T2 L11: Gallbladder, pancreas, spleen

• Bile production

  Liver constantly produces bile

  Stored in gallbladder

  Released when fat enters duodenum

  Bile emulsifies fats so it can be absorbed

  Bile → bile canaliculi → interlobular biliary duct → hepatic ducts → common hepatic duct + cystic duct → common bile duct → hepatopancreatic ampulla (of vater) → major duodenal papilla → duodenum

  
• How does the biliary tree go?

  right hepatic duct (1) meets left hepatic duct (1) → common hepatic duct (3) meets cystic duct (4) → common bile duct (5) → hepatopancreatic ampulla of vater (6) → major duodenal papilla (7) → duodenum

  
• What are the sphincters of the biliary tree?

  sphincter of bile duct (1) + sphincter of pancreatic duct (2) → sphincter of hepatopancreatic ampulla (3) → duodenum

  
• How does bile get stored in the gallbladder?

  when sphincter of hepatopancreatic ampulla is closed

  bile backs up through sphincter of bile duct

  gets stored in gallbladder

  
• What is cholangitis?

  Inflammation of the bile duct system

  can be acute / chronic

  can be caused by infection or obstruction
• Gallbladder

  stores around 50ml of bile

  Peritoneal relationship: Intraperitoneal

  Spiral folds (spiral valve) holds cystic duct open

  1. Cystic duct
  2. Spiral fold
  3. Neck
  4. Body
  5. Fundus

  
• Where is the fundus of the gallbladder located?

  below inferior border of liver
• What are common sites for gallstone obstruction?

  hepatopancreatic ampulla

  cystic duct

  Hartmann's pouch

  
• What can happen with gallstones?

  bile cannot leave gallbladder

  can cause jaundice
• What is Hartmann's pouch?

  inconstant feature of gallbladder

  caused by adhesions between cystic duct and neck of gallbladder

  linked with gallstone formation

  
• What is the structure labelled in this image?

  cystic duct

  
• What is the structure labelled in this image?

  common hepatic duct

  
• What is the structure labelled in this image?

  bile duct

  
• What is the Hepatobiliary Triangle (of Calot)?

  triangle formed by:

  1. Inferior surface of liver (superior border)
  2. Common hepatic duct (medial border)
  3. Cystic duct (inferior border)

  contains:

  • Cystic artery (important)
  • Cystic lymph node
  • fatty connective tissue
  • autonomic nerves

  
• How is the embryological development of the pancreas?

  develops at boundary of foregut and midgut

  develops in two parts:

  • dorsal bud
  • ventral bud

  join together when duodenum rotates

  results in: dual blood supply and innervation

  
• What is the anatomical location of the pancreas?

  transpyloric plane (L1)

  closely associated with duodenum

  posterior to stomach

  SMA and SMV pass between neck and uncinate process

  
• What are the different parts of the pancreas?

  1. Uncinate process (develops at a different place then joins the rest)
  2. Head
  3. Neck
  4. Body
  5. Tail

  
• What are the peritoneal relationships of the pancreas?

  retroperitoneal

  apart from tail (sits within splenorenal ligament)

  
• What are the 2 pancreatic ducts?

  1. Main pancreatic duct (of Wirsung):
  2. courses the length of the gland
  3. joins common bile duct and drains into major duodenal papilla
  4. 2. Accessory duct (of Santorini): drains uncinate process of pancreas, opening slightly proximal to the ampulla (minor duodenal papilla)

  
• What is the location of the spleen?

  Left hypochondrium:

  • inferior to diaphragm
  • lateral to tail of pancreas
  • posterior to stomach
  • protected by inferior ribs

  
• What are the functions of the spleen?

  • Blood filter: remove expended RBCs and platelets; recycles iron and globin
  • Immune role: site of WBC proliferation
  • Blood reservoir: self-transfusion during haemorrhage
  • Prenatally: haematopoietic organ

  
• What are the surfaces of the spleen?

  1. Diaphragmatic surface (posterio-superior)
  2. Visceral surface (antero-medial)

  
• What are the contents of the spleen hilum?

  splenic arteries

  splenic veins

  nerves and lymphatics

  
• What are the peritoneal ligaments derived from the spleen?

  Spleen is intraperitoneal. Its ligaments are derived from dorsal mesogastrium.

  1. Gastrosplenic ligament - carries left gastroepiploic artery and vein
  2. Splenorenal ligament - contains:
  3. splenic artery and vein
  4. tail of pancreas

  
• Label the blood supply to the foregut:

  1. Coeliac Trunk
  2. Common Hepatic A.
  3. Proper Hepatic A.
  4. Cystic A.
  5. Left Hepatic A.
  6. Gastroduodenal A.
  7. Anterior superior pancreaticoduodenal A.
  8. Splenic A.
  9. Superior mesenteric A.
  10. Inferior pancreaticoduodenal A.

  
• Label the venous drainage of the foregut:

  1. Pancreatic veins
  2. Splenic vein
  3. Inferior pancreaticoduodenal v.
  4. Superior mesenteric vein
  5. Anterior superior pancreaticoduodenal v.
  6. Hepatic portal vein

  
• How does the parasympathetic innervation of the liver and gallbladder go?

  1. Vagus nerve
  2. Anterior vagal trunk
  3. Posterior vagal trunk
  4. Celiac branch
  5. Hepatic branch
  6. Hepatic plexus

  
• How do the sympathetic and sensory innervation of the liver and gallbladder go?

  1. Greater splanchnic nerve
  2. Right greater splanchnic nerve
  3. Left greater splanchnic nerve
  4. Celiac ganglia
  5. hepatic plexus

  
• Where does the greater splanchnic nerve synapse?

  at celiac ganglia
• Where does the vagus nerve synapse?

  close to target organ
• How does the lymphatic drainage of the liver and gallbladder go?

  cystic lymph nodes → hepatic lymph nodes → celiac lymph nodes → intestinal trunks → cisterna chyli → thoracic duct → back into venous system
• How does the lymphatic drainage of pancreas go?

  pancreas → pancreatic lymph node → either →

  • coeliac l.n.
  • superior mesenteric l.n.

  → intestinal trunk → cisterna chyli → thoracic duct → venous system
• How does the lymphatic drainage of spleen go?

  spleen → splenic l.n. → intestinal trunk → cisterna chyli → thoracic duct → venous system