Meechai Srisai M.D. ,Ph.D. Nigun Worapunpong M.D. Department of Anatomy Faculty of Medicine

1. Liver, Gallbladder, Biliary tract and portal venous system Meechai Srisai M.D. ,Ph.D. Nigun Worapunpong M.D. Department of Anatomy Faculty of Medicine Chulalongkorn University August 2010

2. Introduction • Digestive system consists of • GI tract • Glands and accessory organs : Salivary glands, Liver ,Gall bladder, Pancreas

3. Liver • Largest organ in body 1200-1600 gm • Surface projection • จุดบนสุด : Rt. Midinguinal line / Rt. 5th rib • จุดล่างขวา : Rt. Midaxillary line / Rt. 10th costal cartilage • จุดล่างซ้าย :Lt.Midinguinal line / Lt. 5th I.C.S.

4. Surface projection of liver

5. Parasagittal section through liver Showing subphrenic recess and hepatorenal recess (Rutherford-Morison pouch)

6. Liver Surfaces of Liver • Diaphragmaticsurface • Visceral surface : structures lie like ‘H’

7. Liver Visceral surface ‘H’ • Cross-bar of H = Porta hepatis • Hepatic artery, Portal vein, Bile ducts, Nerves and Lymphatic vss. • Lt. superior of H = Ligamentum teres hepatis or round ligament of liver (Remnant of umbilical v.) • Lt. inferior of H = Ligamentum venosum (Remnant of ductus venosus) • Rt. superior of H = Gall bladder • Rt. inferior of H = Inferior vena cava

8. Visceral Surface ‘H’

9. Visceral Surface ‘H’

13. Liver Peritoneal relations • Peritoneal ligaments • Lesser omentum • Falciform ligament • Coronary ligaments • Triangular ligaments • Vascular ligaments • Round ligament of the liver • Ligamentum venosum

14. Parts of stomach and lesser omentum

16. Liver Bare areas of the liver เป็นบริเวณที่ ไม่มี peritoneum คลุม • b/t Ant. & Post. Coronary ligaments • Fossa for gall bladder • Porta hepatis • Fissure for round ligament • Fissure for ligamentumvenosum • Fossa for IVC

19. Liver Lobes of liver • Anatomical lobation • Right lobe • Left lobe • Caudate lobe • Quadrate lobe • Functional lobation • Right lobe • Left lobe • By a line passing the gallbladder and IVC

20. Anatomical lobes

21. Anatomical lobes

22. Functional lobes

23. Functional lobes

24. Liver Blood supply of liver • Rt. & Lt. hepatic arteries carry oxygenated blood (25%) • Portal vein carries venous blood (75%) rich in nutrients • Hepatic veins drain venous blood to IVC

28. Autonomic nerves Symp : Celiac plexus Parasymp: Ant. and Post. Vagal trunks Liver Anterior vagal trunk Celiac plexus

29. Liver Lymphatic drainage of liver Liver is a major lymph-producing organ (1/4 -1/2 of lymph → Thoracic duct) • Diaphragmatic surface of liverdrains to Phrenic nodes • Visceral surface and deep lymphatics along portal triadsdrains toPorta Hepatis → Hepatic nodes → Coeliac nodes → Cisterna chyli → Thoracic duct

30. Lymphatic drainage of liver

31. Lymphatic drainage of GI tract

32. Topographic anatomy of abdomen Topographic anatomy CT scan

33. Gallbladder & Biliary tracts

34. Gallbladder & Biliary tracts Biliary system consists of • Gall bladder • Biliary tracts Cystic duct, hepatic ducts, common hepatic duct and common bile duct

35. Gallbladder • Length 6-10 mm. • Capacity ~ 45 cm3 • b/t Rt. lobe & Quadrate lobe of liver • Surface projection Fundus of gallbladder = Murphy’s point

36. Gallbladder Spiral valve Neck Body Gallbladder has 4 portions • Fundus • Body • Neck  Infundibulum : Hartmann’s pouch Internal surface : folds, spiral folds and crypts of Luschka Hartmann’s pouch Crypts of Luschka Fundus

37. Gallbladder Gallbladder Blood supply of gallbladder • Cystic arteryfrom Right Hepatic artery (in Calot’s triangle → Cholecystectomy) • Cystic vein: tributary of Portal vein Cystic artery Calot’s triangle

38. Biliary tract • Cystic duct : ~3 cm : spiral valve of Heisteri • Common hepatic duct : ~3-5 cm : from Rt. & Lt. hepatic ducts • Common bile duct : ~ 7.5 cm 1+2 → 3

39. Biliary tract Common bile duct has 4 parts • Supraduodenal • Retroduodenal • Infraduodenal • Intraduodenal • Common bile duct + Major pancreatic duct • ▼ • Hepatopancreatic ampulla (Ampulla of Vater) • Opening is Greater duodenal papilla in 2nd • part of duodenum (surrounded by Sphincter of Oddi)

41. Icteric sclera Compression of common bile ductresulted in obstructive jaundice

42. Biliary tract Anterior vagal trunk Nerves of Gallbladder • Symp : Celiac plexus • Parasymp : Ant. and Post. vagal trunks Celiac plexus

43. Biliary tract Lymphatic drainage of Gallbladder • Drain to Hepatic nodes of cystic nodes ↓ Celiac nodes

44. Radiograph of gallbladder & biliary tracts

45. Radiograph of gallbladder & biliary tracts

46. Portal venous system • A system of venous blood vessels from GI tract to the liver • Formation : • Superior mesenteric vein + Splenic vein (behind neck of pancreas)

47. Portal venous system Tributaries • Cystic vein • Paraumbilical vein • Right gastric vein • Left gastric vein • Splenic vein • Superior mesenteric vein

48. Portal venous system Portal hypertension • The portal vein provides about 75% of the liver's blood flow and about 60% of its O2supply • 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

49. Portal venous system Portal-CavalAnastomosis Anastomosisamong portal vein and systemic vein(Inferior vena cava) • Left gastric v.→ Esophageal v.→ Azygos v. → SVC : ‘Esophageal varices’ • Splenic v. → Sup. rectal v. → Rectal venous plexuses → middle & Inf. Rectal v. → → → IVC : Dilated rectal venous plexuses = Internal hemorrhoids

50. Portal-systemic anastomosis