Liver, Pancreas, Spleen and Gall bladder anatomy

Peer support 2014Alastair Stephens

Jess Gilbert

Liver

Describe the surface anatomy of the liver.

• Lower border follows the right costal margin– not normally palpable

• Superior border follows upper limit of diaphragm– 5th rib between the MCLs

Porta Hepatis Entry/exit point for portal vein, bile duct, hepatic artery & autonomics

Ligamentum venosum

Inferior vena cava (IVC)

Gall bladderLigamentum teres

within falciform ligament

Right triangular ligament

Coronary ligament

Left triangularligament

Bare AreaLabel the liver.

Name the 4 anatomical lobes of the liver

• Left • Right• Caudate • Quadrate

Right

Left

Cau

date

Qu

adrate

How many functionally independent segments is the liver divided into?

• 8

What are the benefits of these divisions?

• Each segment is served by a hepatobiliary division so can function independently.

What is the blood supply to the liver from? (What percentage do they contribute?)

2 sources:• Portal vein (70%)

– What forms it?– Splenic vein and the superior mesenteric vein

• Hepatic artery (30%)– Where does it originate from?– Coeliac trunk

Portal vein

Splenic vein

Sup. Mesenteric v.Inf. Mesenteric v.variable position

Hepatic

R. hepatic Left hepatic

Coeliac Trunk

Cystic

Jonny, a chronic alcoholic, has an endoscopy that reveals oesophageal varices in the lower oesophagus. Name the anatomical location

that varices usually occur, and why?

• Ano-rectal varices• Peri-umbilical varices (caput medusae)

Where else can varices be located?

• Where the portal and systemic veins join (porto-systemic anastomoses).

• Increased portal venous pressure can cause congestion in the anastamoses leading to dilatation = varices.

What is the peritoneum between the stomach and the liver called?

• Lesser omentum

In liver surgery, why is this clinically relevant?

• The Pringle manoeuvre can be performed– The free edge can be pinched, which contains the

common bile duct, hepatic artery and portal vein. This will cut off the blood supply to the liver.

Pancreas

Within which region does the pancreas sit?

• Epigastric and extends into the left hypochondrium

Which sphincter guards the entrance of the duct into the duodenum?

Via what do pancreatic secretions drain into the second part of the duodenum?

• Major duodenal papilla

• Hepato-pancreatic sphincter (Sphincter of Oddi)

What is the blood supply to the pancreas?

Superior pancreaticoduodenal artery

Inferior pancreaticoduodenal artery

Splenic artery

Where could fluid collect in pancreatitis?

• Lesser sac

Why might pancreatic cancer cause jaundice?

• Blocked bile duct

Spleen

Describe the surface anatomy of the spleen.

• Left posterolateral abdominal wall• Related to ribs 9-11

What is the arterial supply to the spleen?

What is the venous drainage from the spleen?

• Splenic vein to the portal vein

• Splenic artery from the coeliac trunk

Paul has potential splenomegaly, how would you examine his

spleen?

• Start in right iliac fossa and palpate up and across towards left hypochondrium

Gall Bladder

Where can the fundus of the gall bladder normally be palpated?

• Puncture of the gall bladder can cause a biliary peritonitis.

Why could inserting a needle at this level to access the liver be potentially

fatal?

• 9th costal cartilage (L1)

Sarah presents to your GP surgery complaining of pain in her right shoulder. She elicits a

positive Murphy’s sign. What is Murphy’s sign?• Place your hand in the right hypochondrium and ask the

patient to inspire. The diaphragm and so the liver will descend and if the gall bladder is tender, it will graze your hand causing the patient to flinch. This is a positive Murphy’s sign and indicates gall bladder pathology.

What is a likely cause of her right shoulder pain? Why?

• This is an example of referred pain. The diaphragm is irritated by the gall bladder, which is innervated by the phrenic nerve (C3-5). The skin covering the shoulder is also innervated by C3-4.

Thank you!

Any questions?