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Liver & Gall Bladder: Presented by DR - Sujaya Nair
Liver & Gall Bladder: Presented by DR - Sujaya Nair
Presented by
Dr.Sujaya nair
• Synonym- Hepar
• Liver is the largest gland in the body. It is
wedge shaped & it weighs approximately 1
& 2.3kg. it accounts for 2.5% of adult body
weight. In the late foetus it serves as a
haemopoietic organ & therefore is twice as
large (5% of body weight)
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• It consists of both exocrine and endocrine
parts. Exocrine part secretes bile which is
conveyed by the biliary passages. The
endocrine part liberates some useful
chemical substances such as glucose
from glycogen, most of the plasma
proteins (except immuno-globulins) and
heparin directly into the blood stream.
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Location
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External features
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The liver has
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• One prominent border- the inferior
border is sharp anteriorly where it
separates the anterior surface from the
inferior surface. The other borders are
rounded and ill defined
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• One prominent border- the inferior
border is sharp anteriorly where it
separates the anterior surface from the
inferior surface. The other borders are
rounded and ill defined
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• Right lobe is larger and forms 5/6th part of the liver and it
contributes to all 5
surfaces of the
liver and it has two additional lobes called caudate and
quadrate lobes. caudate lobe is situated on the posterior
surface. It is bounded on the right by the groove for
inferior vena cava, on the left by the fissure for
ligamentum venosum, and inferiorly by the porta hepatis.
Above it is continuous with the superior surface, below
and to the right just behind the porta hepatic it is
connected to the right lobe of the liver by the caudate
process. Below and to the left it presents a small
rounded elevation called the papillary process.
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• Quadrate lobe is situated on the inferior
surface and is rectangular in shape. It is
bounded anteriorly by the inferior border,
posteriorly by the porta hepatic, on the
right by the gall bladder fossa and on the
left by the fissure for ligamentun teres
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• Porta hepatis is a deep transverse fissure,
about 2 inches long, situated on the inferior
surface of the right lobe of the liver between the
caudate lobe above and the quadrate lobe
below and in front.It admits portal vein, hepatic
artery and hepatic plexus of nerves and lets out
the right and left hepatic ducts and few
lymphatics. Relations within the porta hepatis,
from behind forwards are the portal vein ,hepatic
artery and the bile duct..The lips of the porta
hepatic provides attachment to lesser omentum
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• Relations-
• peritoneal relations-
– most of the liver is covered by peritoneum.
– bare areas of the liver include
• the main bare area on the posterior surface of the right lobe of the
liver
• groove for inferior vena cava on the posterior surface of the right
lobe of the liver
• gall bladder fossa on the inferior surface of the liver
• porta hepatis
• along the lines of reflection of peritoneum.
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• peritoneal ligaments of the liver are
– falciform ligament connecting antero-superior surface
of the liver to the anterior abdominal wall and
undersurface of the diaphragm.
– left triangular ligament- connecting superior surface of
left lobe of liver to the diaphragm.
– right triangular ligament- connecting the lateral part of
the posterior surface of right lobe of the liver to the
diaphragm.
– coronary ligament- has two layers ,superior and
inferior layers enclosing bare area of the liver.
– lesser omentum
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visceral relations
.–
A. anterior surface
• It is related to the xiphoid process & anterior
abdominal wall in the median Plane& to the
diaphragm on each side.
• The right part of anterior surface lies beneath
the right costal margin & is related with the
diaphragm, 6 to 10 ribs & lower margins of the
right lung & pleura.
• The left part of anterior surface lies beneath the
left costal margin & is related with the
diaphragm, 7 & 8th left costal cartilages.
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• . posterior surface-
• It is triangular & marked by the vertebral impression in
the middle
– bare area is related to the diaphragm & right
suprarenal gland near the lower end of groove for
inferior vena cava.
– caudate lobe lies in the superior recess of the lesser
sac.
– posterior surface of the left lobe is marked by the
oesophageal impression
– fissure for ligamentum venosum is very deep &
extends in front of caudate lobe. Ligamentum
venosum is the remnant of ductus venosus of foetal
life.
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superior surface-
• It is quadrilateral & is marked concave by
cardiac impression in the middle.
• It is convex on each side to fit into the
domes of the diaphragm.
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inferior surface-
• It is quadrilateral & is directed downwards backwards & to the left.
It is marked by
inferior surface of left lobe of liver bears the gastric impression
for the stomach.
inferior surface of the left lobe of the liver bears the colic
impression for the hepatic flexure of the colon, renal impression for the
right kidney & the duodenal impression for second part of duodenum.
•
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Right surface-
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Peritoneal recesses of the liver
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Venous drainage
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Lymphatic drainage
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surface marking
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• lower border is formed by a curved line joining
the following points:
– a point at the left 5th intercostals space, 31/2 inches
from the median plane.
– second point at the tip of the 8th costal cartilage on
the left costal margin.
– third point at the trans-pyloric plane in the midline.
– fourth point at the tip of the 9th costal cartilage on the
right costal margin.
– fifth point 1cm below the right costal margin at the tip
of the 10th costal cartilage.
– sixth point at the 11th thoracic spine.
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• right border is marked on the front by a
curved line convex laterally drawn from
• A point, a little below the right nipple to a
point 1cm below the right costal margin at
the
• tip of the 10th costal cartilage.(i.e 5th point
of lower border).
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Applied Anatomy
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• Hepatocellular damage manifest itself by
jaundice associated with anorexia & nausea. In
such a case liver function is assessed by
thefollowing tests
– serum bilirubin
– bilirubin is conjugated by the liver & is excreted in the
bile.
– Normal s.bilirubin level is 0.5 to 0.8units. it is raised in
hepatocellular
damage
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• serum proteins & albumin globulin ratio
(A:G ratio)
• Liver is the site of origin of albumin & a
part of globulin of plasma proteins
In hepatic dysfunction total
serum proteins are reduced from 8 gms to
5 gms or lower & AG ratio is reversed.
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• Serum alkaline phosphatase
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HEPATITIS
• Common causes
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VIRAL MARKERS
• HEP-A
• IgM anti HAV- Recent infection
• IgG anti-HAV- Past infection
• HEP-B
• HBsAg- recent/ past infection(carrier)
• IgM anti-HBc-recent infection
• IgG anti-HBc-Past infection
• HBeAg-Acute/chronic infection
• AntiHBe-Recovering from acute infection
• AntiHBs-Past infection
• HEP-C
• AntiHCV-Prior infection 3-6 mths before.
• HEP-D
• Anti delta antibody- Positive only in association with HBsAg
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HEPATOMEGALY
• The liver is a highly vascular & soft organ that receives a large amount of blood
immediately before it enters the heart.
• Both IVC & hepatic veins lack valves. Therefore any raise in central venous
pressure is directly transferred to liver which enlarges as it becomes engorged
with blood.
• Marked engorgement stretches the fibrous capsule of the liver causing pain.
• In addition to diseases that produces hepatic engorgement such as CCF,
bacterial & viral diseases such as Hepatitis also causes hepatomegaly.
• A massive enlarged liver can be palpated below the right costal margin & may
even the pelvic brim in the right lower quadrant of the abdomen. Tumours also
enlarge the liver.Liver is the common site of metastatic carcinoma. Cancer cells
may also pass into the liver from the thorax especially the right breast.
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CIRRHOSIS OF LIVER
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LIVER BIOPSY
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LIVER FAILURE
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PORTAL HYPERTENSION
It is defined as a state of increase in the
hydrostatic pressure within the portal vein
or its tributaries.
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TUMOURS OF THE LIVER
Liver tumours are relatively rare.
Benign tumours
Hepatocellular carcinoma
Other primary tumours
Metastatic tumours
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TUMOURS OF THE LIVER
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HEPATOCELLULAR CARCINOMA
HCC is one cancer where the role of HEP-B virus is
demonstrated. The frequency with which HBsAg is found
in the serum of HCC patients is 20-90%.
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JAUNDICE
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LIVER TRANSPLANTATION
Liver transplantation has been proved the
most useful procedure in progressive
untreatable liver diseases.
INDICATIONS
Advanced chronic liver disease.
Fulminant hepatic failure.
Hepatic malignancies.
Inborn errors of metabolism.
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EXTRA HEPATIC BILIARY
APPARATUS
• The biliary apparatus collects bile from the liver, stores it
in the gallbladder & transmits it to the second part of
duodenum.
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Hepatic ducts
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Common hepatic duct
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Gallbladder
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• Measurement- length- 7to 10cm
• Breadth- 3cm
• Capacity- 30 to 50ml
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Parts
• Fundus
• Body
• neck
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Fundus
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Relations
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Body
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Relations
• Superiorly the neck is attached to the liver by areolar tissue in which cystic
vessels are embedded.
• Gall stones lodged in the pouch may cause adhesions with the duodenum
or bile duct & may perforate into any one of them.
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Structure of the gall bladder
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• Serous coat
• It is derived from the peritoneum & is
incomplete. It covers the fundus entirely &
the undersurface & sides of the body &
neck.
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Fibromuscular
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Functions of the gallbladder:
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Venous drainage
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Lymphatic drainage
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Nerve supply
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Anamolies of the gallbladder
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Bile duct
• Changes in the composition of bile that affects the solubility of its constituents.
• High levels of blood & dietary cholesterol.
• Cholecystitis
• DM
• Hemolytic diseases.
• Female gender
• Obesity
• Long term use of OCP’s
• High parity with obesity
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COMPLICATIONS
• Biliary colic
• Inflammation
• Impaction
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ACUTE CHOLECYSTITIS
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TUMOURS of the biliary tract
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CARCINOMA OF GALL BLADDER
UNCOMMON.
Associated with gall stones.
Usually an adenocarcinoma.
Commoner in females.
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JAUNDICE
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TYPES OF JAUNDICE
– HAEMOLYTIC
– OBSTRUCTIVE
– HEPATOCELLULAR
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COURVOISIER’S LAW
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• MUCOCELE OF THE GALLBLADDER
• It forms when a stone impacts in the cystic duct
but bacterial infection does not occur- bile is
reabsorbed, but the epithelium continues to
secrete mucous and the gallbladder becomes
distended. It is easily palpated and may be even
visible, but not tender. such patients have
persistent symptoms like distressing nausea. If
infection does occur, an empyema may develop
rapidly. In such cases a cholecystectomy is
required.
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• Errors in gallbladder surgery are frequently
the result of failure to appreciate the
variations in the anatomy of the biliary
system.
• It is therefore important to clearly identify
the biliary trees before removing the gall
bladder.
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• Gall bladder functions can be investigated
by cholecystography.
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• The most significant lesions of typhoid
fever occurs in lymphoid tissue, bone
marrow & G.B. Gall bladder is invariably
affected & the carrier state may be due to
persistence of typhoid bacilli in this organ.
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CHOLECYSTECTOMY
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• ULTRASONOGRAPHY is now the
standard technique for the inv of a pt with
gallstone.
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TORSION OF THE GALBLADDER- this is
very occurs in older patients with a large
mucocele of the gall bladder.
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• GAS in gallstones- The center of a stone
may contain radiolucent gas in a triradiate
or biradiate fissure and this gives rise to
charecteristic dark shapes on a
radiograph. This is called the ‘mercedes
benz’ sign or seagul sign.
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SURFACE MARKING of gall
bladder
• The fundus of the gall bladder is marked at
the angle between the right costal margin
& the outer border of rectus abdominis.
[linea semilunaris]
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Reference:
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• THANK YOU
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