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The Liver, Gallbladder and Biliary Tree

The Liver, Gallbladder and Biliary Tree. Tristan Boam. Summary. Anatomy Surface Anatomy Epiploic Foramen Liver Liver Pathologies Jaundice Gall Bladder Gall Stones Gall Bladder Pathologies. Liver - Anatomy. Anterior – 2 lobes: Left and Right Separated by Falciform Ligament.

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The Liver, Gallbladder and Biliary Tree

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  1. The Liver, Gallbladder and Biliary Tree Tristan Boam

  2. Summary • Anatomy • Surface Anatomy • Epiploic Foramen • Liver • Liver Pathologies • Jaundice • Gall Bladder • Gall Stones • Gall Bladder Pathologies

  3. Liver - Anatomy • Anterior – 2 lobes: Left and Right • Separated by Falciform Ligament

  4. Liver - Anatomy • Posterior: 2 Lobes – Caudate (Superior) and Quadrate (Inferior) • Ligaments: Ligamentum Venosum (Superior) and Ligamentum Teres (Inferior) • Porta Hepatis and IVC Caudate Quadrate

  5. Liver – Surface Anatomy • Mainly situated in RUQ • Sits under Diaphragm • Below Nipple • Covered on right side by ribs V – X • On left by V – VII • Foregut derivate • Pain referred to Epigastricv region

  6. Liver - Blood Supply • Hepatic Arteries • Hepatic Portal Vein • Hepatic Veins - IVC

  7. Hepatic Arteries • Coeliac Trunk • Common Hepatic Artery • Left and Right Hepatic Arteries • Porta Hepatis • 20 – 30% of O2 to Liver

  8. Hepatic Portal Vein • Tributaries from GI Tract: Oesphageal, Gastric, Splenic, Superior and Inferior Mesenteric Veins • 70 – 80% 02 supply to Liver

  9. Hepatic Veins • Drains Liver to the IVC • Helps to suspend Liver in Abdomen • Can be ruptured in high impact trauma

  10. Lobules and Portal Triads • Hepatocytes detoxify blood from portal vein • Synthesise Bile • Bile Ducts converge to form Common Bile Duct

  11. Epiploic Foramen • Entrance to Lesser Sac • Surgical Access • Borders: • Anterior: Portal Triad • conducted in free edge of • lesser omentum • Posterior: IVC • Superior: Caudate Lobe • Inferior: 1st Part of Duodenum

  12. Symptoms of Liver Disease • May be asymptomatic • Lethargy • Anorexia • Malaise • Jaundice develops later • May also be asymptomatic • Jaundice • Ascites + Hepatomegaly • Haematemesis & Melaena • Confusion Acute Chronic

  13. Jaundice • Pre-Hepatic • Haemolysis • Unconjugated so not in urine • Hepatic (CholestaticIntrahepatic) • Alcohol • Hepatitis • Cirrhosis • Conjugated • Post Hepatic (CholestaticExtrahepatic) • Gallstones • Tumour • Conjugated

  14. Hepatitis • Inflammatory cell infiltrates • Hepatocyte Necrosis • Hepatomegaly • Councilmann bodies in Viral Hepatitis due to apoptosis of hepatocytes

  15. Hepatitis - Causes • Viral • Hepatitis (all) • CMV • EBV • Toxoplasma • Alcohol • Drugs • Paracetamol • Isoniazid • Pregnancy • Hepatitis B ± D & C • Autoimmune • Alcohol • Drugs • Wilson’s Disease • Haemochromatosis Acute Chronic

  16. Cirrhosis • End stages of Chronic Liver Disease • Fibrosis and nodules affecting WHOLE Liver • Compression of venous systems and creation of arteriovenous shunts: • Portal hypertension

  17. Portal hypertension • Increase in hepatic portal vein pressure • Pre-hepatic • Portal vein thrombosis • Compression – carcinoma • Hepatic • Hepatitis • Cirrhosis • Post-hepatic • Rare • Budd-Chiari syndrome (Hepatic Vein Thrombosis) • Right Heart Failure • Constrictive Pericarditis

  18. Porto-systemic Anastomoses • High pressure in portal vein causes backlog in its tributaries • Oesophageal varices • Haemorrhoids • Caput medusae • Ascites and Oedema • Hepato-splenomegaly

  19. Cancer • Liver is often a site of metastasis • Primary tumours are Hepatocellular Carcinomas • Rare in the West

  20. Gallbladder

  21. Gallbladder

  22. Gallbladder • Fundus, Body and Neck • Stores bile • Supplied by cystic artery • Foregut derivate • Gallstones formed by cholesterol imbalance involved in pathologies

  23. Biliary Colic • Temporary obstruction of ducts by a gallstone • Recurrent pain in upper abdomen lasts several hours • Vomiting • Pain may be referred to right shoulder tip • Irritation of diaphragm • Inflammatory fluids in sub-phrenic recess

  24. Cholecystitis

  25. Cholecystitis • Gallstone impacted in cystic duct or neck of gallbladder • Symptoms same as biliary colic • Severe pain in RUQ, guarding • Inflammatory markers +ve, Leucocytosis • Murphy’s sign • Patient inhales • Physician pushes below right costal margin • Pain when patient exhales

  26. Complications of Cholecystitis • Perforation • Gangrene • Empyma • Peritonitis

  27. (Acute/Ascending) Cholangitis Bacteria

  28. Cholangitis • Blockage of common bile duct • Jaundice (obstructive) • Lack of bile flow causes micro-organisms to ascend from the gut • E. Coli, E. Faecalis

  29. Other Gallstone Problems • Pancreatitis • Gallstone Ileus

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