LIVER & GALL BLADDER
• 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)
• 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.
• It occupies whole of the right
hypochondrium, greater part of the
epigastrium and extends into the left
hypochondrium upto the left lateral
• In the living subject the liver is reddish- brown in
colour, soft in consistency & very friable. Its
upper & anterior surfaces are smooth & curved
to fit the undersurface of the diaphragm. Its
posterior surface is irregular in outline. The liver
is enclosed in a thin capsule & is incompletely
covered by a layer of peritoneum. Folds of
peritoneum form supporting ligaments attaching
the liver to the inferior surface of the diaphragm.
It is held in position partly by these ligaments &
partly by the pressure of the organs in the
• Posterior surface of the liver presents a vertical
groove for inferior vena cava. Place the vena
caval groove vertically on the posterior surface,
broad base of the wedge shaped liver on the
right side , the convexo-concave-convex surface
of the liver above, so that the convexity on the
right side is slightly higher than the left side.
The liver has
• 5 surfaces- anterior, posterior, superior,
inferior, and the right. Out of these the
inferior surface is well defined as it is
demarcated by a sharp inferior border
• 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
• 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
• 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.
• 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
• 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
• 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
• 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.
• 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
– coronary ligament- has two layers ,superior and
inferior layers enclosing bare area of the liver.
– lesser omentum
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.
• . posterior surface-
• It is triangular & marked by the vertebral impression in
– 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
– posterior surface of the left lobe is marked by the
– fissure for ligamentum venosum is very deep &
extends in front of caudate lobe. Ligamentum
venosum is the remnant of ductus venosus of foetal
• 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.
• 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.
quadrate lobe is related to lesser omentum, pylorus & first part of
duodenum. when stomach is empty, quadrate lobe is related to first part
of duodenum & a part of transverse colon .
gallbladder fossa lodges the gallbladder.
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.
– It is quadrilateral in shape & convex. It is
related to diaphragm opposite to 7th & 11th
ribs in the mid axillary line.
– Upper 1/3rd is related to diaphragm, pleura &
lung.Middle 1/3rd is related to diaphragm &
costodiaphragmatic recess of the pleura
– lower 1/3rd is related to diaphragm alone.
Peritoneal recesses of the liver
• Two recesses lies above the liver & two
recesses lies below the liver
• right & left supra hepatic recesses
• right & left sub hepatic recesses
• right subhepatic recess is also called as
hepato renal pouch of Morrison. It is the
most dependant part of peritoneal cavity in
the upper abdomen.
• The liver receives 20% blood supply from the
hepatic artery & 80% blood supply from the
portal vein. Before entering the liver, the hepatic
artery & the portal vein divides into right & left
branches. Within the liver they redivide to form
segmental & then interlobular vessels which run
in the portal canals. Further ramifications of
interlobular branches open into hepatic
sinusoids. Thus the hepatic arterial blood mixes
with portal venous blood in the sinusoids.
• Hepatic veins drains directly into the
inferior vena cava.
• Lymphatic drainage is through superficial
& deep lymhatics. The superficial
lymphatics drains into caval, hepatic,
paracardial & celiac lymph nodes. Some
vessels from coronary ligament ends
directly into the thoracic duct.
• Deep lymphatics ends into the nodes
around the inferior vena cava & partly into
the hepatic nodes.
• metabolic-carbohyrate, fats & proteins
• synthetic- bile & prothrombin
• excretory- drugs, toxins, poisons ,cholesterol,
bile pigments & heavy metals.
• protctive- conjugation,
destruction,phagocytosis,antibody formation &
• storage- glycogen, iron, fat, vitamins A &D,
• Nerve supply is through the hepatic plexus
which contains both the sympathetic & the
parasympathetic (vagal) fibres.
• In surface projection the liver is triangular in shape.
• upper border is formed by joining the following points:
– A point on the 5th intercostals space31/2inches from the median
– second point at xiphysternal joint.
– third point at the upper border of the right fifth costal cartilage in
the lateral vertical Plan
– fourth point at the 6th rib in mid axillary line
– fifth point at the inferior angle of the right scapula.
– sixth point at 8th thoracic spine
• 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.
• 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
• tip of the 10th costal cartilage.(i.e 5th point
of lower border).
• 1.In the infrasternal angle the liver is
readily accessible to examination on
percussion though normally it is not
palpable due to normal tone of the recti
muscles & the softness of the liver. A
palpable left lobe in the epigastrium often
indicates cirrhosis of the liver.
• Hepatocellular damage manifest itself by
jaundice associated with anorexia & nausea. In
such a case liver function is assessed by
– serum bilirubin
– bilirubin is conjugated by the liver & is excreted in the
– Normal s.bilirubin level is 0.5 to 0.8units. it is raised in
• serum proteins & albumin globulin 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.
• Serum alkaline phosphatase
This enzyme is excreted in the bile & its level
is raised in obstructive jaundice.
Normal is 3 to 13 king Armstrong units.
Below 30 units in the presence of jaundice it
indicates hepatocellular damage &
above 40 units strongly suggests obstructive
• Thymol turbidity test
• This flocculation test depends upon
globulin fraction in serum. It is increased
only in hepatocellular damage & is
normal in obstructive jaundice.
• Antinuclear factor is present in 80% of
patientswiyh auto-immune chronic active
• Mitochondrial antibodies are diagnostic of
primary biliary cirrhosis.
• Alpha-fetoprotein is a normal foetal plasma
protein which dissapears few weeks after birth;
but it reappears in patients with primary liver
• Ameobic hepatitis is caused due to E.
histolytica passing up the portal vein from
the colon, in case of ameobic colitis. In
late cases jaundice & evidence of
hepatocellular damage may
appear.Multiple lesions coalesce to form
ameobic liver abscess and is common in
upper part of right lobe of liver close to
• . Viral infections are commonest causes of acute liver
injury & includes type A,type B, type C, type D, type E.
• Type A- Infectious Hepatitis
• Type B- Serum Hepatitis
• Type C- It spreads by blood & blood products & is
prevalent in drug addicts & some times occur as a
complication of blood transfusion.
• Fulminating cases of viral Hepatitis may rapidly
progress to hepatic coma which is often fatal.
• Sustained chronic inflamatory reaction in the liver lasting
for more than 6 mths.
• Common causes
• Chronic viral infections – Hepatitis B & D, Hepatitis C
• Drugs & toxins
• Inborn errors of metabolism – Wilsons disease, Alpha 1
anti trypsin deficiency etc.
• IgM anti HAV- Recent infection
• IgG anti-HAV- Past infection
• 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
• AntiHCV-Prior infection 3-6 mths before.
• Anti delta antibody- Positive only in association with HBsAg
• 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
• 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.
CIRRHOSIS OF LIVER
• Is a condition in which liver hardens & shrinks due to
• The liver is the primary site for detoxification & so it is
vulnerable to cellular damage & consequent scarring
accompanied by regenerative nodules.
• There is progressive destruction of hepatocytes in
hepatic cirrhosis & replacement by fat & fibrous tissue.
• Alcoholic cirrhosis is the most common cause of portal
• Hepatic tissue may be obtained for
diagnostic purpose by liver biopsy.
• Because the liver is located in the right
hypochondrium where it receives
protection from the overlying thoracic
cage, the needle is commonly directed
through the right 10th intercostal space in
the mid axillary line.
• The subphrenic abscess are more common on
the right side because of the frequency of the
ruptured appendices & perforated duodenal
• Since the rt & lt subphrenic recesses are
continuous with the hepatorenal recess pus
from subphrenic abscess may drain into the
hepatorenal recess esp when patients are
HEPATORENAL POUCH OF
• Some times fluid collects into hepatorenal
pouch following surgical removal of
gallbladder. That is, as a routine procedure
after operation of gallbladder a drainage
tube is kept for few days till no fluid is
aspirated by siphonage.
• This occurs when liver function is reduced to
such an extend that other body activities are
• It may be acute or chronic & may be the
outcome of :
– acute viral hepatits
– extensive necrosis due to poisoning
– cirrhosis of the live
– following medical procedures eg: abdominal
• www.similima.com 45
• This term describes a characteristic syndrome
of disturbed mental function and
neuromuscular abnormalities in a patient .
The cells affected are the astrocytes in the
brain. The condition is characterised
by apathy disorientation, muscular rigidity,
delirium & coma.
It is defined as a state of increase in the
hydrostatic pressure within the portal vein
or its tributaries.
The normal portal venous pressure is 5-
TUMOURS OF THE LIVER
Liver tumours are relatively rare.
They can be broadly discussed as:
Other primary tumours
TUMOURS OF THE LIVER
• Benign tumours of the liver are very rare.
• Secondary malignant tumours in the liver are common
especially from primary tumours in the GIT, lungs &
• Metastasis tends to grow rapidly & causes death.
• Malignancy develops in number of cases of acute
hepatitis caused by type B virus.
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%.
Malnutrition is a probable cause.
Haemochromatosis has been associated with HCC.
Aspergillus flavus have also been incriminated.
Alpha fetoprotein is the most useful marker
• The following factors may cause jaundice as
liver failure develops.
• Inability of the hepatocytes to conjugate &
• Obstruction to the movement of bile through the
bile channels by fibrous tissue that has distorted
the structural framework of liver lobules.
Liver transplantation has been proved the
most useful procedure in progressive
untreatable liver diseases.
Advanced chronic liver disease.
Fulminant hepatic failure.
Inborn errors of metabolism.
EXTRA HEPATIC BILIARY
• The biliary apparatus collects bile from the liver, stores it
in the gallbladder & transmits it to the second part of
• The apparatus consists of :
• Right & left hepatic ducts
• The common hepatic duct
• Gall bladder
• Cystic duct
• Bile duct
• The right & left hepatic ducts emerge at
the porta hepatis from the right & the left
lobes of the liver. The arrangement of
structures at the porta hepatis is vein,
artery & duct.
Common hepatic duct
• It is formed by the union of the two hepatic ducts. It runs
downwards for about 3cm and is joined on its right side
at an acute angle by the cystic duct to form the bile duct.
• Accessory hepatic ducts are present in about 15%
subjects. They usually arise from right lobe of the liver &
terminate either into the gallbladder or into the common
hepatic duct or into the upper part of the bile duct. They
are responsible for oozing of bile after cholecystectomy.
• It is a pear shaped hollow viscous, slate
blue in colour, situated obliquely in a non
peritoneal fossa on the inferior surface of
the right lobe of the liver & it extends from
the right end of the porta-hepatis to the
inferior border of the liver.
• Measurement- length- 7to 10cm
• Breadth- 3cm
• Capacity- 30 to 50ml
Gall bladder is divided into 3 parts:
• It is the lower expanded free end of the
gallbladder which projects below the liver.
• Fundus is directed downwards forwards &
to the right meeting the anterior abdominal
wall at an angle of 30 degrees.
• It is invested by the peritoneum on all
• In front – anterior abdominal wall
• Behind- transverse colon
• It extends from the fundus to the neck & is
directed upwards backwards & to the left.
• Upper surface is non peritoneal.
• Lower surface & sides are covered with
• The upper end is continuous with the neck. The
inferior surface is related to the beginning of the
the first &
transverse colon &www.similima.com second part of the66
• It forms an ‘S’ shaped curve& extends
from the body to the cystic duct.
• At first the neck passes upwards &
forwards, then turns abruptly downwards &
backwards & is continuous with the cystic
duct separated by a constriction.
• Superiorly the neck is attached to the liver by areolar tissue in which cystic
vessels are embedded.
• Inferiorly, it is related to the first part of duodenum.
• The mucous membrane of the neck is folded spirally to prevent any
obstruction to the inflow or out flow of bile. The posterior medial wall of the
neck is dilated to form the Hartmann's pouch, which is directed downwards
& backwards. The portion of the neck giving attachment to Hartmann's
pouch is called ‘isthmus’ of the gall bladder.
• Gall stones lodged in the pouch may cause adhesions with the duodenum
or bile duct & may perforate into any one of them.
Structure of the gall bladder
• From outside inwards it presents 3 coats
• Serous coat
• It is derived from the peritoneum & is
incomplete. It covers the fundus entirely &
the undersurface & sides of the body &
• The smooth muscle fibres are supported by the
fibro-elastic coat & are disposed irregularly, the
longitudinal being prominent. The mucous
membrane is devoid of muscularis mucosae,
hence sub mucous coat is absent. The mucosa
consists of lamina propria & surface epithelium &
is devoid of glands. Some mucous glands may
be present at the neck. The surface is lined by
simple columnar epithelium.
Functions of the gallbladder:
• it stores and concentrates bile ten times more
than liver bile.
• It reduces the alkalinity of hepatic bile.
• It equalizes ductal biliary pressure
• Gallbladder is not indispensable, because its
surgical removal is not associated with liver
• Gastric artery is the chief source.
• Cystic vein drains into the intrahepatic part
of portal vein. Sometimes cystic vein
drains into right branch of portal vein at the
• It drains into the hepatic lymph nodes
close to the porta-hepatis.
• It is supplied by the sympathetic nerves via
celiac & hepatic plexus. A few twigs of the
phrenic nerve carrying post ganglionic
sympathetic fibres reach the gallbladder through
the phrenic & hepatic plexus. This explains why
a reffered pain is sometimes felt at the tip of the
right shoulder during the inflammation of the gall
Anamolies of the gallbladder
• Agenesis of the gall bladder
• Double gall bladder, connected by a single cystic duct or
double cystic duct
• Septate gall bladder
• Intrahepatic gall bladder
• Mobile or floating gallbladder
• Phrygian cap is a folded fundus of the gall bladder with
out any pathological significance
• It measures 3-4cm in length and 2mm in
caliber. It begins from the neck of the gall
bladder & ends by joining the right side of
the common hepatic duct at an acute
angle. The interior of cystic duct presents
about 5-12 cresentric valves known as
spiral valves of heister which makes the
• It is 7.5 cm long & 6mm in caliber.
• Bile duct is formed close to the porta hepatis by
the union of the common hepatic duct and the
• From its formation the bile duct passes
downwards & backwards & slightly to the left
within the free margins of the lesser omentum &
in front of the epiploic foramen.
• Then it descends behind the first part of
duodenum and lodges in a groove behind the
head of pancreas. www.similima.com 79
• In the posteromedian wall of second part
of duodenum bile duct comes in contact
with main pancreatic duct. Both ducts
pierce the duodenal wall separately &
unites to fom a dilatation called the
‘ampulla of vater’.
• The constricted end of ampulla opens at
the summit of the major douodenal papilla.
This opening is guarded by the sphincter
of oddi. www.similima.com 80
• GALL STONES [ CHOLELITHIASIS
Gall stones consists of deposits of constituents of bile, most commonly
cholesterol. Most small or one large stone may form.
• Predisposing factors include
• Changes in the composition of bile that affects the solubility of its constituents.
• High levels of blood & dietary cholesterol.
• Hemolytic diseases.
• Female gender
• Long term use of OCP’s
• High parity with obesity
• Biliary colic
• This is usually a complication of gall stones or
exacerbation of chronic cholecystitis.
Inflammation develops followed by secondary
• In severe cases there may be fibrinous
exudates into gall bladder, suppuration,
gangrene, perforation & peritonitis.
• On examination there is muscle guard &
tenderness over gallbladder. Murphy’s sign is
positive on palpation under the right costal
margin when patient is asked to take deep
breath he winces with a catch in his breath.
• Insidious onset. Gall stones are usually
present & may be accompanied by biliary
colic. There is usually secondary infection
with suppuration. Ulceration of the tissues
between the gall bladder & duodenum or
colon may occur with fistula formation &
TUMOURS of the biliary tract
• Benign tumours are rare.
• Malignant tumours are relatively rare.
• Common sites are
• neck of G.B
• Junction of cystic & bile duct
• Ampula of bile duct
CARCINOMA OF GALL BLADDER
Associated with gall stones.
Usually an adenocarcinoma.
Commoner in females.
• It is a sign of abnormal bilirubin metabolism & excretion.
• Jaundice occurs when there is excessive haemolysis of
RBC’s producing more bilirubin than the liver can deal
• Abnormal liver function
• incomplete uptake of unconjugated bilirubin by
• ineffective conjugation of bilirubin.
• interference with bilirubin secretion.
• Obstruction to the flow of bile from the liver to the
TYPES OF JAUNDICE
• Dialatation of the gall bladder occurs only
in extrinsic obstructions of the bile duct,
like pressure by Ca head of pancreas.
• Intrinsic obstruction do not cause any
dialatation because of associated fibrosis.
• 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
• Errors in gallbladder surgery are frequently
the result of failure to appreciate the
variations in the anatomy of the biliary
• It is therefore important to clearly identify
the biliary trees before removing the gall
• Gall bladder functions can be investigated
• 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.
• Surgical removal of the gall bladder.
• Laproscopic removal often replaces the
open surgical method. Bile duct injury is a
serious complication of
• ULTRASONOGRAPHY is now the
standard technique for the inv of a pt with
• C.T is not useful in inv of the biliary tree.
• MRCP (magnetic resonance cholangio-
pancreatography) is the standard inv of
the biliary tree.
• TRAUMA- Injuries to the gallbladder and
the biliary tree are rare. They occur as a
result of a penetrating wound or a crush
TORSION OF THE GALBLADDER- this is
very occurs in older patients with a large
mucocele of the gall bladder.
• 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.
SURFACE MARKING of gall
• The fundus of the gall bladder is marked at
the angle between the right costal margin
& the outer border of rectus abdominis.
• Clinically oriented Anatomy- Keith l Moore
• Anatomy & physiology in health & illness-
• Essentials of human Anatomy- A K Datta
• Human Anatomy- BD Chaurasia
• THANK YOU