Page 1
Meechai Srisai M.D. ,Ph.D.Meechai Srisai M.D. ,Ph.D.Nigun Worapunpong M.D.Nigun Worapunpong M.D.
Department of AnatomyDepartment of AnatomyFaculty of MedicineFaculty of Medicine
Chulalongkorn UniversityChulalongkorn UniversityAugust 2010August 2010
Liver, Gallbladder,Liver, Gallbladder,Biliary tract and Biliary tract and portal venous portal venous
systemsystem
Page 2
IntroductionIntroduction
• Digestive system consists of – GI tract – Glands and accessory
organs : Salivary glands, Liver ,Gall bladder, Pancreas
Page 3
Liver Liver
• Largest organ in body 1200-1600 gm• Surface projection
– จุ�ดบนสุ�ด : Rt. Midinguinal line / Rt. 5th rib– จุ�ดล่�างขวา : Rt. Midaxillary line / Rt. 10th
costal cartilage – จุ�ดล่�างซ้�าย : Lt. Midinguinal line / Lt. 5th I.C.S.
Page 4
Surface projection Surface projection of liverof liver
Page 5
Parasagittal section Parasagittal section through liverthrough liver
Showing subphrenic Showing subphrenic recess and recess and
hepatorenal recesshepatorenal recess(Rutherford-Morison pouch)(Rutherford-Morison pouch)
Page 6
Surfaces of LiverSurfaces of Liver1. Diaphragmatic surface
2. Visceral surface : structures lie like ‘H’
Liver Liver
Page 7
Visceral surface ‘H’Visceral surface ‘H’1.1. Cross-bar of H Cross-bar of H = Porta hepatisPorta hepatis
– Hepatic artery, Portal vein, Bile ducts, Nerves and Lymphatic vss.
2.2. Lt. superior of H Lt. superior of H = Ligamentum teres hepatis or round ligament of liver (Remnant of umbilical v.)
3.3. Lt. inferior of H Lt. inferior of H = Ligamentum venosum (Remnant of ductus venosus)
4.4. Rt. superior of H Rt. superior of H = Gall bladder
5.5. Rt. inferior of H Rt. inferior of H = Inferior vena cava
Liver Liver
Page 8
VisceralVisceralSurfaceSurface
‘‘H’H’
Page 9
VisceralVisceralSurfaceSurface
‘‘H’H’
Page 13
Peritoneal relationsPeritoneal relations
1.1. Peritoneal ligamentsPeritoneal ligaments– Lesser omentum– Falciform ligament– Coronary ligaments– Triangular ligaments
2.2. Vascular ligamentsVascular ligaments– Round ligament of the liver– Ligamentum venosum
Liver Liver
Page 14
Parts of stomach and lesser omentum
Page 16
Liver Liver
Bare areas of the liverBare areas of the liver เป็�นบริ�เวณที่�� ไม่�ม่� เป็�นบริ�เวณที่�� ไม่�ม่� peritoneum peritoneum คล่�ม่คล่�ม่
1. b/t Ant. & Post. Coronary ligaments2. Fossa for gall bladder3. Porta hepatis4. Fissure for round ligament5. Fissure for ligamentum venosum6. Fossa for IVC
Page 19
Lobes of liverLobes of liver
1.1. Anatomical lobationAnatomical lobation• Right lobe• Left lobe• Caudate lobe• Quadrate lobe
2.2. Functional lobationFunctional lobation• Right lobe• Left lobe• By a line passing the gallbladder and IVC
Liver Liver
Page 20
Anatomical lobesAnatomical lobes
Page 21
Anatomical lobesAnatomical lobes
Page 22
Functional lobesFunctional lobes
Page 23
Functional lobesFunctional lobes
Page 24
Blood supply of liverBlood supply of liver
1. Rt. & Lt. hepatic arteries carry oxygenated blood (25%)(25%)
2. Portal vein carries venous blood (75%) (75%) rich in nutrients
3. Hepatic veins drain venous blood to IVC
Liver Liver
Page 28
Autonomic nervesAutonomic nerves• Symp : Celiac plexus• Parasymp : Ant. and
Post. Vagal trunks
Liver Liver
Celiac plexusCeliac plexus
Anterior vagal trunkAnterior vagal trunk
Page 29
Lymphatic drainage of liverLymphatic drainage of liver
Liver is a major lymph-producing organ
(1/4 -1/2 of lymph → Thoracic duct)• Diaphragmatic surface of liver drains
to Phrenic nodes • Visceral surface and deep lymphatics
along portal triads drains to Porta Hepatis → Hepatic nodes → Coeliac nodes → Cisterna chyli → Thoracic duct
Liver Liver
Page 30
Lymphatic drainage of liverLymphatic drainage of liver
Page 31
Lymphatic Lymphatic drainage of drainage of GI GI
tracttract
Page 32
Topographic anatomy of abdomenTopographic anatomy of abdomen
CT scanCT scanTopographic anatomyTopographic anatomy
Page 33
Gallbladder & Biliary tractsGallbladder & Biliary tracts
Page 34
Biliary system consists of
1.1. Gall bladderGall bladder
2.2. Biliary tractsBiliary tractsCystic duct, hepatic ducts, common hepatic duct and common bile duct
Gallbladder & Biliary tractsGallbladder & Biliary tracts
Page 35
• Length 6-10 mm. • Capacity ~ 45 cm3 • b/t Rt. lobe & Quadrate
lobe of liver• Surface projection
Fundus of gallbladder = Murphy’s pointMurphy’s point
Gallbladder Gallbladder
Page 36
Gallbladder has 4 portions1. Fundus2. Body3. Neck Infundibulum :
Hartmann’s pouch
Internal surface Internal surface : : folds, spiral folds, spiral folds and crypts of Luschkafolds and crypts of Luschka
Gallbladder Gallbladder
BodyBody
FundusFundus
Hartmann’sHartmann’spouchpouch
NeckNeck
Crypts Crypts of of
LuschkaLuschka
Spiral valveSpiral valve
Page 37
Blood supply of gallbladderBlood supply of gallbladder
1. Cystic artery from Right Hepatic artery
(in Calot’s triangle → Cholecystectomy)
2. Cystic vein : tributary of Portal vein
Gallbladder Gallbladder GallbladderGallbladder
Cystic arteryCystic artery
Calot’s triangleCalot’s triangle
Page 38
1.1. Cystic duct Cystic duct : ~ 3 cm
: spiral valve of Heisteri
2.2. Common hepatic ductCommon hepatic duct
: ~ 3-5 cm
: from Rt. & Lt. hepatic
ducts
3.3. Common bile ductCommon bile duct
: ~ 7.5 cm
1+2 → 31+2 → 3
Biliary tractBiliary tract
Page 39
Common bile duct has 4 parts– Supraduodenal– Retroduodenal– Infraduodenal– Intraduodenal
Biliary tractBiliary tract
Common bile duct + Major pancreatic duct
▼
Hepatopancreatic ampulla (Ampulla of Vater)(Ampulla of Vater)
Opening is Greater duodenal papilla in 2nd
part of duodenum (surrounded by Sphincter of OddiSphincter of Oddi)
Page 41
Compression of commonCompression of common
bile ductbile duct resulted inresulted in
obstructive jaundiceobstructive jaundice
Icteric scleraIcteric sclera
Page 42
Biliary tractBiliary tract
Celiac plexusCeliac plexus
Anterior vagal trunkAnterior vagal trunk
Nerves of GallbladderNerves of Gallbladder• Symp : Celiac plexus• Parasymp : Ant. and
Post. vagal trunks
Page 43
Lymphatic drainage of GallbladderLymphatic drainage of Gallbladder• Drain to Hepatic nodes of cystic nodes
↓ Celiac nodes
Biliary tractBiliary tract
Page 44
Radiograph of gallbladder Radiograph of gallbladder & biliary tracts& biliary tracts
Page 45
Radiograph of gallbladder Radiograph of gallbladder & biliary tracts& biliary tracts
Page 46
• A system of venous blood vessels from GI tract to the liver
• FormationFormation : – Superior mesenteric Superior mesenteric
vein vein + + Splenic vein Splenic vein (behind neck of pancreas)
Portal venous systemPortal venous system
Page 47
TributariesTributaries1. Cystic vein
2. Paraumbilical vein
3. Right gastric vein
4. Left gastric vein
5. Splenic vein
6. Superior mesenteric vein
Portal venous systemPortal venous system
Page 48
Portal hypertensionPortal hypertension• The portal vein provides about 75% of the liver's
blood flow and about 60% of its O2 supply
• Normal portal pressure is 5-10 mmHg (7-14 cm H2O), which exceeds inferior vena caval pressure by 4-5 mm Hg (the portal venous gradient)
• Higher values are defined as portal hypertension
Portal venous systemPortal venous system
Page 49
Portal-Caval AnastomosisPortal-Caval AnastomosisAnastomosis among portal vein and systemic vein (Inferior vena cava)
1.1.Left gastric v.Left gastric v.→ Esophageal v.→ Azygos v. → SVC : ‘Esophageal varices’
2.2.Splenic v.Splenic v. → Sup. rectal v. → Rectal venous plexuses → middle & Inf. Rectal v. → → → IVC : Dilated rectal venous plexuses = Internal hemorrhoids
Portal venous systemPortal venous system
Page 50
Portal-systemicPortal-systemicanastomosisanastomosis
Page 51
Esophageal Esophageal
varicesvarices
Page 52
Internal Internal
hemorrhoidshemorrhoids
Page 53
InternalInternalhemorrhoidhemorrhoid
ExternalExternalhemorrhoidhemorrhoid
Page 54
Portal venous systemPortal venous system
3.3. Paraumbilical v.Paraumbilical v. → Superficial epigastric v. → External iliac v.→ IVC : ‘Caput Medusae’
4.4. Colic v. Colic v. anastomosis to Retroperitoneal v. → IVC
DilatedDilated
SuperficialSuperficial
Epigastric veinsEpigastric veins
Page 55
Caput Caput medusaemedusae
Page 56
• Signs & symptomsSigns & symptoms– Esophageal varices :
Hematemesis– Internal hemorrhoids– Caput Medusae– Splenomegaly– Ascites – etc.
Portal hypertensionPortal hypertension