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7/29/2019 Microsoft PowerPoint - Anatomy Enterohepatic..pdf
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dr.Yani Istadi,M.Med.Ed
Anatomy Enterohepatic
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Anatomy of Liver
3 lb. organ located inferior to the diaphragm
4 lobes -- right, left, quadrate & caudate
round ligament is remnant of umbilical vein
Liver is a large, solid, wedge shaped gland which occupies whole
of right hypochondrium, the greater part of the epigastrium and part
of the left hypochondrium upto the left lateral plane.
ANATOMY OF LIVER
It is the largest gland of the body and contributes about 2%
of the total body weight.
Weighs 1600gm in male and 1300gm in female
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It has five surfaces:
Anterior
Posterior
Superior
Inferior and
Right
It is divided into right and left lobe by falciform ligament
anteriorly and superiorly, by the fissure of ligamentum teres
inferiorly and by the fissure for ligamentum venosum posterioly.
Right lobe is much larger than the left lobe and forms five sixth of
the liver , and also presents the caudate and quadrate lobe.
Porta hepatis is a deep , transverse fissure situated on the inferior
surface of the right lobe.
Portal vein , the hepatic artery and the hepatic plexus of nerves enter
the liver through the porta hepatis while right and left hepatic ducts
and few lymphatics leave it.
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Inferior Surface of Liver
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Hepatic segments.
On the basis of intrahepatic distribution of hepatic
artery, portal vein and biliary ducts, liver is divided
into right and left hemilivers.
Further divided into a total of eight segments.
Each segments have their own hepatic artery branch
and biliary tree.
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Blood supply
80% of blood supply is derived from portal vein.
20% is derived from hepatic artery.
Before entering the liver both hepatic artery and portal vein
divide into right and left branches.
Within the liver they redivide into segmental vessels, which
further divide to form interlobular vessels which run in
portal canals.
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Lymphatic drainage
Superficial lymphatics terminate in:CavalHepaticParacardial andCoeliac lymph node.
Deep lymphatics terminate in:Supra diaphragmatic and
Hepatic lymph node.
Liver receives its nerve supply from hepatic plexus which containsboth sympathetic and parasympathetic or vagal plexus.
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The Gallbladder and Bile
Sac on underside of liver -- 10 cm long
500 to 1000 mL bile are secreted daily from liver
Gallbladder stores & concentrates bile
bile backs up into gallbladder from a filled bile duct
between meals, bile is concentrated by factor of 20
Yellow-green fluid containing minerals, bile acids, cholesterol, bilepigments & phospholipids
bilirubin pigment from hemoglobin breakdown
intestinal bacteria convert to urobilinogen = brown color
bile acid (salts) emulsify fats & aid in their digestion
enterohepatic circulation is recycling of bile salts from ileum
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The sphincter of Oddi, a thick coat of circular smooth muscle,
surrounds the common bile duct at the ampulla of Vater
The arterial supply to the bileducts is derived from thegastroduodenal and the righthepatic arteries, with majortrunks running along themedial and lateral walls of thecommon duct (3 o'clock and 9
o'clock).
Anomalies of the duct
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Anomalies contd
Small ducts (of Luschka) may drain directly from the liver
into the body of the gallbladder. If present, but not
recognized at the time of a cholecystectomy, a bile leak with
the accumulation of bile (biloma) may occur in the abdomen
The gallbladder
Bile leaves the liver via:
Bile ducts, which fuse into the
common hepatic duct
The common hepatic duct,
which fuses with the cysticduct
These two ducts form the bile
duct
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Biliary duct system
Biliary tree (intrahepatic): bile canaliculi --> intralobar bile
ductules --> intrahepatic bile ducts in portal tracts --> left
and right hepatic duct.
Left and right hepatic ducts combine to common hepatic
duct. The confluence of common hepatic duct and cystic
duct (from gall bladder) gives rise to the common bile
duct.
The common bile duct merges with the pancreatic duct
and forms the ampulla of Vater before entering the
duodenum.
Sphincter of Oddi regulates flow into duodenum.
Biliary system (cont.)
Biliary tree (intrahepatic):
bile canaliculi --> terminal bile ductules --> perilobar ducts --> interlobar ducts
--> septal ducts --> lobar ducts --> left and right hepatic duct
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contd
The peritoneal lining covering the liver covers the fundus and the
inferior surface of gall bladder
What is intra-hepatic gallbladder?
Intra-hepatic Gall bladder
The gallbladder has a complete peritoneal covering, and is
suspended in a mesentery off the inferior surface of the liver,
and rarely it is embedded deep inside the liver parenchyma
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Histology
Lined by a single, highly-folded, tall columnar epitheliumthat contains cholesterol and fat globules
The mucus secreted into the gallbladder originates in thetubuloalveolar glands found in the mucosa lining theinfundibulum and neck of the gallbladder, but are absentfrom the body and fundus
The epithelial lining of the gallbladder is supported by alamina propria
What is the histological difference from rest of the GI tract?
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The gallbladder differs histologically from the rest of the
gastrointestinal tract in that it lacks a muscularis mucosa and
submucosa.
Blood supply
Cystic artery that supplies the gallbladder is usually a branch
of the right hepatic artery (>90% of the time).
What is hepatocystic triangle ( calots triangle ) ?
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contd the area bound by the cystic duct, common hepatic duct,
and the liver margin
When the cystic artery reaches the neck of the
gallbladder, it divides into anterior and posterior
divisions
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Anomalies
Veins & Lymphatics
Venous return - small veins that enter directly into the liver,
or rarely to a large cystic vein that carries blood back to the
portal vein.
Lymphatics drain into nodes at the neck of the gallbladder. A
visible lymph node overlies the insertion of the cystic artery
into the gallbladder wall
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Nerves The preganglionic sympathetic level is T8 and T9. Impulses
from the liver, gallbladder, and the bile ducts pass by meansof sympathetic afferent fibers through the splanchnic nervesand mediate the pain of biliary colic.
The hepatic branch of the vagus nerve supplies cholinergicfibers to the gallbladder, bile ducts, and the liver
Gallbladder and Associated Ducts
Figure 23.20
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Gross Anatomy of Pancreas
Retroperitoneal gland posterior to stomach
head, body and tail
Location
Lies deep to the greater curvature of the stomach
The head is encircled by the duodenum and the tail abuts the spleen
Endocrine and exocrine gland
secretes insulin & glucagon into the blood
secretes 1500 mL pancreatic juice into duodenum water, enzymes, zymogens, and sodium bicarbonate
zymogens are inactive until converted by other enzymes
other pancreatic enzymes are activated by exposure to bile and ions in theintestine
Pancreatic duct runs length of gland to open at sphincter of Oddi
accessory duct opens independently on duodenum
Pancreatic
Acinar Cells Zymogens = proteases
trypsinogen
chymotrypsinogen
procarboxypeptidase
Other enzymes
amylase digests starch
lipase digests fats
ribonuclease and
deoxyribonuclease digest
RNA and DNA
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contd
The spleen plays a significant though not indispensable rolein host defense, contributing to both humoral and cell-mediated immunity.
Antigens are filtered in the white pulp and presented toimmunocompetent centers within the lymphoid follicles.
This gives rise to the elaboration ofimmunoglobulins(predominantly IgM).
Following an antigen challenge, such an acute IgM responseresults in the release of opsonic antibodies from the white
pulp of the spleen. Clearance of the antigen by the splenicand hepatic reticuloendothelial (RE) systems is thenfacilitated.
Contd
The spleen also produces the opsonins, tuftsin and properdin
Tuftsin, a likely stimulant to general phagocytic function in the
host, appears to specifically facilitate clearance of bacteria.
Protein properdin is important in the initiation of the alternate
pathway of complement activation.
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Jaundice
acholic
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Fatty metamorphosis (fatty change) of the liver
Liver is slightly enlarged and has a pale yellow
appearance, seen both on the capsule and cut surface
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Ultrasound shows single stone (arrow). Size 1.2 x 0.97 cm
L = liver G = gallbladder
Cholelithiasis: Ultrasound
cystic
duct
common
bile duct
gall
bladder
gall stones
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Multiple stones in gallbladder
Endoscopic view of gallstone
(extracted endoscopically with 'basket' device)
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Bile secretion = digestive/absorptive function of the liver
Components of bile
bile salts (conjugates of bile acids)
bile pigments (e.g. bilirubin)
cholesterol
phospholipids (lecithins)
proteins
electrolytes (similar to plasma, isotonic with plasma)
600-1200 ml /day
Types of gallstones
cholesterol gallstones (most common)
bile pigment gallstones (unconjugated bilirubin)
mixed stones
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mixed stones (cholesterol and bilepigments)
mixed stones (cholesterol and bilepigments)
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Bile Duct Carcinoma:
Rare tumor and about two third are located at the hepatic duct bifurcation
Risk factors: primary sclerosing cholangitis, choledochal cysts, ulcerative
colitis, hepatolithiasis, biliary-enteric anastomosis, and biliary tract infections
with Clonorchis or in chronic typhoid carriers.
95% are adenocarcinoma
Anatomical division:*intrahepatic ; treated like HCC
*perihilar (Klatskin tumors)
*proximal
*distal
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