Liver and Biliary System - GIHEP Lecture Notes PDF

Liver and extra hepatic biliary system Gastrointestinal tract Dr Sara Sulaiman [email protected] Learning outcomes By the end of this lecture, you should be able to: Describe the anatomy of the liver and biliary tree Describe the peritoneal reflections and ligaments connected to the li...

Liver and extra hepatic biliary system Gastrointestinal tract Dr Sara Sulaiman [email protected] Learning outcomes By the end of this lecture, you should be able to: Describe the anatomy of the liver and biliary tree Describe the peritoneal reflections and ligaments connected to the liver Outline the anatomy of the portal venous system Describe and name the main porto-systemic anastomoses and explain why these are clinically relevant Describe the anatomy of the major duodenal papilla Identify the liver, gallbladder and common bile duct on radiological imaging Recommended reading Abrahams, Peter H. et al. McMinn & Abrahams’ Clinical Atlas of Human Anatomy. Seventh edition. Maryland Heights, Missouri: Elsevier Mosby, 2013. PrintDrake, Richard L. Gray’s Anatomy For Students. 4th. ed. Philadelphia: Elsevier, Inc., 2020. Print. Moore, Keith L., Arthur F. Dalley, and A. M. R. Agur. Essential Clinical Anatomy. 4th ed. Philadelphia, Pa.; London: Lippincott Williams & Wilkins, 2011. Print. Netter, Frank H. (Frank Henry). Atlas of Human Anatomy. 5th ed. Philadelphia, Pa.; London: Saunders, 2010. Print. Smith, C., Dilley, A., Mitchell, B. and Drake, R.L., 2017. Gray’s Surface Anatomy and Ultrasound: Gray’s Surface Anatomy and Ultrasound E-Book. Elsevier Health Sciences. Spratt, J., Salkowski, L.R., Loukas, M., Turmezei, T., Weir, J. and Abrahams, P.H., 2020. Weir & Abrahams' Imaging Atlas of Human Anatomy. Elsevier Health Sciences.  Largest gland in the body Weighs 1500g (2% body weight) Liver Receives 1500ml / min blood Right and central upper abdomen Functions: Right Hypochondrium & Epigastric region Protein synthesis 4th right intercostal space to costal margin Digestion Lies deep to ribs 5 to 11(depending of Metabolism breathing) Toxin inactivation May be palpated on inspiration Immune Bile production 5 Cholesterol production 6 7 Glucose storage & release 8 Haemoglobin processing 9 10 Regulation of blood clotting Clearance of bilirubin What are the two blood  Largest visceral organ Two surfaces: Liver Diaphragmatic: smooth and associated with: Left lobe Subphrenic recess Right lobe Hepatorenal recess Falciform Visceral: covered with visceral ligament peritoneum (except for the fossa for the gallbladder) Bare area Round ligament of the liver (part of the Associated with many organs (fibrous remnant of the diaphragmatic Porta hepatis (gateway to the liver) umbilical vein at the free surface of the IVC margin of the falciform Anterior liver which is not ligament) covered by Porta hepatis peritoneum) Renal impression Posterior Subphrenic recess (between the diaphragm and Gastric impression the superior and anterior surface Colic impression of the liver) Oesophageal What is the impression clinical Hepatorenal recess (between Gallbladder significance the liver and right kidney of recesses? and suprarenal glands) Visceral surface Hepatogastric ligament Falciform ligament Left lobe Right lobe Round ligament of the liver Hepatoduodenal ligament Bare area Associated ligaments Left triangular ligament The liver is attached to: Coronary ligament Anterior abdominal wall by the falciform ligament The round ligament of the liver (ligamentum teres) is at the free margin Fissure for The stomach by the hepatogastric ligament ligamentum Right venosum triangular The duodenum by the hepatoduodenal ligament ligament The diaphragm by the right and left triangular ligaments and anterior and posterior Round ligament of coronary ligaments the liver  Falciform Coronary ligament IVC Hepatic veins Bare area ligament Coronary ligament Left triangular Left triangular ligament ligament Right triangular Round ligament of ligament the liver Fissure for ligamentum venosum lobes Divided into right and left lobes by the falciform ligament Left lobe On the visceral surface a H-pattern can be Right lobe noted: Right sagittal fissure made by the fossa for Falciform the gallbladder and the IVC ligament Left sagittal fissure made by the fissure for Round ligament of of ligamentum venosum & fissure of round the liver ligament (ligamentum teres) Caudate lobe Right sagittal fissure Caudate lobe between the fissure for Left lobe ligamentum venosum and the fossa for the IVC. Right lobe Quadrate lobe between the fissure for ligamentum teres and the fossa for the Left sagittal gallbladder. fissure Quadrate lobe Anatomical and functional lobes Anatomical Functional Left and right, caudate and quadrate Left and right halves Further subdivide functional halves into 8 segments Into four divisions (or sectors/sections) and Caudate lobe further subdivided into eight hepatic (or surgical) segments Independent functional units: on the Left basis of biliary drainage and blood lobe supply Right lobe Caudate lobe Left Quadrate lobe half Right half Quadrate lobe  Portal triad Hepatic artery Porta hepatis Porta proper Hepatic portal vein Common bile duct hepatis Hepatoduodenal ligament Free margin of the lesser omentum Epiploic foramen (of Pringle’s Manoeuvre Winslow) Image from: Olek Remesz (wiki-pl: Entrance to the Orem, commons: Orem), CC BY-SA 3.0 omental bursa Lesser , via Wikimedia Commons omentum Lymphatics and nerves will also enter the liver at the porta hepatis Gallbladder The fundus of the gallbladder projects on the lower border of the liver and touches the parietal peritoneum of the anterior abdominal wall at the tip of the ninth costal cartilage Surface landmark: At the intersection of the lateral border of the right rectus abdominis and the costal margin Murphy’s point: at the level of the transpyloric plane and the right ribcage Lies in the gallbladder fossa on the visceral surface of the right lobe of the liver, adjacent to the quadrate lobe Storage and concentration of bile secreted by the liver (Capacity of ~50mL)  Right hepatic duct Left hepatic duct Cystic duct Gallbladder Common hepatic duct Right hepatic duct Left hepatic Common bile Cystic duct Pear-shaped structure. duct duct Fundus, body and neck Neck The common bile duct courses Common to the right of the hepatic Body hepatic duct artery and anterior to the hepatic portal vein in the free margin of the lesser omentum. Hepatopancreatic Common bile ampulla (of Vater) duct Fundus The common bile duct joins Main pancreatic the main pancreatic duct to duct form the hepatopancreatic ampulla (of Vater) and opens into the duodenum at Common bile duct the major duodenal papilla surrounded by the sphincter Main pancreatic duct of the ampulla (of Oddi). Sphincter of the hepatopancreatic ampulla (of Oddi) (sometimes called Major duodenal papilla Glission’s sphincter) Common bile duct Infundibulum of the gallbladder “Hartman’s pouch” Found as a pouch in the junction of the neck of the gallbladder and the cystic duct Supra-duodenal part Common bile Retro-duodenal part duct Para-duodenal part Main pancreatic duct Major duodenal hepatopancreatic ampulla papilla  Blood to the liver Hepatic portal vein Liver receives splenic blood from: Hepatic artery Rt. Hepatic Lt. Hepatic Hepatic artery a. Superior proper: a. proper mesenteric vein oxygenated blood from the circulation. Inferior mesenteric vein Hepatic portal vein: deoxygenated blood from the Cystic a. small intestine, (Usually from the high in nutrients. right hepatic artery) Trace the hepatic artery proper back to the aorta.  Blood from the hepatic portal vein and hepatic artery will Hepatic veins passes through the liver IVC Blood will be returned to the IVC by the hepatic veins Cystic veins drain neck of gallbladder directly into portal vein, venous drainage of gallbladder fundus and body flows directly to the liver (into the hepatic sinusoids) Hepatic portal vein At what level does the hepatic portal vein form? Describe the relationship of the hepatic portal vein to the pancreas.  Anastomosis between the small epigastric veins (systemic) Porto-caval and the para-umbilical veins (portal)- can result in caput anastomosis medusae Anastomosis between the In normal conditions, blood from oesophageal veins (drains the portal vein will pass by the into the azygos liver and then goes back to the vein) and the systemic circulation (IVC) via the left gastric hepatic veins. vein (portal)-can result in If the portal pressure increases oesophageal (e.g. liver cirrhosis) blood flow to varices the liver is obstructed which leads Anastomosis to blood-taking alternative between the pathways through: Anastomosis inferior between the Gastroesophageal junction (middle) rectal retroperiton veins (drains The anus eal veins into the internal Anterior abdominal wall (systemic) and iliac vein>IVC) the colic Bare areas of secondarily veins (portal) and the retroperitoneal organs superior rectal vein (drains into Venous enlargement will be the IMV>hepatic noticed in these sites. portal vein)-can result in rectal varices Lymphatics Superficial lymphatics from anterior Phrenic diaphragmatic and visceral surfaces drain lymph nodes into three or four nodes that lie in the porta hepatis (hepatic lymph nodes) Hepatic lymph nodes drain into celiac lymph nodes Coeliac lymph nodes drain into Hepatic lymph nodes cisterna chyli (then to the thoracic duct) Superficial lymphatics from the posterior diaphragmatic and visceral surfaces drain to phrenic lymph nodes Phrenic lymph nodes drain to Cystic node posterior mediastinal lymph nodes to the right thoracic duct Gallbladder drain to hepatic nodes through cystic node (located at the neck Celiac lymph of the gallbladder) then to coeliac nodes nodes Nerves Hepatic nerve plexus – derived from the coeliac plexus and accompanies the hepatic artery and hepatic portal Vagus nerve vein Parasympathetic from the vagus Nerves to the gallbladder pass along the cystic artery from the coeliac nerve plexus Parasympathetic from the vagus Remember that the parasympathatic fibres synapse at ganglia near or embedded in the organs. That’s why you cannot see Nerves Hepatic nerve plexus – derived from T7 T8 the coeliac plexus and accompanies T9 the hepatic artery and hepatic portal T10 vein Parasympathetic from the vagus Greater splanchnic Sympathetic from the celiac nerve plexus Nerves to the gallbladder pass along Celiac ganglia the cystic artery from the celiac nerve plexus Parasympathetic from the vagus Sympathetic from celiac plexus Contraction of the gallbladder is hormonally simulated Cholecystokinin (CCK) → Bile release Clinical conditions related to the liver Portal hypertension Abscess/infection Oesophageal varices Hepatomegaly Caput medusae Dengue Carcinoma Leishmaniasis Primary or metastases Malaria Trauma Storage disorder/enzyme Pringl’e manoeuvre deficiency Cirrhosis Case courtesy of Ayaz Hidayatov, Radiopaedia.org, rID: 75151 Endoscopic retrograde cholangiopancreatogram (ERCP) (catheter from scope passed through major duodenal papilla into ampulla of Vater with injected contrast column above). 1. Common bile duct 2. Common hepatic duct 3. Cystic duct 5. Endoscope in duodenum 6. Gall bladder 7. Hepatopancreatic (Vater’s) ampulla* 9. Left hepatic duct 11. Pancreatic duct 12. Right hepatic duct Magnetic resonance cholangiopancreatogram (MRCP). 1. Common bile duct 2. Common hepatic duct 3. Cystic duct 4. Duodenum 6. Gall bladder 8. Jejunum 9. Left hepatic duct 10. Neck of gall bladder 11. Pancreatic duct 12. Right hepatic duct  A 48-year-old female is admitted to the ER complaining of abdominal pain over the last several days. The pain begins below her ribs and is now located across her upper abdomen, extending to her back between her shoulders. The pain is worse after a meal. She has been feverish and had chills, nausea, and vomited twice. She described her urine as “coca cola”. Upon physical exam, you notice yellowing of her skin and eye-sclera. Imaging is shown. Describe what you see. Cholecystitis Cholelithiasis are the most common cause of biliary obstruction. Most gallstones remain in the gallbladder; however, some may enter the biliary duct system. If a gallstone blocks the cystic duct, cholecystitis may occur due to the stasis of bile within the gallbladder. Appreciation of anatomy is critical during laparoscopic cholecystectomy. The Triangle of Calot and the hepatocystic triangle must be visualised. The Critical View of Safety Approach for Lapar oscopic Cholecystectomy (for interest only) Clinical conditions related to the gallbladder Gallstones Present as: Biliary colic>>>epigastric pain Cholecystitis>>> RUQ pain, Murphy’s sign Investigations: Ultrasound MRCP - Magnetic Resonance Cholecystopancreatography ERCP - Endoscopic retrograde cholangiopancreatogram (ERCP) Complications: Common bile duct stones Cholangitis: inflammation of the bile duct system Pancreatitis What if your patient is dark- skinned? Remember that jaundice is more difficult to note on darker-skinned people What conditions would result in jaundice?