1. CBL- LIVER &HEPATOBILIARY
APPARATUS
BY DR. ABDUL WAHEED ANSARI
CHAIRPERSON & PROF. ANATOMY
RAK COLLEGE OF MEDICAL SCIENCES
RAK MEDICAL & HEALTH SCIENCES UNIVERSITY
U.A.E.
Thursday, December 18, 2014
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2. Learning outcomes for the CBL-Hepatobiliary apparatus
• Describe the gross anatomical features of Liver & Gall bladder.
• Their blood supply and relations to surrounding structures,
nerve supply and lymphatic drainage.
• Histological features of liver and gall bladder.
• Anatomical explanation for cholelethiasis and portal
hypertension.
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3. A clinical case of cirrhosis of liver and hepatic
encephalopathy
Mr. N.N. 56 yrs. old male with 1 month H/0 of abdominal distention, confusion, inability to concentrate and
dyspnea.
Social History: Excessive alcohol use for approx. 20 yrs.
On Examination:B.P= 130/70 Pulse 80, Apyrexial, Jaundice, Clubbing,Foetor hepaticus present.
No circulatory changes - palmer erythema, spider, telangiectasia, cyanosis.
No endocrine changes - gynecomastia, testicular atrophy.
No bleeding tendency- bruises, purpura, epistaxis.
Abdomen: Abdominal distention, marked ascites present, unable to detect visceromegaly.
Neuro: Apathetic, confused, disorientated, drowsy, slurred speech. Flapping tremor present.
Diagnosed as alcohol- induced liver cirrhosis
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4. The liver is located in the upper part of the
abdominal cavity just beneath the diaphragm
• The greater part of the liver is situated
under cover of the right costal margin
and also extends to the left to reach
the left hemi-diaphragm.
• The diaphragm separates liver from
pleura, lungs, pericardium and heart.
• Thus it occupies most of the right
hypochondrium and epigastrium and
also a small portion extends into the
left hypochondrium.
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5. Superior surface is the largest surface, convex in shape and is
molded to the undersurface of the domes of the diaphragm.
• This surface is covered by peritoneum except for a small
triangular area between the two diverging layers of falciform
ligament.
• The majority of the superior surface lies beneath the right dome
(related to the right diaphragmatic pleura and base of the right
lung).
• Centrally there is a shallow cardiac impression corresponding to
the position of the heart above the central tendon of the
diaphragm and is related to the pericardium.
• The left side of the superior surface lies beneath part of the left
dome of the diaphragm and is related to part of the left
diaphragmatic pleura and base of the left lung.
Anterior surface
• Triangular and convex in shape, the anterior surface is covered
by peritoneum except at the attachment of the falciform ligament.
• Much of it is in contact with the anterior attachment of the
diaphragm.
• Separated by the diaphragm, the anterior surface is related on
the right with the pleura and 6th to 10th ribs and their cartilages
and with 7th and 8th costal cartilages on the left.
• The midline area of the anterior surface lies behind the xiphoid
process and the anterior abdominal wall in the infracostal angle.
Posterior surface
• The posterior surface is convex, wide on the right,
but narrow on the left.
• Much of the posterior surface is attached to the
diaphragm by loose connective tissue in the region
of the 'bare area'.
The inferior surface of the left lobe of liver presents
gastric impression which is related inferiorly with the
fundus of stomach and upper lesser omentum.
Fissure for ligamentum teres lodges the ligamentum
teres.
Quadrate lobe is related to pylorus, first part of
duodenum and lower part of lesser omentum.
Fossa for gallbladder lodges the gallbladder.
To the right of the fossa for the gall bladder, inferior
surface of liver is related with the first part of
duodenum, the hepatic flexure of colon, the right
kidney and right suprarenal gland. 5
6. The porta hepatis is hilum of the liver present in the
inferior surface
It provides a passageway to the neurovascular and
biliary structures, except the hepatic veins.
It is anteriorly bounded by the quadrate lobe and
the caudate process posteriorly.
The portal vein, hepatic artery and hepatic nervous
plexus ascend into the parenchyma of the liver.
The right and left hepatic bile ducts and some
lymph vessels emerge from it.
At the porta hepatis, the hepatic ducts, the hepatic
artery with its branches and the portal vein are
arranged in that order from before backwards.
The margin of porta gives attachment to the lesser
omentum.
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7. Ligaments of liver
• falciform ligament
• ligamentum teres of liver
• coronary ligament
• right triangular ligament
• left triangular ligament
• ligamentum venosum
• Lesser omentum-gastrohepatic
ligament
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8. A case of chronic cholecystitis and cholelethiasis
• A 46-year-old woman presents to the ER
in acute distress with symptoms of
severe pain in the right upper abdominal
region.
• In the past, she had repeated attacks of
severe pain in the right upper quadrant,
frequently following a heavy meal.
• These attacks were accompanied by
nausea and vomiting.
• She suffers from indigestion, particularly
after eating fatty foods.
• Preliminary Diagnosis: Biliary colic and
chronic calculus cholecystitis
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Ultrasound image of gall bladder showed
gall stones
9. Foramen of Winslow/Epiploic foramen-is a passage
between greater sac and lesser sac of peritoneal cavity
• Boundaries of foramen of
Winslow/Epiploic foramen
• Superiorly it is formed by Caudate
lobe of liver.
• Inferiorly it is formed by first part of
duodenum.
• Anteriorly the lesser omentum having
hepatic artery, bile duct and portal
vein.
• Posteriorly the inferior vena cava.
• http://www.youtube.com/watch
?v=So9czudJk1A
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11. The extra hepatic biliary apparatus
• Bile secretions are produced by hepatocytes
and drained by right and left hepatic ducts.
• The common hepatic duct arises by joining
the two hepatic ducts.
• A gall bladder joins the common hepatic
duct by cystic duct.
• A common bile duct is joined by main
pancreatic duct coming from pancreas and
opens in to 2nd part of duodenum by major
duodenal papilla.
• The bile coming from hepatic duct is ten
times less concentrated when compared
with the bile coming from gall bladder.
• There is a sphincter of Oddi at the major
duodenal papilla.
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13. The portal triad is a unit where there are portal vein,
hepatic artery and bile duct embedded in connective
tissue at the corner of a classical hepatic lobule
• The lobule is the structural unit of the
liver and rather easy to observe.
• In contrast, the hepatic acinus is more
difficult to visualize, but represents a
unit that is of more relevance to
hepatic function because it is
oriented around the afferent vascular
system.
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14. Histology of gall bladder
• The lumen of the gallbladder is lined with a
high columnar epithelium.
• The connective tissue wall contains abundant
elastic fibers and layers of smooth muscle
which predominantly run obliquely.
• These epithelial cells are devoted to
absorption of inorganic salts and water, and
provide the mechanism for the gallbladder's
ability to concentrate bile.
• Over concentration leads to formation of bile
stones.
• The bile coming from liver is very much
diluted, where as bile in the gall bladder is
10X concentrated.
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15. Portal vein formation
• The superior mesenteric vein joins
the splenic vein to form the portal
vein, which carries the blood rich in
nutrients absorbed from intestines for
metabolism.
• The portal vein lies posterior to the
hepatic artery and bile duct in the
lesser omentum.
• The branches of portal vein enters the
liver and distributed
• Portal hypertension is a
manifestation when there is an
obstruction of blood flow in the
portal venous system, like in cirrhosis
of liver.
• It manifests in the form of ascites,
hemorrhoids, spider nevei, icterus
and caput medussae and
encephalopathy.
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