anatomy imaging hepato biliary liver gall bladder pancreas common bile duct

1. ANATOMY OF :
LIVER
GALL BLADDER
PANCREAS
By
Dr Himani sharma
PG I

2. LIVER

3. CHARACTERISTICS OF NORMAL LIVER
• Liver length measured in the midclavicular line range from 13 to
17 cm (15.5 cm is used most frequently).
• The mean longitudinal diameter is 10.5 cm, with standard
deviation (SD) of 1.5 cm, and the mean midclavicular
anteroposterior diameter is 8.1 cm (SD 1.9 cm)
• Echogenicity : ≥Right kidney, ≤pancreas, <spleen
• Parenchyma Homogeneous
• Surface Smooth

4. LIVER SURFACES
• Divided into 2 anatomical regions:
1.Diaphragmatic surface:
 Smooth and dome-shaped surface
 Anterior part of liver
 Inferior to diaphragm
 Separated from diaphragm by
subphrenic recess and from kidney
and suprarenal glands by
hepatorenal recess
 Covered by peritoneum except
bare area

5. 2. Visceral surface
 Covered by visceral
peritoneum except porta
hepatis and gall bladder bed.
 The visceral surface is related to:
 Right side of the stomach i.e.
gastric and pyloric areas
 Superior part of the
duodenum i.e. duodenal
area
 Lesser omentum
 Gall bladder
 Right colic flexor
 and right transverse area ;
colic area
 Right kidney and suprarenal
gland; Renal area

6. OLD LOBAR ANATOMY
• Traditional anatomic teaching divides the liver into a large
right and a small left lobe.
• They are divided anteriorly by the attachment for the
falciform ligament, and on the visceral surface by the
grooves for the ligamenta teres and venosum.
• Two further lobes are described:
a) caudate lobe posteriorly between the IVC and the fissure
for the ligamentum venosum, and the
b) quadrate lobe anteroinferiorly between the gallbladder bed
and the fissure for the ligamentum teres.
• These lobes are part of the conventional right lobe.

7. Size of caudate lobe :
sagittal plane : 45±9 mm
AP diameter : 24±6 cm

8. LOBES
• Couinaud divided the liver into
a functional left and right lobe
by a main portal scissurae
containing the middle hepatic
vein.
• This is known as CANTLIE'S
LINE.
• Cantlie's line runs from the
middle of the gallbladder fossa
anteriorly to the inferior vena
cava posteriorly.

9. COUINAUD’S SEGMENTS
• 8 segments
• Have their own blood
supply lymphatics and
billiary drainage.
• Right,middle and left
hepatic veins divide liver
longitudinally into 4
segments.
• Each of these segments is
further divided transversly
by an imaginary plane
passing thorugh right and
left main portal pedicles.
IVC
PV

11. COUINAUD TRADITIONAL
Segment I Caudate lobe
Segment II Lateral segment left lobe (superior)
Segment III Lateral segment left lobe (inferior)
Segment IV a
Segment IV b
Medial superior segment left lobe
Medial inferior segment left lobe
Segment V Anterior segment right lobe (inferior)
Segment VI Posterior segment right lobe (inferior)
Segment VII Posterior segment right lobe (superior)
Segment VIII Anterior segment right lobe (superior)

12. • Right hepatic vein divides the right lobe into anterior and
posterior segments.
• Middle hepatic vein divides the liver into right and left lobes
(or right and left hemiliver). This plane runs from the inferior
vena cava to the gallbladder fossa.
• Left hepatic vein divides the left lobe into a medial and lateral
part.
• Portal vein divides the liver into upper and lower segments.

13. Ligaments
• The liver is covered by a thin connective tissue layer called
Glisson’s capsule.
• At the porta hepatis, the main portal vein, the proper hepatic
artery, and the common bile duct are contained within
investing peritoneal folds known as the hepatoduodenal
ligament .
• The falciform ligament conducts the umbilical vein to the liver
during fetal development. After birth, the umbilical vein
atrophies, forming the ligamentum teres . As it reaches the
liver, the leaves of the falciform ligament separate. The right
layer forms the upper layer of the coronary ligament; the left
layer forms the upper layer of the left triangular ligament

14. • The most lateral portion of the coronary ligament is known as
the right triangular ligament .
• The peritoneal layers that form the coronary ligament are
widely separated, leaving an area of the liver not covered by
peritoneum. This posterosuperior region is known as the bare
area of the liver.
• The ligamentum venosum carries the obliterated ductus
venosus, which until birth shunts blood from the umbilical
vein to the IVC.

15. Anterior view
Posterior view

16. The arterial supply of the liver
• The hepatic artery
(diameter 5mm) one of the
three branches of the
coeliac trunk in the free
edge of the lesser
omentum, anterior to the
portal vein and medial to
the bile duct.
• It divides into approximately
equal-sized right and left
hepatic arteries before
entering the liver at the
porta hepatis.

17. Portal venous drainage
• The portal system supplies 80% of blood in liver.
• Diameter of portal vein is <13mm
• It normally forms posterior to the neck of the pancreas by the
union of the superior mesenteric vein (SMV) and the splenic
vein at the level of the L1/L2 disc space.
• It runs posterior to the bile duct and the hepatic artery to the
porta hepatis.
• At the porta it divides into right and left branches to supply the
right and left lobes.

18. Portal vein formation
Branches of portal vein

19. Hepatic veins
• The portal vein is 7 to 10 cm long and 0.8 to 1.4 cm in diameter
• Diameter of IVC is <28mm.
• The liver is drained by hepatic veins, which drain upwards and
backwards to the IVC without an extrahepatic course.
• The distribution of the hepatic veins right, middle and left
hepatic veins drain corresponding thirds of the liver.
• A lower group of small veins drain directly to the IVC from the
lower parts of the right and caudate lobes.
• Hepatic veins have no valves.

20. Lymphatic drainage of the liver
• Lymphatics accompany the portal vessels and ducts draining to
nodes in the porta hepatis, to hepatic nodes.
• From here lymph drains via retropyloric nodes to the coeliac
nodes and thence to the cisterna chyli.
• The anterior parts of the liver drain to the deep lymphatics.
• The posterior part drain toward the bare area of the liver.
• These lymphatics pass through the diaphragm with the IVC and
drain into posterior mediastinal lymph nodes.

21. Radiograph
• Limited role
To Demonstrate-
• hepatomegaly
• calcification

22. USG
• Initial imaging modality for suspected liver
pathology.
• Position-Supine or left decubitus
• Transducer-convex(3.5-5Mhz)
• Approach-Subcostal
Xiphisternal
Intercostal

23. RL SEP FROM LL BY INTERLOBAR
FISSURE
CAUDATE LOBE SAGG VEIW-ARROWS
FISSURE FOR LIG VENOSUM

24. Sagittal image of porta hepatis
showing CBD & main portal vein
enclosed in the hepatoduodenal
ligament
Hepatic venous anatomy. The
three hepatic veins—right (RHV),
middle (MHV), and left (LHV)

26. CT SCAN
Normal liver is homogenous and has density
higher than spleen .
• Normal liver parenchyma – 40-80 HU
• 8-10 HU greater than spleen

32. GALL BLADDER

33. Anatomy of Gallbladder
• pear-shaped sac, about 7–10 cm long and 3cm in diameter
• Diameter of wall of gall bladder is <3mm
• 30-50 ml capacity
• lying on the visceral surface of the right lobe of the liver in a
fossa between the right and quadrate lobes Divided into four
anatomic areas:
– fundus
– the corpus (body)
– the infundibulum
– the neck

34. The relations of the gallbladder
• Anterosuperiorly:
— The gallbladder bed of the liver
— The fundus is related to the anterior abdominal wall at the
point where the lateral edge of the right rectus muscle meets the
ninth costal cartilage; and
• Posteroinferiorly:
— The neck: lesser omentum
— The body: first part of the duodenum
— The fundus: transverse colon.

36. Calot’s triangle

37. • Blood supply :
– cystic artery
• usually a branch of the right hepatic artery (>90% of the
time).
• always is found within the hepatocystic triangle, the area
bound by the cystic duct, common hepatic duct, and the
liver margin (triangle of Calot).
• When the cystic artery reaches the neck of the
gallbladder, it divides into anterior and posterior divisions.

38. Benign Biliary Conditions 38

39. • Venous drainage:
– either through:
• small veins that enter directly into the liver
• large cystic vein that carries blood back to the portal vein
(rarely)
• lymphatic drainage
– nodes at the neck of the gallbladder.
– Frequently, a visible lymph node overlies the insertion of the
cystic artery into the gallbladder wall.
• Nerve supply:
– vagus nerve
– sympathetic branches that pass through the celiac plexus

40. Cystic duct
• 3-4 cm long
• Runs downwards,backwards and to the left
• Ends by joining CHD at an acute angle to
become CBD.
• Mucous membrane of the cystic duct forms a
series of crescentic folds arranged spirally-
spiral valve of Heister.

41. Bile ducts
Intrahepatic
• Normal diameter upto 3mm
each of bile duct
• fuse close to the porta
hepatis into right and left
hepatic ducts.
Extrahepatic
• right and left hepatic ducts
join to form the common
hepatic duct
• cystic duct
• common bile duct or
choledochus.
• The common bile duct enters
the second portion of the
duodenum through a muscular
structure, the sphincter of
Oddi

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43. • The common hepatic duct is joined
with the cystic duct to form the
common bile duct
• 8cm in length and
• approximately 7mm in diameter
• lies in :
• front of the portal vein
• to the right of the hepatic
artery.
common hepatic duct

44. • about 7 to 11 cm in length
• 5 to 10 mm in diameter.
• supraduodenal
• retroduodenal
• infraduodenal
• intraduodenal
• Runs obliquely downward within the
wall of the duodenum for 1 to 2 cm
before opening on a papilla of
mucous membrane (ampulla of
Vater).
Common bile duct

45. Plain Radiograph
• Plain radiograph is usually taken as part of
sequence of investigation of abdominal pain.
• It gives information about radiopaque stones,
mural calcification, mural gas and gas in biliary
tree.

46. USG
USG showing CBD
Normal GB

47. CT

48. PANCREAS

49. Anatomy of pancreas
• A gland with both exocrine and endocrine functions.
• Parts of pancreas: head, uncinate process, neck, body and tail
• 15-25 cm long.
• Size of the head of the pancreas ranged from 6 to 28 mm
(17.7±4.2mm)
• Body size from 4-23 mm
• Tail size 5-28 mm
• Weighs 60-100 g
• Location: retro-peritoneal (tail being intraperitoneal) , 2nd
lumbar vertebral level
• Extends in an oblique, transverse position
• It is iso or hyperchoic compared to hepatic parenchyma

51. Anatomic Relations
Anterior
Posterior

52. Blood supply
Arterial Supply:
• splenic artery
• pancreaticoduodenal arteries

53. Venous Drainage:
 Suprapancreatic PV
 Retropancreatic PV
 Splenic vein
 Infrapancreatic SMV
• Ultimately, drains into portal vein
• Normal diameter of splenic vein is <10mm
Innervations:
• Sympathetic fibers (from the splanchnic nerves)
• Parasympathetic fibers (from the vagus)

54. Ducts of pancreas
• The pancreatic duct
begins in the tail of
pancreas.
• Joins CBD at the Ampulla
of Vater.
• It measures approximately
1.5 mm in the tail, 2 mm
in the body and 3 mm in
the head.
• Lesser duct (Santorini)
drains superior portion of
head and empties
separately into 2nd portion
of duodenum

55. Lymphatic drainage
• Has rich networks
that drain into 5
nodal groups:
1. Superior nodes
2. Anterior nodes
3. Inferior nodes
4. Posterior PD
nodes
5. Splenic nodes

56. Plain films of the abdomen
• The pancreas is not visible unless calcified
• When the pancreas is inflamed it may cause ileus
formation in the nearby duodenum and proximal jejunum,
which is visible on plain films.

57. Superior mesentric
artery
Splenic vein
Normal Pancreatic body landmarks

58. CT

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