersurface of the domes of the diaphragm.

• This surface is covered by peritoneum except for a small triangular area between the two diverging layers of falciform ligament.

• The majority of the superior surface lies beneath the right dome (related to the right diaphragmatic pleura and base of the right lung).

• Centrally there is a shallow cardiac impression corresponding to the position of the heart above the central tendon of the diaphragm and is related to the pericardium.

• The left side of the superior surface lies beneath part of the left dome of the diaphragm and is related to part of the left diaphragmatic pleura and base of the left lung.

Anterior surface

• Triangular and convex in shape, the anterior surface is covered by peritoneum except at the attachment of the falciform ligament.

• Much of it is in contact with the anterior attachment of the diaphragm.

• Separated by the diaphragm, the anterior surface is related on the right with the pleura and 6th to 10th ribs and their cartilages and with 7th and 8th costal cartilages on the left.

• The midline area of the anterior surface lies behind the xiphoid process and the anterior abdominal wall in the infracostal angle.

Posterior surface• The posterior surface is convex, wide on the right,

but narrow on the left.

• Much of the posterior surface is attached to the diaphragm by loose connective tissue in the region of the 'bare area'.

The inferior surface of the left lobe of liver presents gastric impression which is related inferiorly with the fundus of stomach and upper lesser omentum.

Fissure for ligamentum teres lodges the ligamentum teres.

Quadrate lobe is related to pylorus, first part of duodenum and lower part of lesser omentum.

Fossa for gallbladder lodges the gallbladder.

To the right of the fossa for the gall bladder, inferior surface of liver is related with the first part of duodenum, the hepatic flexure of colon, the right kidney and right suprarenal gland. 5

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The porta hepatis is hilum of the liver present in the inferior surface

It provides a passageway to the neurovascular and biliary structures, except the hepatic veins.

It is anteriorly bounded by the quadrate lobe and the caudate process posteriorly.

The portal vein, hepatic artery and hepatic nervous plexus ascend into the parenchyma of the liver.

The right and left hepatic bile ducts and some lymph vessels emerge from it.

At the porta hepatis, the hepatic ducts, the hepatic artery with its branches and the portal vein are arranged in that order from before backwards.

The margin of porta gives attachment to the lesser omentum.

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Ligaments of liver

• falciform ligament

• ligamentum teres of liver

• coronary ligament

• right triangular ligament

• left triangular ligament

• ligamentum venosum

• Lesser omentum-gastrohepatic ligament

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A case of chronic cholecystitis and cholelethiasis

• A 46-year-old woman presents to the ER in acute distress with symptoms of severe pain in the right upper abdominal region.

• In the past, she had repeated attacks of severe pain in the right upper quadrant, frequently following a heavy meal.

• These attacks were accompanied by nausea and vomiting.

• She suffers from indigestion, particularly after eating fatty foods.

• Preliminary Diagnosis: Biliary colic and chronic calculus cholecystitis

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Ultrasound image of gall bladder showed gall stones

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Foramen of Winslow/Epiploic foramen-is a passage between greater sac and lesser sac of peritoneal cavity

• Boundaries of foramen of Winslow/Epiploic foramen

• Superiorly it is formed by Caudate lobe of liver.

• Inferiorly it is formed by first part of duodenum.

• Anteriorly the lesser omentum having hepatic artery, bile duct and portal vein.

• Posteriorly the inferior vena cava.

• http://www.youtube.com/watch?v=So9czudJk1A

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The extra hepatic biliary apparatus

• Bile secretions are produced by hepatocytes and drained by right and left hepatic ducts.

• The common hepatic duct arises by joining the two hepatic ducts.

• A gall bladder joins the common hepatic duct by cystic duct.

• A common bile duct is joined by main pancreatic duct coming from pancreas and opens in to 2nd part of duodenum by major duodenal papilla.

• The bile coming from hepatic duct is ten times less concentrated when compared with the bile coming from gall bladder.

• There is a sphincter of Oddi at the major duodenal papilla.

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The portal triad is a unit where there are portal vein, hepatic artery and bile duct embedded in connective tissue at the corner of a classical hepatic lobule

• The lobule is the structural unit of the liver and rather easy to observe.

• In contrast, the hepatic acinus is more difficult to visualize, but represents a unit that is of more relevance to hepatic function because it is oriented around the afferent vascular system.

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Histology of gall bladder

• The lumen of the gallbladder is lined with a high columnar epithelium.

• The connective tissue wall contains abundant elastic fibers and layers of smooth muscle which predominantly run obliquely.

• These epithelial cells are devoted to absorption of inorganic salts and water, and provide the mechanism for the gallbladder's ability to concentrate bile.

• Over concentration leads to formation of bile stones.

• The bile coming from liver is very much diluted, where as bile in the gall bladder is 10X concentrated.

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Portal vein formation

• The superior mesenteric vein joins the splenic vein to form the portal vein, which carries the blood rich in nutrients absorbed from intestines for metabolism.

• The portal vein lies posterior to the hepatic artery and bile duct in the lesser omentum.

• The branches of portal vein enters the liver and distributed

• Portal hypertension is a manifestation when there is an obstruction of blood flow in the portal venous system, like in cirrhosis of liver.

• It manifests in the form of ascites, hemorrhoids, spider nevei, icterus and caput medussae and encephalopathy.

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References:-

• http://teachinganatomy.blogspot.ae/2013/02/hepatobiliary-system-liver-and-gallbladder.html

• http://www.oucom.ohiou.edu/dbms-witmer/Downloads/2007-03-27%20Biliary.pdf

• http://stevegallik.org/histologyolm_Ch17_P03.html

• http://www.vivo.colostate.edu/hbooks/pathphys/digestion/liver/histo_gb.html

• https://academic.amc.edu/martino/grossanatomy/site/Medical/Lab%20Manual/Gastrointestinal/answers/mediastinum8.htm

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