-12. -Renad Habahbeh. -Dr Mohammad mohtasib

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1 -12 -Renad Habahbeh - -Dr Mohammad mohtasib

2 The Gallbladder -The gallbladder has a body, a fundus (a rounded end), a neck, Hartmann s pouch before the neck and a cystic duct that meets the common hepatic duct to form the common bile duct. - Hartmann s pouch is a pouch which can be obstructed by single stone due to some pathological condition. The gallbladder is capable of concentrating the bile up to times but the concentration is about 20 times by absorption of water. -Has an impression surface of the liver and it lies on the side of quadrate lobe. - Sometimes it has short mesentery (intraperetoneum), if it doesnt have any mesentery (embedded in the liver) then 3 surfaces of the gallbladder are covered by the peritoneum and the post. surface is covered only in connective tissue. - Lies in the epigastric and right hypochondriac regions. -Single stone forms in hartmann's pouch because of an infection. Might migrate through the cystic duct causing obstructive jaundice. 2

3 The sphincter of oddi is a thickening of smooth muscles. Its mechanism of function: The sphincter of oddi is always closed, so that all secretions of the liver return back to the gallbladder where they get concentrated by absorption of water. The gallbladder is the storage site for bile, the bile gets concentrated inside the gallbladder. So instead of secreting 20 L of diluted bile through the hepatic duct after a fat-rich meal, the gallbladder secretes 1-2 ml of concentrated bile. This sphincter relaxes when it receives stimulation, whether this stimulation is neural (parasympathetic) or hormonal, and then the wall of the gallbladder contracts releasing the concentrated bile. Relations of the gallbladder Anteriorly: The anterior abdominal wall and the inferior surface of the liver (It s embedded in the right lobe of the liver and adherent to the quadrate lobe of the liver). 3

4 Posteriorly: The transverse colon and the 1 st and 2 nd part of the duodenum. Cholecystectomy Cholecystectomy means the surgical removal of the gallbladder and it s done by doing two ligations and cutting the cystic artery and doing the same thing to the vein and the cystic duct then removing the gallbladder, the patient will then be completely dependent on the diluted bile secreted directly by the liver into the duodenum.so when this patient eats a meal, even if it has a minimal amount of fat he/she will suffer from many complications such as diarrhea. Acute Cholecystitis It s the inflammation of the gallbladder. This acute inflammation might become chronic and raises the risk of forming a stone in the gallbladder (due to the stasis and concentration of the secretions), a stone in the gallbladder is called Cholelithiasis. Hartman s pouch is a pouch that precedes the neck and its common site for single-stone formation. Any stone that forms in the gallbladder must be surgically removed (cholecystectomy) because this stone may be a cause of cancer. 4

5 Histology of the gallbladder We notice: -Type of epithelium: simple columnar without goblet cells - Folding mucosa forming Honey-comb appearance Sometimes the submucosa is absent. - muscularis layer appear in the form of patches. Cystic duct The cystic duct is 4 cm long and connects the neck of the gallbladder to the common hepatic duct to form the common bile duct (it s ligated in cholecystectomy as previously mentioned). The common bile duct It s 10 cm long and it s divided into 3 parts : 1) Supraduodenal part: Above the duodenum. 2) Retroduodenal part: behind the 1st part of 5

6 duodenum. 3) Retropancreatic part: behind and through the head of pancreas. The common bile duct opens into the 2 nd part of the duodenum.it has an important relation to the 1 st part of the duodenum as it passes posterior to it along with the portal vein and the gastroduodenal artery. Arterial supply of the gallbladder The cystic artery, a branch of the right hepatic artery, supplies the gallbladder Venous drainage Opposite to the arterial supply, the cystic vein directly drains into the right branch portal vein. Lymphatic drainage Drainage Into the celiac lymph nodes. After draining cystic and hepatic lymph nodes. Nerve supply -Parasympathetic by the vagus nerve (wall of gallbladder) -Sympathetic by the splanchnic nerve(inhibition of sphincter of oddi) -hormonal by CCK (cholecystokinin) that induces contraction of the wall of the gallbladder 6

7 The bile: Bile composed of water, ions, bile acids, organic molecules (including cholesterol, phospholipids, and bilirubin) and it may lead to stone formation (cholecystitis) and stones have many types depending on the type of material. Note: Gangrene doesn t happen to the gallbladder as it receives its blood supply directly from the liver while Gangrene might happen to the appendix. ERCP: Endoscopic retrograde cholangiopancreatography If we cut the smooth muscle layer, the bile secretion will be diluted and concentrated then it returns back to normal after healing. -Please refer to the slides for pictures and for more details that the doctor overlooked/skimmed over. :) 7

8 The pancreas The pancreas is found in the epigastric region and it's tail extends to the spleen in the left hypogastric region. Parts of the pancreas 1) The head: -it s disc-shaped. - A part of the head extends to the left behind the superior mesenteric vessels and is called the uncinate process. 2) The neck: The portal vein is formed behind the neck by the superior mesenteric and the splenic veins. 3) The body: 8

9 The head is present in the concavity of the duodenum.the main pancreatic and the main bile duct originates from this part. 4) The tail: Passes forward in the splenicorenal ligament (which consists of two layers of peritoneum extending between the hilum of spleen to the left kidney). This ligament must be protected during splenectomy as injury to the tail of pancreas may cause a leakage of the pancreatic secretions causing infection in the abdomen ( peritonitis). Contents of the splenicorenal ligament: tail of pancreas, Splenic artery and splenic vein. The pancreas has 3 surfaces and three borders: -The splenic artery (tortuous) runs along the posterior border( superior/upper border). -The anterior border is attached to the mesocolon of the transverse colon (two layers of peritoneum; upper border ascends upward to diaphragm and lower border descends downwards to the posterior abdominal wall. The anterior surface is covered by peritoneum of posterior wall of the lesser sac. Tuber omental : where the ant. surface of pancreas join the neck. -The posterior surface is devoid of peritoneum and is in contact with the aorta, the splenic vein and the left kidney. -The inferior surface is narrow between the anterior and posterior surfaces. It is covered by the peritoneum of greater omentum. 9

10 Relations: It s a retroperitoneal structure, found in the posterior abdominal wall in the epigastric and left hypochondrial region. Anteriorly : The transverse colon, mesocolon, the lesser sac and the stomach (remember: It s a part of the stomach bed). Posteriorly: - the bile duct, the portal (which is behind the neck of pancreas) and splenic veins, the inferior vena cava, the aorta, the origin of the superior mesenteric artery (which is behind the body of pancreas), the left psoas muscle, the left suprarenal gland, the left kidney, and the hilum of the spleen (the impression of the tail of pancreas lies below the hilum of the spleen). -It s a mixed gland that has an endocrine portion (the islets of Langerhans that secretes insulin and glucagon) and an exocrine portion (secretes pancreatic juice). Note: the origin superior mesenteric ARTERY is posterior to the body of pancreas while the superior mesenteric VESSELS are anterior to the uncinate process. (Therefore the uncinate process is between the aorta and the superior mesenteric vessels). 10

11 The pancreatic ducts: The main pancreatic duct opens into the major duodenal papilla. The accessory pancreatic duct opens into the minor duodenal papilla. (One inch above the main duct). Histology of the pancreas A section in the pancreas showing the endocrine part (islets of Langerhans) and the exocrine portion (the pancreatic acini). Endocrine part: under the light microscope, alpha and beta cells (islets of Langerhans) are shown. Exocrine: the pancreatic acini has certain characteristics in the pancreas from which one of them is polarity. The base is basophilic and the apex contains small zymogen granules. There are also centroacinar cells in the lumen of acini which extend to the intercalated duct. The intercalated ducts drain into interlobular ducts which then drain into the interlobar ducts and then into the pancreatic duct. NOTE: there are no striated ducts in the pancreas. NOTE: Alpha cells secrete glucagon which increases glucose levels in the blood unlike insulin which is secreted by Beta cells. Arterial supply of the pancreas The splenic and the superior pancreaticoduodenal (from the celiac trunk) and inferior pancreaticoduodenal (from the superior mesenteric) arteries supply the pancreas. As we see, the superior mesenteric and the celiac trunk supply the pancreas, so it follows the foregut and the midgut. Venous drainage 11

12 The inferior pancreaticoduodenal vein drains to the superior mesenteric vein. The superior pancreaticoduodenal vein which drains to the portal vein. Lymphatic drainage Pancreaticoduodenal lymph nodes drain into the superior mesenteric and the celiac lymph nodes. Nerve supply Parasympathetic from the vagus nerve. Sympathetic from the celiac ganglia, superior mesenteric ganglia, and sympathetic nerves around the renal artery. Congenital defects of pancreas: Annular pancreas: obstruction of the duodenum results in vomiting. Ectopic pancreas: part of the pancreas is in a site outside it s normal position. Clinical notes -Pancreatic anomalies will be discussed in embryology. -Cancer of the head of the pancreas (obstruction of bile duct) causes obstructive jaundice. Cancer of the body creates a pressure on the inferior vena cava and the portal vein causing portal hyper tension and congestion of the inferior vena cava. Acute pancreatitis: inflammation of the pancreas and the common cause is alcoholism

13 The spleen (check lab sheet #4) It is a reservoir of blood. - The spleen has: 1) 2 ends An upper end which is near to the posterior midline (4 cm far). A lower end which is lateral located on the midaxillary line. 2)2 borders An Upper border (or anterior/superior) which is sharp, thin and notched. A lower border (or posterior/ inferior) which is rounded, smooth and related to the renal impression above it. 13

14 3)2 surfaces Visceral surface: related to the stomach (that forms the gastric impression), the left kidney (renal impression), the tail of the pancreas( impression below the hilum and the left colic flexure (colic impression). And a costal surface :related to the 9 th, 10th and 11 th costal cartilage on the left side and its axon is parallel to the 10 th left rib. A trauma to this area will lead to a ruptured spleen. The costal surface is also related to the diaphragm which separates the spleen from the left pleural and lung.the spleen is completely covered by peritoneum. The hilum has two ligaments; the gastrosplenic and splenicorenal.contents between the 2 layers (very important): The gastrosplenic: short gastric vessels going to the fundus, beginning of left gastroepiploic artery going to the layers of greater omentum. The splenicorenal (leinorenal) ligament carries the splenic vessels and the tail of the pancreas. Blood supply of the spleen: the splenic artery (tortuous) branch from the celiac trunk. It runs along the upper border of the pancreas and then divides into 6 branches before entering the hilum. Veins: The splenic vein leaves the hilum and runs behind the tail and body of 14

15 pancreas. Behind the neck of pancreas, the splenic vein joins the superior mesenteric vein to form the portal vein. The lymph vessels emerge from the hilum and pass through a few lymph nodes along the course of the splenic artery and then drain into the celiac nodes. The nerves accompany the splenic artery and are derived from the celiac plexus. The en

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