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Anatomy Enterohepatic
dr.Yani Istadi,M.Med.Ed

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Anatomy of Liver
3 lb. organ located inferior to the diaphragm 4 lobes -- right, left, quadrate & caudate
round ligament is remnant of umbilical vein

Liver is a large, solid, wedge shaped gland which occupies whole of right hypochondrium, the greater part of the epigastrium and part of the left hypochondrium upto the left lateral plane.

ANATOMY OF LIVER
It is the largest gland of the body and contributes about 2%

of the total body weight. Weighs 1600gm in male and 1300gm in female

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It has five surfaces:

Anterior

Posterior Superior Inferior and Right

It is divided into right and left lobe by falciform ligament

anteriorly and superiorly, by the fissure of ligamentum teres inferiorly and by the fissure for ligamentum venosum posterioly. Right lobe is much larger than the left lobe and forms five sixth of the liver , and also presents the caudate and quadrate lobe.

Porta hepatis is a deep , transverse fissure situated on the inferior

surface of the right lobe. Portal vein , the hepatic artery and the hepatic plexus of nerves enter the liver through the porta hepatis while right and left hepatic ducts and few lymphatics leave it.

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Inferior Surface of Liver

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Hepatic segments.
On the basis of intrahepatic distribution of hepatic artery, portal vein and biliary ducts, liver is divided into right and left hemilivers. Further divided into a total of eight segments. Each segments have their own hepatic artery branch and biliary tree.

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Blood supply
80% of blood supply is derived from portal vein. 20% is derived from hepatic artery. Before entering the liver both hepatic artery and portal vein

divide into right and left branches. Within the liver they redivide into segmental vessels, which further divide to form interlobular vessels which run in portal canals.

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Lymphatic drainage
Superficial lymphatics terminate in:

Caval Hepatic Paracardial and Coeliac lymph node.

Deep lymphatics terminate in:

Supra diaphragmatic and Hepatic lymph node.

Liver receives its nerve supply from hepatic plexus which contains

both sympathetic and parasympathetic or vagal plexus.

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Interactions between the liver and other organ systems

Liver: Associated Structures

The lesser omentum anchors the liver to the stomach The hepatic blood vessels enter the liver at the porta hepatis The gallbladder rests in a recess on the inferior surface of the right lobe

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Liver: Associated Structures

Bile leaves the liver via:
Bile ducts, which fuse into the common hepatic duct The common hepatic duct, which fuses with the cystic duct
These two ducts form the bile duct

PLAY

InterActive Physiology: Secretion, pages 11-12

GALLBLADDER AND EXTRAHEPATIC BILIARY SYSTEM

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The Gallbladder and Bile

Sac on underside of liver -- 10 cm long 500 to 1000 mL bile are secreted daily from liver Gallbladder stores & concentrates bile
bile backs up into gallbladder from a filled bile duct between meals, bile is concentrated by factor of 20

Yellow-green fluid containing minerals, bile acids, cholesterol, bile pigments & phospholipids
bilirubin pigment from hemoglobin breakdown
intestinal bacteria convert to urobilinogen = brown color

bile acid (salts) emulsify fats & aid in their digestion

enterohepatic circulation is recycling of bile salts from ileum

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ANATOMY
The Gallbladder:
Pear-shaped sac. 30-50 ml. Located in the fossa on the inferior surface of the liver 4 anatomic areas. Blood supply: cystic artery ( triangle of calot). Venous drainage: small veins enter directly to the liver. Lymphatic: nodes at the neck of the GB.

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The Gallbladder
Thin-walled, green muscular sac on the ventral surface of the liver Stores and concentrates bile by absorbing its water and ions Releases bile via the cystic duct which flows into the bile duct

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The Bile ducts:

The extra hepatic components. Common bile duct portions. Blood supply: gastroduodenal and R hepatic arteries.

Bile ducts
o o o o o R hepatic L hepatic Common Hepatic Cystic CBD

o L>R o CHD 1-4cm, 4mm diameter o CBD - 7-11cm, 5 - 10 mm , supra, retro and panc portion

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CBD
The common bile duct runs obliquely downward within the wall of the duodenum for 1 to 2 cm before opening on a papilla of mucous membrane ( 10 cm from pylorus ) There the pancreatic duct frequently joins it

Three main configurations

In about 70% of people these ducts unite outside the duodenal wall and traverse the duodenal wall as a single duct. In about 20%, they join within the duodenal wall and have a short or no common duct, but open through the same opening into the duodenum. In about 10%, they exit via separate openings into the duodenum

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The sphincter of Oddi, a thick coat of circular smooth muscle, surrounds the common bile duct at the ampulla of Vater

The arterial supply to the bile ducts is derived from the gastroduodenal and the right hepatic arteries, with major trunks running along the medial and lateral walls of the common duct (3 o'clock and 9 o'clock).

Anomalies of the duct

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Anomalies

contd

Small ducts (of Luschka) may drain directly from the liver into the body of the gallbladder. If present, but not recognized at the time of a cholecystectomy, a bile leak with the accumulation of bile (biloma) may occur in the abdomen

The gallbladder
Bile leaves the liver via: Bile ducts, which fuse into the common hepatic duct The common hepatic duct, which fuses with the cystic duct These two ducts form the bile duct

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Biliary duct system Biliary tree (intrahepatic): bile canaliculi --> intralobar bile ductules --> intrahepatic bile ducts in portal tracts --> left and right hepatic duct. Left and right hepatic ducts combine to common hepatic duct. The confluence of common hepatic duct and cystic duct (from gall bladder) gives rise to the common bile duct. The common bile duct merges with the pancreatic duct and forms the ampulla of Vater before entering the duodenum. Sphincter of Oddi regulates flow into duodenum.

Biliary system (cont.)

Biliary tree (intrahepatic): bile canaliculi --> terminal bile ductules --> perilobar ducts --> interlobar ducts --> septal ducts --> lobar ducts --> left and right hepatic duct

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Anatomy of the biliary tree :

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Physiology of bile :

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Enterohepatic circulation :

The gallbladder is divided into four anatomic areas :

The fundus The corpus (body) The infundibulum The neck

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contd

The peritoneal lining covering the liver covers the fundus and the inferior surface of gall bladder What is intra-hepatic gallbladder?

Intra-hepatic Gall bladder

The gallbladder has a complete peritoneal covering, and is suspended in a mesentery off the inferior surface of the liver, and rarely it is embedded deep inside the liver parenchyma

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Histology
Lined by a single, highly-folded, tall columnar epithelium that contains cholesterol and fat globules The mucus secreted into the gallbladder originates in the tubuloalveolar glands found in the mucosa lining the infundibulum and neck of the gallbladder, but are absent from the body and fundus The epithelial lining of the gallbladder is supported by a lamina propria

What is the histological difference from rest of the GI tract?

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The gallbladder differs histologically from the rest of the gastrointestinal tract in that it lacks a muscularis mucosa and submucosa.

Blood supply
Cystic artery that supplies the gallbladder is usually a branch of the right hepatic artery (>90% of the time). What is hepatocystic triangle ( calots triangle ) ?

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contd

the area bound by the cystic duct, common hepatic duct, and the liver margin When the cystic artery reaches the neck of the gallbladder, it divides into anterior and posterior divisions

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Anomalies

Veins & Lymphatics

Venous return - small veins that enter directly into the liver, or rarely to a large cystic vein that carries blood back to the portal vein. Lymphatics drain into nodes at the neck of the gallbladder. A visible lymph node overlies the insertion of the cystic artery into the gallbladder wall

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Nerves
The preganglionic sympathetic level is T8 and T9. Impulses from the liver, gallbladder, and the bile ducts pass by means of sympathetic afferent fibers through the splanchnic nerves and mediate the pain of biliary colic. The hepatic branch of the vagus nerve supplies cholinergic fibers to the gallbladder, bile ducts, and the liver

Gallbladder and Associated Ducts

Figure 23.20

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Ducts of Gallbladder, Liver & Pancreas

Congenital Anomalies Gallbladder

Abnormal position Left sided (with or without situs inversus), intrahepatic (5%), retroperitoneal, suprahepatic; also within falciform ligament, lesser sac or abdominal wall

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contd

Agenesis (absence) Cysts Diverticula Hourglass gallbladder Hypoplasia Micro gallbladder Multiseptate gallbladder Phrygian cap Inversion of distal fundus into body, may become adherent Wandering gallbladder

to which it

Pancreas

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Gross Anatomy of Pancreas

Retroperitoneal gland posterior to stomach
head, body and tail

Location
Lies deep to the greater curvature of the stomach The head is encircled by the duodenum and the tail abuts the spleen

Endocrine and exocrine gland

secretes insulin & glucagon into the blood secretes 1500 mL pancreatic juice into duodenum
water, enzymes, zymogens, and sodium bicarbonate zymogens are inactive until converted by other enzymes other pancreatic enzymes are activated by exposure to bile and ions in the intestine

Pancreatic duct runs length of gland to open at sphincter of Oddi

accessory duct opens independently on duodenum

Pancreatic Acinar Cells

Zymogens = proteases
trypsinogen chymotrypsinogen procarboxypeptidase

Other enzymes
amylase digests starch lipase digests fats ribonuclease and deoxyribonuclease digest RNA and DNA

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Activation of Zymogens

Trypsinogen converted to trypsin by intestinal epithelium Trypsin converts other 2 as well as digests dietary protein

Hormonal Control of Secretion

Cholecystokinin released from duodenum in response to arrival of acid and fat
causes contraction of gallbladder, secretion of pancreatic enzymes, relaxation of hepatopancreatic sphincter

Secretin released from duodenum in response to acidic chyme

stimulates all ducts to secrete sodium bicarbonate

Gastrin from stomach & duodenum weakly stimulates gallbladder contraction & pancreatic enzyme secretion

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Relation of the pancreas to the liver, gallbladder, and duodenum

Ducts of Gallbladder, Liver & Pancreas

Bile passes from bile canaliculi between cells to bile ductules to right & left hepatic ducts Right & left ducts join outside the liver to form common hepatic duct Cystic duct from gallbladder joins to form common bile duct Duct of pancreas and common bile duct combine to form hepatopancreatic ampulla emptying into the duodenum at the major duodenal papilla
sphincter of Oddi (hepatopancreatic sphincter) regulates release of bile & pancreatic juice

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Duodenum and Related Organs

Figure 23.20

Spleen

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Spleen
Largest reticuloendothelial organ in the body consisting of an encapsulated mass of vascular and lymphoid tissue Arising from the primitive mesoderm as an outgrowth of the left side of the dorsal mesogastrium, by the fifth week of gestation the spleen is evident in an embryo 8 mm long. Continues differentiation and migration to the left upper quadrant, where it comes to rest

contd

An average adult spleen is 9 to 11 cm in length Under the 9th 11th rib Weighs 90 150 g Has 2 notches Moves with respiration Method of palpation of spleen?

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Ligaments of the spleen

splenocolic ligament gastrosplenic ligament phrenosplenic ligament splenorenal ligament

Accessory spleen
A hilar 54% B pedicle 25% C Tail 6% D splenocolic 2 % E great omentum 12% F mesentery 0.5% G left ovary 0.5%

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Blood vessels
Splenic artery Short gastric vessels Splenic vein

Histology
Red pulp White pulp Marginal zone

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Spleen
The red pulp is comprised of large numbers of venous sinuses, which ultimately drain into tributaries of the splenic vein The red pulp serves as a dynamic filtration system, enabling macrophages to remove microorganisms Spleen contributes to the process of erythrocyte maturation Hematopoiesis in the human fetus beginning in the fourth month, which can be reactivated in childhood if marrow capacity is exceeded.

Splenic function
(1) filtration (2) host defense (3) storage (4) cytopoiesis

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contd

The spleen plays a significant though not indispensable role in host defense, contributing to both humoral and cellmediated immunity. Antigens are filtered in the white pulp and presented to immunocompetent centers within the lymphoid follicles. This gives rise to the elaboration of immunoglobulins (predominantly IgM). Following an antigen challenge, such an acute IgM response results in the release of opsonic antibodies from the white pulp of the spleen. Clearance of the antigen by the splenic and hepatic reticuloendothelial (RE) systems is then facilitated.

Contd

The spleen also produces the opsonins, tuftsin and properdin Tuftsin, a likely stimulant to general phagocytic function in the host, appears to specifically facilitate clearance of bacteria. Protein properdin is important in the initiation of the alternate pathway of complement activation.

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Kasus-kasus Klinik

Jaundice
= yellowness of skin, scleras and mucous membranes due to accumulation of free or conjugated bilirubin in the blood. Becomes clinically manifest when total plasma bilirubin is >2 mg/dl (> 34 M) = hyperbilirubinemia

Causes of hyperbilirubinemia: - excess production of bilirubin (e.g. hemolytic anemia) - decreased uptake of bilirubin into hepatic cells - disturbed intracellular protein binding and conjugation - disturbed secretion of conjugated bilirubin into bile canaliculi - intrahepatic and extrahepatic bile duct obstruction

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Jaundice

acholic

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Fatty metamorphosis (fatty change) of the liver

Liver is slightly enlarged and has a pale yellow appearance, seen both on the capsule and cut surface

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Advanced stage of fatty change of the liver

Micronodular cirrhosis
The regenerative nodules less than 3 mm in size. The process of cirrhosis develops over many years

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Cirrhotic liver

hepatic encephalopathy

McPhee et al., Pathophysiology of Disease, 4th ed. 2003, Fig. 1412

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Portal hypertension and portal-to-systemic shunting

Caput medusae: dilated abdominal veins

Esophageal varices

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Esophageal varices

Spider naevus

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Ascites

Gallstones
Cholelithiasis: gallstones in gallbladder Choledocholithiasis: gallstones in bile ducts

Most common disorder related to gallbladder: - Gallstones are present within the gallbladder of over 20 million people in USA - Most people do not know (asymptomatic; no treatment required) - Symptomatic stones: the gallbladder should be removed (persistence and recurrence of symptomes, complications)

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Causes and complications from gallstones

Endoscopic cholangiogram

E: endoscope black arrow: dilated bile duct white arrow: stone blocking bile duct

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Cholelithiasis: Ultrasound

gall bladder

cystic duct common bile duct

gall stones

Ultrasound shows single stone (arrow). Size 1.2 x 0.97 cm L = liver G = gallbladder

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Multiple stones in gallbladder

Endoscopic view of gallstone (extracted endoscopically with 'basket' device)

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Bile secretion = digestive/absorptive function of the liver

Components of bile bile salts (conjugates of bile acids) bile pigments (e.g. bilirubin) cholesterol phospholipids (lecithins) proteins electrolytes (similar to plasma, isotonic with plasma)

600-1200 ml /day

Types of gallstones

cholesterol gallstones (most common) bile pigment gallstones (unconjugated bilirubin) mixed stones

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Multiple stones in gallbladder

cholesterol gallstones

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cholesterol gallstones with cholesterolosis

cholesterolosis

pigment stones

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mixed stones (cholesterol and bile

pigments)

mixed stones (cholesterol and bile

pigments)

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Investigations

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but: intrahepatic stone can form..!

Carcinoma of the Gallbladder:

Rare, aggressive and poor prognosis. High risk : porcelain gallbladder (20%), chronic inflammation, stones > 3 cm, symptomatic gallstones, polypoid lesions , choledochal cysts, sclerosing cholangitis, anomalous pancreaticobiliary duct junction, and exposure to carcinogens (azotoluene, nitrosamines). Pathology: adenocarcinomas, squamous cell, adenosquamous, oat cell, and other anaplastic lesion. Lymphatic, venous, and direct invasion. Clinical feature: indistinguishable from cholecystitis and cholelithiasis. US, CT Treatment: Surgery remains the only curative option, however, palliative procedures for patients with unresectable cancer can be performed. 5-year survival rate of all patients with gallbladder cancer is less than 5%

TUMORS

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Bile Duct Carcinoma:

Rare tumor and about two third are located at the hepatic duct bifurcation Risk factors: primary sclerosing cholangitis, choledochal cysts, ulcerative colitis, hepatolithiasis, biliary-enteric anastomosis, and biliary tract infections with Clonorchis or in chronic typhoid carriers. 95% are adenocarcinoma Anatomical division: *intrahepatic ; treated like HCC *perihilar (Klatskin tumors) *proximal *distal

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Selamat Belajar

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