Deirdre Fox Study Guides MB2 2023
Problem 2.03
Study Guide 1
1. Discuss the anatomy of the spleen in terms of its:
a. Location and surface anatomy
The spleen (lien) is found in the left hypochondriac region of the abdomen (left upper
quadrant).
Anterior Posterior Inferior Medial
Diaphragm
Left colic flexure Left kidney
Stomach Left lung
(splenic flexure) Tail of the pancreas
Ribs 9-11
More precisely, the spleen is located posterior to the stomach and anterior to the left
hemidiaphragm at the level of ribs 9-10.
Medial to the spleen is the left kidney; superior is the diaphragm, while inferiorly it rests
directly on the left colic flexure (splenic flexure).
Anatomical Relations
It lies in close proximity to other structures in the abdomen:
b. External features (surfaces, borders, relations, ligaments attached)
The spleen is a purple, fist-sized organ. It is wrapped by a fibroelastic capsule which allows
the spleen to significantly increase its size when necessary.
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The spleen is an intraperitoneal organ, so all of its surfaces are covered with
visceral peritoneum.
Only the hilum of the spleen, the site through which the splenic artery and vein pass, is
peritoneum-free.
Surfaces:
Organs near to the spleen leave their impressions on its surfaces which, together with spleen
borders, can easily be observed and described.
Diaphragmatic (lateral) surface leans onto the adjacent part of the diaphragm, thus it is
slightly convexed to perfectly fit into the concavity of the left hemidiaphragm. This surface
also shows impressions from ribs 9-11.
Medial surface of the spleen (Visceral) shows three areas of impression. The colic area is the
impression of the left colic flexure, the gastric area is the impression of the stomach, and
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the renal area is the impression of the left kidney. The splenic hilum is found in the central
part of this surface.
Borders:
The spleen has three borders (superior, inferior, and anterior) as well as
two extremities (anterior and posterior).
The superior border bounds the gastric area, the inferior border bounds the renal area
and the anterior border bounds the colic area.
Ligaments:
The gastrosplenic ligament connects the hilum with the greater curvature of the stomach. It
contains the short gastric vessels and left gastroomental (gastroepiploic) arteries and veins.
The splenorenal ligament connects the hilum of the spleen with the left kidney. It transmits
the splenic artery and vein.
The spleen sits on the phrenicocolic ligament which originates from the colon and is also
known as the sustentaculum lienis.
Structure:
The spleen is roughly ovoid in shape. The parenchyma of the spleen is called pulp. Based
on the color of the pulp on fresh sections, white and red pulp can be distinguished.
It is an Ovoid fibrous capsule with internal maze of sinuses containing dense lymphoid
tissue of the spleen (white pulp- it is the accumulation of lymphocytes around an arterial
vessel) surrounded by blood sinusoids having cords of lymphoid tissue (red pulp-
consists of splenic venous sinuses and cords (of Billroth), linings of splenic macrophages
around the sinuses)
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Its size varies in different individuals and in the same individual at different times. For
example, it hypertrophies during infectious diseases (portal hypertension) and atrophies
in old age (Sarcopenia).
Neurovasculature:
Blood Supply- Left Gastric Artery
Abdominal Aorta Coeliac Trunk Splenic Artery
Common Hepatic Artery
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Venous Drainage-
Lymphatic Drainage:
The lymphatic vessels of the spleen follow the splenic vessels and drain into the pancreaticosplenic
lymph nodes, and ultimately the coeliac nodes.
Nerve Supply: Coeliac Plexus
Clinical Relation:
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Obstruction of venous drainage through splenic vein, leads to increased pressure and reversal of the
normal direction of blood flow through the vein. This backflow of blood through the splenic vein can
cause splenomegaly, a condition in which the spleen becomes engorged and enlarged.
In order to shunt blood around the occluded splenic vein and maintain circulation, collateral
pathways are employed in the form of portosystemic anastomoses and splenoportal collaterals.
For example, the blood is shunted through the portosystemic anastomosis between the gastric veins
(portal) and the esophageal veins (systemic). This often results in dilated submucosal veins within
the stomach and lower esophagus called gastric and esophageal varices, respectively.
2. Outline the biliary system
The biliary system is the part of the accessory digestive tract that is responsible for
producing, storing and transporting bile.
It includes the gallbladder, and the intra- and extrahepatic biliary tree (i.e. bile
canaliculi, hepatic, cystic, and bile ducts).
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The gallbladder is a pear-shaped sac that concentrates and stores bile secreted from the
liver. It can hold between 30 and 60 mL of bile and, when stimulated, it releases its contents
into the duodenum, through the cystic and biliary ducts. The fundus (base) of
the gallbladder usually appears below the edge of the liver in contact with the anterior
abdominal wall at the tip of the ninth right costal cartilage.
Nerve Supply: hepatic plexus- gallbladder
Small branches of the vagus nerve (CN X) - retroduodenal common bile duct and
hepatopancreatic ampulla of Vater.
It lies on the right edge of the hepatic quadrate lobe , in the gallbladder fossa on the visceral
surface, partly covered by peritoneum on its posterior and inferior surfaces. The anterior
surface contacts the hepatic visceral surface.
The gallbladder comprises three parts: the fundus, body and neck, which tapers and makes
an S-shaped bend to join with the cystic duct. The cystic duct is 2–4 cm long and joins the
common hepatic duct to form the common bile duct. This travels anterior to the portal vein
and courses through the head of pancreas to open into the second part of the duodenum
through the sphincter of Oddi (hepatopancreatic sphincter) at the ampulla of Vater
(duodenal papilla- where the pancreatic duct (Duct of Wirsung) and bile duct join together
to drain into the duodenum).
The neck, as well as the cystic duct, has a spiral folding of its mucus membrane, forming a
spiral valve (of Heister). This keeps the cystic duct open constantly for two purposes:
To allow bile to pass into the gallbladder from the liver when the bile duct is closed
[by the sphincter of Oddi( Sphincter of pancreatic duct) and the choledochal
sphincter(Boyle Sphincter-sphincter for common bile duct)]
To allow bile to be secreted into the duodenum when the gallbladder contracts.
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(A) Anterior aspect: gall bladder fundus projecting below liver. (B) Gall bladder and extrahepatic biliary
tree.
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Patterns of Pain
Gallbladder Pain- Location: Pain in the midepigastrium (may be perceived as heartburn)
Referral:
RUQ of abdomen
RUQ pain may be associated with right shoulder pain
Both may be associated with back pain between the scapulae; back pain can occur alone as
the primary symptom
Pain may be referred to the right side of the midline in the interscapular or subscapular area
Anterior rib pain (soreness or tender) at the tip of the tenth rib (less often, can also affect
ribs 11 and 12)
Possible etiology:
Gallstones (cholelithiasis), Gallbladder inflammation (cholecystitis), Neoplasm, Medications:
use of hepatotoxic drugs
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Common Bile Duct Pain- Location: Pain in midepigastrium or RUQ of abdomen
Referral:
Epigastrium: heartburn (choledocholithiasis)
RUQ pain may be associated with right shoulder pain
Both may be associated with back pain between the scapulae
Pain may be referred to the right side of the midline in the interscapular or subscapular area
Possible etiology:
Common duct stones
Common duct stricture (previous gallbladder surgery)
Pancreatic carcinoma (blocking the bile duct)
Medications: use of hepatotoxic drugs
Neoplasm
Primary biliary cirrhosis
Choledocholithiasis (one or more gallstones (obstruction of common duct)
The primary pain pattern from the liver, gallbladder, and common bile duct (dark red) presents typically in
the midepigastrium or right upper quadrant of the abdomen. Innervation of the liver and biliary system is
through the autonomic nervous system from T5 to T11. Liver impairment is primarily reflected through the
ninth thoracic distribution. Referred pain (light red) from the liver occurs in the thoracic spine from
approximately T7 to T10 and/or to the right of midline, possibly affecting the right shoulder (right phrenic
nerve). Referred pain from the gallbladder can affect the right shoulder by the same mechanism. The
gallbladder can also refer pain to the right interscapular (T4 or T5 to T8) or right subscapular area.
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Study Guide 2
1. Discuss the anatomy of the liver in terms of:
a. location
The liver is a large organ found in the upper right quadrant of the abdomen. The liver is
predominantly located in the right hypochondrium and epigastric areas, and extends into the
left hypochondrium
b. external features (surfaces, borders, lobes, relations, ligaments attached)
Lobes: right, left, caudate, quadrate
Surfaces: diaphragmatic, visceral
Ligaments: coronary, left triangular, falciform, round ligament, venous
Fissures and recesses: porta hepatis (central fissure), subphrenic recess, hepatorenal recess
The external surfaces of the liver are described by their location and adjacent structures. There
are two liver surfaces – the diaphragmatic and visceral:
Diaphragmatic surface – the anterosuperior surface of the liver.
o It is smooth and convex, fitting snugly beneath the curvature of the diaphragm.
o The posterior aspect of the diaphragmatic surface is not covered by visceral
peritoneum, and is in direct contact with the diaphragm itself (known as the ‘bare
area’ of the liver).
Visceral surface – the posteroinferior surface of the liver.
o With the exception of the fossa of the gallbladder and porta hepatis, it is covered
with peritoneum.
o It is moulded by the shape of the surrounding organs, making it irregular and flat.
o It lies in contact with the right kidney, right adrenal gland, right colic flexure,
transverse colon, first part of the duodenum, gallbladder, oesophagus and
the stomach.
There are a number of ligaments that attach the liver to the surrounding structures. These are
formed by a double layer of peritoneum.
Falciform ligament – this sickle-shaped ligament attaches the anterior surface of the liver to
the anterior abdominal wall. Its free edge contains the ligamentum teres, a remnant of the
umbilical vein.
Coronary ligament (anterior and posterior folds) – attaches the superior surface of the liver
to the inferior surface of the diaphragm and demarcates the bare area of the liver The
anterior and posterior folds unite to form the triangular ligaments on the right and left lobes
of the liver.
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Triangular ligaments (left and right):
o The left triangular ligament is formed by the union of the anterior and posterior
layers of the coronary ligament at the apex of the liver and attaches the left lobe of
the liver to the diaphragm.
o The right triangular ligament is formed in a similar fashion adjacent to the bare area
and attaches the right lobe of the liver to the diaphragm.
Lesser omentum – Attaches the liver to the lesser curvature of the stomach and first part of
the duodenum. It consists of the hepatoduodenal ligament (extends from the duodenum to
the liver) and the hepatogastric ligament (extends from the stomach to the liver). The
hepatoduodenal ligament surrounds the portal triad.
In addition to these supporting ligaments, the posterior surface of the liver is secured to
the inferior vena cava by hepatic veins and fibrous tissue.
