2. LIVER
• Largest gland of the body, consists of Both exocrine and endocrine parts.
• Liver subserves important function of regulating body temperature.
• Liver is wedge shaped, Avg 1.5 kg, 1/36th of total body wt.
• it is large in child due hemopoitic function.
• Location: right hypochondrium & epigastric region or right upper quadrant
• Surfaces:
– Diaphragmatic surface: anterior, superior & posterior direction
– Visceral surface: inferior direction. Covered by visceral peritoneum except
in the fossa for gallbladder & at the porta hepatis.
*** Factor keeping liver in position:
1. Hepatic veins
2. Intraabdominal pressure
3. Ligaments of liver
• Surgical removal of 2/3rd of the liver is the compatible of life.
• The porta hepatis consist of hepatic artery proper, portal vein, hepatic duct
3. 3
LIVER
• Ligaments:
– Falciform lig.: attach the
liver to the anterior
abdominal wall
– Round ligament of liver:
degeneration of Lt
umbilical vein
– Triangular lig.( left &
right): attach the liver to
the diaphragm
– Coronary lig.( anterior &
posterior): attach the
liver to the diaphragm
– Hepatogastric lig:
connect the liver-
stomach
– Hepatoduodenal lig:
connect the liver-
duodenum
4. Run after excellence, money & fame will run after you
• Physiological Lobes: divided into left & right lobes by the gallbladder &
inferior vena cava. Includes caudate lobe on the upper part and
quadrate lobe on the lower part of liver.
Bare area of liver: an area between the liver & diaphragm which is devoid
of peritoneum.
Importance of physiological lobe
Physiological lobes indicates separation of Arterial supply, Venous
drainage & bile drainage
Measurement
Male – 1.4 to 1.8 kg
Female – 1.2 to 1.4 kg
At birth – 150 g
Proportional weight
Adult – 1/36th of total body weight
New born – 1/18th of total body weight
5. 5
LIVER
Relation and Impression:
Superior surface
- Cardiac impression
Right lateral:
- Upper third. Lung
extends upto 8th rib
- Middle third: Pleura
extends upto 10th rib
- Lower third: Diaphragm
comes in direct contact
with 10th & 11th ribs.
• So Niddle biopsy should be Rt
9th or 10th ICS during forced
expiration.
6. LIVER
Posterior surface
1. The Bare area- Portosystemic anastomosis, Part of rt suprarenal gland
2. Groove for IVC:Its floor is pierced by hepatic vein,devoid of valves,
3. Caudate lobe: Bounded on Rt by venacaval groove, Lt by fissure for
ligamentum venosum .Only part of liver covered by Lesser sac(with process)
4. Fissure for ligamentum venosum (Fig datta2.6)
5. Groove for esophagus
7. 7
LIVER
Inferior surface: Most of surface is covered by peritonium except fissure for
ligamentum teres, porta hepatis, fossa for gall bladder.
1. Gastric impression
2. Tuber omentale
3. Fissure for ligamentum teres: remnant of obliterated lt umbilical vein.
4. Quadrate lobe: Bounded on right by fossa for gall bladder, on left by fissure
fore ligamentum teres
5. Porta hepatis: Transeverse non peritoneal fissure. Arrangements before
backwards-DAV
Structure leaves through port- Rt & lt. hepatic duct, cystic duct, lymphatics
Structure entering through port- Rt & lt. hepatic artery, rt. & lt. division of
portal vein plexus of nerves. It is not true gateway.
6. Caudate & papillary process
7. Fossa for gall bladder: Non peritoneal, extends from cystic notch to rt. End of
porta hepatis.
8. Duodenal impression:
9. Colic impression
10. Renal impression
8.
9. Q. The caudate lobe of the liver
(Residency, March -14)
a) Receives arterial supply from both right and left
hepatic arteries
b) Receives portal vein branches from the right lobe only
c) Is characteristically enlarged in Budd-chiari syndrome
d) Is seen anterior to the portal vein on computed
tomography (CT)
e) Is separated from the left lobe by the falciform
ligament
T F T F ( Posterior) F ( Ligamentum venosum)
10. *** Epiploic Foramen:
Communicates the lesser sac with the Hepatorenal
pouch of greater sac.
In front Rt free margin of lesser omentum
Behind Inferior vena cava
Roof Caudate process of liver
Floor First part of duodenum
11.
12.
13. *** Hepatorenal pouch of Morison:
In front Undersurface of Rt lobe of liver
Behind Right kidney & Rt colic flexure
Above Inferior layer of coronary ligament
Below Recess is open & Communicate with Rt
paracolic gutter .
Left side Communication with lesser sac through
epiploic foramen.
14.
15. Posterior surface Rt to Lt Inferior surface
•The bare area
•groove for IV
•Caudate lobe
•Fissure for ligamentum
venosum
•Esophageal & gastric
impression
• Renal (Right)
• Colic impression
• duodenal impression
• fossa for gall bladder,
• Quadrate lobe
• gastric impression
• Tuber omentale
• Fissure for ligamentum
teres
• Porta hepatis
• Caudate & papillary process
16. • Histological structure of liver:
Liver is composed of parenchyma
cells (hepatocytes), connective
tissue stroma, sinusoids, bile
canaculi,
portal triads and tributaries of
hepatic veins. The hepatocytes
are arranged in plates or cords
that areone cell thick and
separated by venous sinusoids.
Microscopic organization of liver
celis is grouped into three celi
clusters:
• l. Hepatic lobules
• 2. Portal lobules
• 3. Portal acinus
Microscopic organization of liver
17. • Hepatic lobule (Structural unit of liyer)/ Independent venous unit
Hexagonal areas a central vein at its centre & portal triad at the corner.
Each portal triad contains a branch of portal vein, hepatic artery & bile ductule;
all these ensheathed by Glisson's capsule Each hepatic lamina is made of about
20 hepatic cells from the periphery to the central vein.
• Portal lobule (nutritional lobule):
Functional areas of liver. These polygonal areas of liver tissue centered on a
portal triad, drawn by joining the central veins of the three adjacent hepatic
lobules. The bile from this area drains into bile ductule in the portal canal.
• Portal acinus (Metabolic unit of liver)
Diamond shaped area formed by connecting adjacent two central veins. This
can be divided into 3 zones based on the proximity of the hepatocytes to the
incoming blood. It is useful in considerations of blood flow, patterns of
ox;vgenation & pathological degeneration.
• Zone I; The inner zone around the vascular backbone and is well
oxygenated. (Gluconeogenesis, Bilt salt formation)
• Zone 2: The intermedi ate zone and is moderately oxygenated.
(Monooxygenation, Glycolysis, Glucoronidation)
• Zone 3; The outer zone close to the central vein and is least oxygenated and
most susceptible to anoxic injury.
18.
19.
20. • Space of Disse: Between the walls of the sinusoids
and the hepatic laminae of cells there exist potential
spaces known as spaces of Disse or perisinusoidal
spaces. These spaces are fitled with blood plasma
and chylomicrons which percolate through the
fenestrated walls of the sinusoids, and contain, in
addition, lto cells.
• Space of Mall/Periportal : are the potential spaces
in interlobular spaces between the Glisson's capsule
& the portal canal and the hepatic plates of cells.
The lymphatics of the liver begin in the spaces of
Mall as blind radicles.
• Individual liver cell is roughly cuboidal presenting six
surface,out of which two surface are related to the
sinusoids and the remaining surface are surrounded
by polygonal network of bile canaculi.
21. Run after excellence; money & fame will run after you
Cells Functions
Hepatocyte Metabolism(CHO,Protein,fat), Synthetic,
Secretory, Storage, Excretory, Detoxification,
Haematopoietic
Ito cell/Hepatic
stellate/
Perisinusoidal
lipocyte
Regeneration – By growth factor
Fibrosis – By FGF
Secrete the collagenous matrix including
proteoglycan
Storage – Fat soluble vitamins, B12, Folate
Kupffer cell Phagocytosis
Large granular
lymphocyte/pit
cell
They are natural killer cell protect against virus
etc.
22.
23.
24. Q. Main support of liver? (FCPS- SBA SUR ;
JULY, 16)
a) Falciform ligament
b) Inferior vena cava
c) Caudate lobe
d)
e)
25. Blood supplv of the liver:
• The liver receives-
20% of its blood supply through the hepatic artery,
and
80% through the portal vein.
• Mode of blood supply of the liver:
Hepatic artery & portal vein→ Right & left
branches→ Segmental vessels → Interlobular
vessels → Open into hepatic sinusoids → Drain into
intralobular veins → Join to form sublobular veins-
→ This in turn unite to form hepatic veins →
Directly drain into inferior vena cava.
26. Q. In the normal liver (July-09)
a) The space of Mall separates the hepatocytes from
sinusoidal endothelium
b) The hepatic artery supplies 25% of the total hepatic
oxygen supply
c) Kupffer cells are derived from blood monocytes
d) It cells store vitamin- D
e) The right and left lobes are divided into 10 vascular
segments
A N S : F T T F T
27. Biliary Apparatus
• Pathway of bile:
Hepatocytes → Bile canaliculi→ Canals of
Hering →Bile ductules →Right & left hepatic
ducts →common hepatic duct →cystic duct
→Gall bladder (stored) → common bile duct
→Unites with main pancreatic duct →Ampulla
of Vater → Opens into the second part of
duodenum in the major duodenal papilla.
28. 28
GALLBLADDER
Parts of gallbladder:
• Fundus: may project from
the inferior border of liver
• Body of gallbladder.
• Neck of gallbladder.
• Duct: cystic duct
• Hepatic duct & cystic duct
open to common bile duct
(ductus coledochus) and
drains to descending part
of duodenum.
• Measurement:
Length: 7 to l0 cm.
Maximum breadth:3 cm.
Capacity:30-50 ml.
29. 29
GALLBLADDER
• Projection to anterior
abdominal: The fundus of
gallbladder can be located at
the angle between the right
border of rectus abdominis
muscle and the lower costal
margin.
30. Calot’s Triangle
Above and laterally Under-surface of liver,
Below and laterally Cystic duct,
Medially Common Hepatic duct
Content Cystic Artery
• Identification of this triangle is an important pre-requisite for the
surgeon before putting ligature to the pedicle of the gall bladder.
31. • Sites where pain from the gall bladder can be referred.
1. Through the vagus to the stomach (epigastrium).
2. Through the sympathetic nerves to the inferior angle of the right
scapula.
3. Through the phrenic nerve to the right shoulder.
• Serous coat:
• Fibro muscular coat: Consists of smooth muscle fibers run in
various directions mixed with fibrous tissue.
• Mucous coat: The mucosa consists of lamina propria and surface
epithelium, and is devoid of glands.
• The mucous membrane numerous folds or rugae (honey-comb in
appearance).
• The surface is lined by simple columnar epithelium. The tall
columnar and pencil cells are provided with microvilli or the free
surface and increase the absorptive surface of gall bladder.
• The mucous membrane is devoid of muscularis mucosa; hence
submucous coat is absent.
32. Q. The gall bladder--(RESIDENCY MD/MS: MARCH-16)
a) Is closely related to the duodenum
b) Is supplied by a branch of the right hepatic artery
c) Is located between the costal margin and the medial
margin of the rectus abdominis muscle
d) Have a muscular layer that arranged distinctly in
different layers
e) Lies adjacent to the tip of the 10th right costal
cartilage
ANS: T T F F(Disposed irregularly) F(9th )
33. Common Bile Duct
• Supraduodenal Part(Above first part ofduodenum)
Behind - Portal vein.
Left side - Trunk of hepatic artery,
• Retro-duodenal Part (Behind first part)
In front - First part of duodenum.
Behind - Portal vein.
Left side - Gastro-duodenal artery.
• Infra-duodenal Part (Below first part)
In front- Head of pancreas.
Behind-Posterior row of vasa recta, IVC
Left side-Superior mesenteric &,Portal vein
• Intra-duodenal Part (within the second part)
Its length is about 2 cm and ampulla 5 mm. Its
course is represented by a longitudinal fold in
interior of second part of duodenum. which
extends upwards from the major papilla.
34. 34
PANCREAS
• Extends across the posterior abdominal
wall from the duodenum (on the right) to
the spleen (on the left)
• Location: posterior to the stomach,
retroperitoneal, Separated by the cavity of
lesser sac.
• It consist:
– The head :within the C-shaped of
duodenum
– The uncinate process: projection of
the lower part of the head, posterior
to the superior mesenteric artery &
vein
– The neck: anterior to the Formation
of portal vein,superior mesenteric
artery & vein.
– The body: anterior to abdominal
aorta to the front of left kidney.
– The tail ends as it passes between
layers of the splenorenal ligament &
reaches the spleen.
35.
36. PANCREAS
• Relation
• Lower border of the neck
gives attachment of root
of transverse mesocolon.
• Anterior border of the
body gives attachment of
root of transverse
mesocolon Wheres the
layers diverge.
• ** Posterior surface of
body
• Having portal system
37. Q. The head of the pancreas is related
posteriorly with the following structures (Non
Residency, July-14)
a) Duodenum
b) Anterior surface of the right renal hilum
c) Common bile duct
d) Inferior venacava
e) Splenic vein
F F T T F
38. • Structure of pancreas
• Exocrine part:
- Consists of numerous lobules separated by interlobular
septa.
- Lobule contain of numerous alveoli. Alveoli connect with
main duct Through intercalary, intralobular, interlobular
ducts.
- Alveolar cells- single layer of tall columner cells
- Junction between ducts & alveoli- cubical cells/
Centroacinar cells.
• Endocrine part:
- Numerous islet of Langerhans, Outside the alveoli, more
in tail.
- Alpha:20% Granules dense,rouded
- Beta: 68% Granules rectangular crystal
- Delta: 10%Granule pale,argylophilic, somatostatin
inhibit insulin & glucagon secretion.
- PP cell: 2% Granule dark,secrete PPH which stimulate
gastric & intestinal enzyme secretion & inhibit intestinal
motility.
- Enterochromaffin secrete serotonin.
39.
40. 40
PANCREAS
• Pancreatic ducts:
– Major pancreatic duct : begins in the tail of the pancreas. The main pancreatic
duct join the bile duct and forms the papilla of Vater, which enters the
descending part of the duodenum at the major duodenal papilla of Vater.
– Minor pancreatic duct: drains into the duodenum, above the major duodenal
papilla at the minor duodenal papilla
Head
Body
Tail
41. Q. During the development of the pancreas (Residency,
March -14)
a) It originates at 4th week of gestation as paired
evaginations of the foregut
b) The ventral bud gives rise to body and tail
c) In 50% of cases the duct system fail to fuse
d) The pancreatic buds fuse to form one pancreas at
approximately 12th week to gestation
e) The islets of langerhans make up 10% of pancreas in
fetal life
T (5th wk also) F F F (7th weeks) T (islets formed at 3
month, insulin 5 month)
42. • Haemolymph organ, belongs to
reticuloendothelial system.
• Secondary lymphoid organ, manufacture RBC
before birth & lymphocyte after birth.
• Lies mainly lt hypochondrium(lateral two third)
& Partly epigastrium (medial one third). HERRI’S
DICTUM
• Size decrease in starvation, old age, severe
exercise, severe Hemorrhage.
• Moving with respiration & not essential to life.
• Human spleen contain 1/3 of total body
platelet.
• Medial & Lateral end, Superior & inferior
border, Diaphragmatic & visceral surface.
• Ligaments:
- Gastrosplenic: Anterior layer from greater sac &
posterior layer from lesser sac . Contain short
gastric & lt gastroepiploic vessels.
- Linorenal: Contain splenic vessels & nerves,
lymphatics & tail of pancreas.
- Phrenicosplenic :
- Phrenicocolic: Extends from lt colic flexure to
diaphragm.
43. SPLEEN
• Spleen invested by outer serous coat
inner fibro elastic coat.
• Fibroelastic coat give rise to numerous
trabecular septa.
• Each compartment bounded by
trabecular septa is lobule of spleen.
Structure of splenic parenchyma
-Comprises many unit of red & white
pulp around the central arteriole.
- WHTIE PULP central arteriol
invested by lymphatic sheath.
- T cell in the center as periarteriolar
lymphatic sheath, B cell in the
middle & Dendritic antigen
presenting cells periphery.
Red pulp: 75% of splenic parenchyma.
Contain large number of venous sinusoid
Draining the tributaries of splenic vein.
- Venous sinusoid are incomplete
endothelium filled by stave cells.
Alter the size of slit maintain the
passage of blood.
- Splenic cords are sponge like, consists
of macrophage it remove senesent &
defective RBC, microorganism, cellular
debris.
44.
45. Q. By which cell spleen removed senescent
cell? (FCPS- SBA SUR ; JULY, 16)
a) Macrophage
b) Reticular cell
c) Endothelial cell
d) Steve cell
e) Neutrophil
ANS: A
46. Mode of blood supply
Splenic artery divides into 5 or more branches
↓
Enter the spleen through trabeculae, Trabecular artery
↓
Enter the parenchyma & enveloped by periarteriolar lymphatic sheath(Central artery/
white pulp artery)
↓
After leaving the white pulp they subdivide to straight penicillar arterioles
• Pulp arteries
• Sheath arteriole
• terminal arterial capillary
↓
Venous sinusoid → pulp vein
↓
Trabecular vein
↓
Splenic vein
