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Karaciğer, safra, pankreas histoloji ve anatomisi

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  • 1. Liver, Pancreas, and Gallbladder Anatomy-Histology Correlate By: Michael Lu, Class of ‘07
  • 2. -The liver and gallbladder play important roles indigestion via the production and storage of bile. Theliver is also the major organ for metabolism anddetoxification. The pancreas also produces digestiveenzymes to break down proteins, sugars, and fats.- The processes described above are the exocrinefunctions of the liver and gallbladder. But they alsohave endocrine roles, secreting compounds into thebloodstream. The hepatocytes produce albumin,fibrinogen, and thrombin, for example. The pancreaticislets produce insulin, glucagon, and somatostatin.- The liver, gallbladder, and pancreas receive bloodsupply from the celiac trunk. One main branch is thecommon hepatic artery, leading to the hepatic arteryproper that branches into left and right hepaticarteries to supply the liver. The right hepatic arterygives off the cystic artery to supply the gallbladder.- The pancreas is supplied by multiple vessels. Thebody and tail are supplied by the dorsal, inferior, andgreat pancreatic arteries, which all branch off thesplenic artery (another main branch of the celiactrunk). The head, neck, and uncinate process aresupplied by anastomoses of arteries branching off theceliac trunk and superior mesenteric artery. Thegastroduodenal artery, from the common hepaticartery, divides into the anterior and posteriorsuperior pancreaticoduodenal arteries. Theyanastomose with inferior branches of the inferiorpancreatico-duodenal artery from the superiormesenteric artery. The same arteries supply the
  • 3. -The liver has diaphragmatic and visceral surfaces which contact the diaphragm and abdominal viscera,respectively. Note the right triangular, left triangular, and coronary ligaments that attach to the diaphragm.Note also the bare area not covered by peritoneum. Anteriorly, there is a fold of peritoneum connecting the liverto the umbilicus called the falciform ligament, which contains the round ligament or ligamentum teres. It isthe remnant of the umbilical vein that brought oxygenated blood from the placenta to the fetus heart. Theligamentum venosum is the remnant of the fetal ductus venosus that shunted blood from the umbilical vein tothe inferior vena cava to bypass the liver. In the adult liver, the porta hepatis includes the hepatic arteries fromthe hepatic artery proper, the hepatic portal vein, and the hepatic and cystic ducts joining to form thecommon bile duct.- The portal vein brings nutrients and other compounds absorbed by the GI tract to be stored and/or processed.- Anatomical lobes: Note how the inferior vena cava, gallbladder, ligamentum teres, ligamentum venosum, andporta hepatis form an “H” shape on the visceral surface. It divides the liver into 4 anatomical lobes based on outerappearance – the right, left, caudate, and quadrate lobes.- Functional lobes: These are based on the distribution of the hepatic arteries, portal vein, and hepatic bile duct.
  • 4. - The liver is divided into many hepatic lobules. Inflow to the liverinvolves hepatic arteries, which bring oxygenated blood to hepatictissue, and portal veins, which bring nutrients and othercompounds absorbed by the GI tract to be processed and/orstored in the liver. Outflow also involves two routes – hepatic veinswhich drain into the inferior vena cava and the common hepaticduct which joins the cystic duct and empties bile into theduodenum.- Major characteristics of the liver are portal triads (labeled“portal” in bottom left and shown in the middle) and central veins(labeled in bottom left and shown in the right). Red arrows indicatedirection of blood flow within blood sinusoids flanking cords ofliver cells.- Note the portal triad contains 1) the portal vein, 2) the hepaticartery, and 3) the bile duct. Each has its typical appearance. Thecentral vein is lined with endothelial cells, with perforations intowhich the sinusoids empty.
  • 5. - The central veins lead to sublobular veins, which reach collecting veins,hepatic veins, and finally the inferior vena cava. The venous outflow ofthe liver has no regard to the organization of the lobules.- The liver sinusoids are shown in higher magnification in the bottom left.They are dilated, capillary-like vessels lined by fenestrated, discontinuousepithelium (labeled “e”). Interspersed among the endothelial cells areKupffer cells (labeled “k”), which are fixed macrophages within thehepatic tissue. They have distinct cytoplasm that may enter the sinusoidallumen and function like other macrophages within the body. They alsobreak down damaged red blood cell hemoglobin.- In the bottom middle panel, there are many spaces between thehepatocytes and sinusoidal epithelial cells marked by arrowheads. Theyare referred to the space of Disse where exchange between hepatocytesand blood flow takes place.- Once again, in the bottom right, we review the Kupffer cell, endothelialcell of the liver sinusoid, and the space of Disse.
  • 6. - The liver lobules can be defined in 3 ways: - 1) Classic lobule – centered around the central vein with the portal triads at each corner. Shown below on the left, the classic lobule may not always be hexagonal in shape. - 2) Portal lobule (not shown) – centered on the portal triad, based on bile secretion, and approximately triangular in shape. - 3) Liver acinus of Rappaport – this is the most functionally important classification. Shown below on the right, the acinus is roughly oval in shape with 2 central veins and 2 portal triads on opposite ends. Based on the blood flow within hepatic tissue, the acinus is divided into 3 zones. Cells in different zones are specialized for different activity. Zone 1 cells, being closest to the portal triads and hence most oxygenated blood, have the most drug- metabolizing enzymatic activity. Following that same reasoning, zone 3 hepatocytes near the central veins are most susceptible to ischemia.- As mentioned earlier, the liverhas both endocrine andexocrine functions. The variousproteins that hepatocytessecrete enter the bloodstreamvia the liver sinusoids. The liveralso secretes bile in theconventional exocrine fashion.- The hepatocytes secrete bileinto sealed extracellular spacescalled bile canaliculi. Thetypical “chicken-wire”appearance is more easilyvisualized with silver stain.
  • 7. - Once again, inflow to the liver involvesoxygenated blood via hepatic arteries andabsorbed nutrients and compounds fromthe GI tract via the hepatic portal veins.- All venous drainage from the GI tract andabdominal visceral organs enters the portalsystem back to the liver. The overall orderis as following: arteries → capillaries →veins → portal vein → hepatic sinusoids →veins → vena cava → heart.- In contrast, the caval system is asfollowing: arteries → capillaries → veins →vena cava → heart. Obviously, this is thecirculatory system within the rest of thebody.- The portal and caval system are notexclusive from each other. There are 4 sitesof portocaval anastomoses: - 1) esophageal veins - 2) paraumbilical veins - 3) rectal veins - 4) retroperitoneal veins- If there is liver damage or cirrhosis –accumulation of fibrous tissue thatconstricts the sinusoids – there may beportal hypertension. This may lead tovaricose veins at the 4 sites of
  • 8. - The gallbladder is found under the right lobe of the liver. Itsfunction is to store bile produced by the liver, which leaves via thecystic duct. It also enters the gallbladder in the cystic duct,traveling retrograde when the bile is not needed for digestion. Notethe fundus, body, neck, and infundibulum of the gallbladder.- Note the right and left hepatic ducts coming together as thecommon hepatic duct, joining the cystic duct to form thecommon bile duct. This descends to the 2nd part of theduodenum, is joined by the pancreatic duct, and empties itscontents into the duodenal lumen via the major duodenal papilla.- The gallbladder is supplied by the cystic artery, which isextremely important to find during a cholecystectomy. In mostpeople it branches off the right hepatic artery, but could also comeoff the left hepatic, proper hepatic, or gastroduodenal arteries.- Note the extensive folds of mucosa extending into the lumen,consisting of tall, simple columnar epithelium. The underlyingconnective tissue is comprised of lamina propria, with no distinctlydefined submucosa. There are scattered bundles of smoothmuscle in the muscularis. The adventitia has rather denseconnective tissue connecting the gallbladder to the liver.
  • 9. - Finally, we will look at the pancreas. Toreview: The head of the pancreas andduodenum are supplied from both the celiactrunk and the superior mesenteric artery.- The body and tail of the pancreas aremostly supplied by branches of the splenicartery, namely the dorsal, greater, andinferior pancreatic arteries.- Piece of advice: It can be very confusingwhen identifying these arteries. First orientyourself, note whether the duodenum is inanatomical position or reflected (as it is onthe bottom left), and identify where thearteries branch from and where they lead.
  • 10. - The pancreas contains multiple ducts, but the main pancreaticduct runs from the tail to the head of the pancreas. There may bea smaller accessory pancreatic duct. They join the common bileduct to empty into the duodenum. The pancreas is retroperitoneal.- Histologically, we can see the septa (S) between pancreaticlobules with interlobular ducts (D). As mentioned above, thepancreas also has both exocrine and endocrine functions. Most ofthe bottom left panel is filled with exocrine pancreatic tissue.Secretory portions are called acini. The scattered endocrine isletsof Langerhans (I) are paler staining.- An islet is magnified in the bottom right. It is a compact mass ofepithelial cells that receive rich vascular supply (arrows). It istypically very difficult to identify the different cell types in the islets.Briefly, the alpha cells secrete glucagon, the beta cells secreteinsulin, and the delta cells secrete somatostatin.
  • 11. -Once again, most of the pancreas contains exocrine acini. Pancreatic enzymes are very diverse, includingextremely efficient proteases, lipases, and amylases.- Separate acini are shown in the left. The pancreatic acinar or secretory cells are polarized, meaning the basalportions are filled with basophilic rough ER. The apical regions are filled with zymogen granules that containmany stored pro-enzymes.- Centroacinar cells, with paler staining, can be seen in the middle of some acini and mark the beginning of theduct system (marked “A” in the middle panel). They converge at “B” to form intercalated ducts, marked as “C”.The intercalated duct cells may be hard to identify, but they actively pump water and bicarbonate into the ductlumen. Intercalated ducts empty into interlobular ducts, marked as “small duct” in the bottom right, which lead tothe main pancreatic duct.