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

IntroductionIntroduction

• Digestive system consists of – GI tract – Glands and accessory

organs : Salivary glands, Liver ,Gall bladder, Pancreas

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.

Surface projection Surface projection of liverof liver

Parasagittal section Parasagittal section through liverthrough liver

Showing subphrenic Showing subphrenic recess and recess and

hepatorenal recesshepatorenal recess(Rutherford-Morison pouch)(Rutherford-Morison pouch)

Surfaces of LiverSurfaces of Liver1. Diaphragmatic surface

2. Visceral surface : structures lie like ‘H’

Liver Liver

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

VisceralVisceralSurfaceSurface

‘‘H’H’

VisceralVisceralSurfaceSurface

‘‘H’H’

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

Parts of stomach and lesser omentum

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

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

Anatomical lobesAnatomical lobes

Anatomical lobesAnatomical lobes

Functional lobesFunctional lobes

Functional lobesFunctional lobes

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

Autonomic nervesAutonomic nerves• Symp : Celiac plexus• Parasymp : Ant. and

Post. Vagal trunks

Liver Liver

Celiac plexusCeliac plexus

Anterior vagal trunkAnterior vagal trunk

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

Lymphatic drainage of liverLymphatic drainage of liver

Lymphatic Lymphatic drainage of drainage of GI GI

tracttract

Topographic anatomy of abdomenTopographic anatomy of abdomen

CT scanCT scanTopographic anatomyTopographic anatomy

Gallbladder & Biliary tractsGallbladder & Biliary tracts

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

• 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

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

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

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

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)

Compression of commonCompression of common

bile ductbile duct resulted inresulted in

obstructive jaundiceobstructive jaundice

Icteric scleraIcteric sclera

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

Lymphatic drainage of GallbladderLymphatic drainage of Gallbladder• Drain to Hepatic nodes of cystic nodes

↓ Celiac nodes

Biliary tractBiliary tract

Radiograph of gallbladder Radiograph of gallbladder & biliary tracts& biliary tracts

Radiograph of gallbladder Radiograph of gallbladder & biliary tracts& biliary tracts

• 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

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

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

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

Portal-systemicPortal-systemicanastomosisanastomosis

Esophageal Esophageal

varicesvarices

Internal Internal

hemorrhoidshemorrhoids

InternalInternalhemorrhoidhemorrhoid

ExternalExternalhemorrhoidhemorrhoid

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

Caput Caput medusaemedusae

• Signs & symptomsSigns & symptoms– Esophageal varices :

Hematemesis– Internal hemorrhoids– Caput Medusae– Splenomegaly– Ascites – etc.

Portal hypertensionPortal hypertension