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LIVER GALL BLADDER

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LIVER GALL BLADDER Powered By Docstoc
					LIVER & GALL BLADDER

      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

• It occupies whole of the right
  hypochondrium, greater part of the
  epigastrium and extends into the left
  hypochondrium upto the left lateral
  line


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             External features

• 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
  abdominal cavity
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          Anatomical position

• 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.




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             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
  anteriorly.



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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.

    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.
•

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           Right surface-

– 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.



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 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.
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                Blood supply

• 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.



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           Venous drainage

• Hepatic veins drains directly into the
  inferior vena cava.




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         Lymphatic drainage

• 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.
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                  Functions

• metabolic-carbohyrate, fats & proteins
• synthetic- bile & prothrombin
• excretory- drugs, toxins, poisons ,cholesterol,
  bile pigments & heavy metals.
• protctive- conjugation,
  destruction,phagocytosis,antibody formation &
  excretion
• storage- glycogen, iron, fat, vitamins A &D,
  blood etc.
•
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             Nerve supply

• Nerve supply is through the hepatic plexus
  which contains both the sympathetic & the
  parasympathetic (vagal) fibres.




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                    surface marking

•   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
        plane.
     – 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




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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

• 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.


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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

 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
 jaundice.
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• Thymol turbidity test




• This flocculation test depends upon
  globulin fraction in serum. It is increased
    only in hepatocellular damage & is
  normal in obstructive jaundice.
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             IMMUNOLOGICAL
                MARKERS
• Antinuclear factor is present in 80% of
  patientswiyh auto-immune chronic active
  hepatitis.

• 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
  cancer.

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               HEPATITIS

• 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
  bare area.
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              VIRAL HEPATITIS

• . 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.
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         CHRONIC HEPATITIS
• 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.

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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

• Is a condition in which liver hardens & shrinks due to
  progressive fibrosis.
• 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
  hypertension.



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           LIVER BIOPSY

• 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.
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• The subphrenic abscess are more common on
  the right side because of the frequency of the
  ruptured appendices & perforated duodenal
  ulcers.

• 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
  bedridden.
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  HEPATORENAL POUCH OF
MORRISON

• 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.



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              LIVER FAILURE

•   This occurs when liver function is reduced to
    such an extend that other body activities are
    impaired.
•

•   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
        paracentesis
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HEPATIC ENCEPHALOPATHY

•    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.



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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.

The normal portal venous pressure is 5-
10 mmHg.




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   TUMOURS OF THE LIVER
Liver tumours are relatively rare.

They can be broadly discussed as:

Benign tumours
Hepatocellular carcinoma
Other primary tumours
Metastatic tumours
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   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 &
  the breast.
• Metastasis tends to grow rapidly & causes death.
• Malignancy develops in number of cases of acute
  hepatitis caused by type B virus.




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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%.

Malnutrition is a probable cause.

Haemochromatosis has been associated with HCC.

Aspergillus flavus have also been incriminated.

Alpha fetoprotein is the most useful marker

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                 JAUNDICE

• The following factors may cause jaundice as
  liver failure develops.

• Inability of the hepatocytes to conjugate &
  excrete bilirubin

• Obstruction to the movement of bile through the
  bile channels by fibrous tissue that has distorted
  the structural framework of liver lobules.


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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.

• The apparatus consists of :

•   Right & left hepatic ducts
•   The common hepatic duct
•   Gall bladder
•   Cystic duct
•   Bile duct

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             Hepatic ducts

• 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.




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          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.




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               Gallbladder

• 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.



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• Measurement- length- 7to 10cm

• Breadth- 3cm

• Capacity- 30 to 50ml




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                    Parts

Gall bladder is divided into 3 parts:

• Fundus
• Body
• neck




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                 Fundus

• 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
  sides.



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               Relations

• In front – anterior abdominal wall
• Behind- transverse colon




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                       Body

• 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
  peritoneum

• 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
  duodenum.
                  Neck

• 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.



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                              Relations
•   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.




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     Structure of the gall bladder

•   From outside inwards it presents 3 coats
•   serous
•   fibromuscular
•   mucous




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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

• 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.



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   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
  dysfunction.
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              Blood supply

• Gastric artery is the chief source.




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           Venous drainage

• Cystic vein drains into the intrahepatic part
  of portal vein. Sometimes cystic vein
  drains into right branch of portal vein at the
  porta- hepatis.




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         Lymphatic drainage

• It drains into the hepatic lymph nodes
  close to the porta-hepatis.




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               Nerve supply

• 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
  bladder.



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 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
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               Cystic duct

• 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
  lumen patent.

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                   Bile duct

• 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
  cystic ducts.
• 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
               APPLIED ANATOMY
•   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.
•   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

• This is usually a complication of gall stones or
  exacerbation of chronic cholecystitis.
  Inflammation develops followed by secondary
  microbial infection.
• 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.
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  CHRONIC CHOLECYSTITIS

• 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 &
  fibrous adhesion.


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    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


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CARCINOMA OF GALL BLADDER
UNCOMMON.
Associated with gall stones.
Usually an adenocarcinoma.
Commoner in females.




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                   JAUNDICE

• 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
  with.
• Abnormal liver function
• incomplete uptake of unconjugated bilirubin by
  hepatocytes.
• ineffective conjugation of bilirubin.
• interference with bilirubin secretion.
• Obstruction to the flow of bile from the liver to the
  duodenum.

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   TYPES OF JAUNDICE

– HAEMOLYTIC
– OBSTRUCTIVE
– HEPATOCELLULAR




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     COURVOISIER’S LAW

• 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.



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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

• Surgical removal of the gall bladder.

• Laproscopic removal often replaces the
  open surgical method. Bile duct injury is a
         serious complication of
  cholecystectomy.



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• ULTRASONOGRAPHY is now the
  standard technique for the inv of a pt with
  gallstone.

• C.T is not useful in inv of the biliary tree.

• MRCP (magnetic resonance cholangio-
  pancreatography) is the standard inv of
  the biliary tree.
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• TRAUMA- Injuries to the gallbladder and
  the biliary tree are rare. They occur as a
  result of a penetrating wound or a crush
  injury.




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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:

• Clinically oriented Anatomy- Keith l Moore
• Anatomy & physiology in health & illness-
  Ross &Wilson
• Essentials of human Anatomy- A K Datta
• Human Anatomy- BD Chaurasia




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•   THANK YOU

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