AP: Hepatic System, Biliary System, and Pancreas

10/21/25

stomach 4 regions

1. cardia

2. fundus

3. body

4. pylorus

stomach

lined with RUGAE

• prominent longitudinal mucosal gastric folds for absorption and stretch

• gets more prominent as you get closer to pyloric region

cardia

surrounds the superior opening of the stomach at the T11 level.

the region of GE junction

fundus

rounded, often gas filled portion superior to and left of the cardiabody

body

large central portion inferior to the fundus

pylorus

connects stomach to the duodenum (joins 1st part of duodenum)

• divided into the pyloric antrum, pyloric canal, and pyloric sphincter

pyloric sphincter

demarcates the transpyloric plane at level L1

ring of smooth muscle connecting stomach and small intestine

lesser curvature of stomach

right border of stomach

• lesser omentum attaches

• hepatogastric ligament is here!

hepatogastric ligament

attachment point between lesser omentum and liver

greater curvature

convex superior border

greater omentum suspended from margin

gastroesophageal junction

transition point where esophagus and stomach meet

squamous epithelium of esophagus → columnar epithelium of the gastric cardia

risk factors: chronic GERD/obesity

liver digestive function

production of bile

liver*

1. nutrient processing

2. detoxification

3. cholesterol production

4. storage of fat and glycogen

5. blood sugar regulation*

parts of the liver

• right lobe

• left lobe

• quadrate lobe

• caudate lobe

• falciform ligament

• round ligament/ligamentum teres

• portal hepatis

right lobe of liver

largest

gallbladder is here

left lobe of liver

the falciform ligaments anteriorly separates the right and ____

quadrate lobe of liver

lies between gallbladder and round ligament of the liver

caudate lobe of liver

lies between the IVC, ligamentum venosum, and porta hepatis

falciform ligament of liver

peritoneal reflection off anterior abdominal wall with round ligament in its margin

extends to umbilicus (ligamentum teres)

divides to L and R lobe of liver

round ligament/ligamentum teres of liver

ligament that contains obliterated umbilical vein

found with falciform

bare area of liver

attachment to diaphragm but with no ligaments/peritoneal covering, location on two sides

part of the posterosuperior right lobe that directly touches and attaches to the right diaphragm without peritoneal covering.

porta hepatis

site where vessels, ducts, lymphatics, and nerves enter or leave liver (hilum)

fundus

superior part just under dome of diaphragm

greater omentum

double layer extension of peritoneum extending from greater curvature of stomach then double backs and attaches to transverse colon

comprised of gastrocolic, gastrosplenic, gastrophrenic, and splenorenal ligaments, and upper anterior part of transverse mesocolon

lesser omentum

double layer of peritoneum extending from lesser curvature of stomach and proximal duodenum to inferior surface of liver

liver triangular ligaments

right and left

suspend the liver and attach to diaphragm

liver role

• storage of energy sources (Glycogen, fat, protein, vitamins)

• production of cellular fuels (Glucose, fatty acids, ketoacids)

• production of plasma proteins, clotting factors, lymph

• metabolism of toxins and drugs

• makes bile

• excretes bilirubin

• phagocytosis of foreign material

celiac trunk origin and location

arises from anterior surface of the abdominal aorta below the aortic hiatus of the diaphragm and at the T12 vertebral level

1. left gastric

2. splenic artery

3. left gastroepiploic artery

4. common hepatic artery

5. proper hepatic artery

6. gastroduodenal artery

7. superior pancreaticoduodenal artery

8. right gastroepiploic artery

left gastric artery

from the splenic artery

lesser curvature of stomach, lower esophagus, fundus

splenic artery

branches to the LGA (left gastroepiploic artery)

spleen, pancreas, greater curvature of stomach

common hepatic artery

splits into the proper hepatic artery and the gastroduodenal artery

liver, gallbladder, stomach, pancreas, duodenum

proper hepatic

L and R hepatic artery

R hepatic artery

gives rise to cystic artery

celiac trunk function

provides blood supply to the stomach, GB, liver, spleen, head of pancreas, duodenum

gastroduodenal artery

splits into the superior pancreaticoduodenal artery and right gastroepiploic artery

portal triad

common bile duct, proper hepatic artery, and portal vein

common bile duct

extension of the cystic duct and common hepatic duct

proper hepatic artery

splits from celiac trunk → common hepatic artery → proper hepatic artery

bile

exits the system while everything else wants to enter

portal vein*

formed by SMV and splenic vein

travels cephalad behind hepatic artery and splits at liver hilum to enter liver via right and left branches*

spleen function

filtration and storage of RBC and PLTs

metabolize iron

role in immune system

size of clenched fist

spleen location

found LUQ, posterolateral to stomach, protected by lower left rib cage

gastrosplenic ligament (spleen)

connection to stomach

contain short gastric arteries (branches of splenic vessels) and supply blood to fundus

splenorenal ligament (spleen)

connection to left kidney

contains splenic artery and vein

phrenicocolic ligament (spleen)

connection to diaphragm

sliding hiatus hernia

a portion of the stomach that is going back and forth

it’s like one side inside of another

happens at the GE junction

can cause reflux

surgery to repair

paraoesophageal hiatus hernia

fundus of the stomach squeezes through the diaphragm and gets stuck there

cannot be reduced

happens at the GE junction

can cause reflux

surgery to repair

GERD common symptoms

heartburn

mimics chest/back pain

chronic cough asthma

GERD risk factors

obesity

moderate/high ETOH

smoking

sedentary lifestyle/post-prandial activity

dietary triggers

pharm side effects

GERD critical conditions

precancerous conditions (Barrett’s) and esophageal edenocarcinoma

GERD long term complication

esophagitis/strictures

GERD anatomy

GE junction

crus of diaphragm

GERD tx

lifestyle modification

surgery

discontinue meds causing side effects

GERD surgery

nissen fundoplication (wrapping fundus around GE function)

GERD meds

doxy/tetra, biphosphonates, iron supplements, GLP-1

right sagittal groove, left sagittal groove, transverse groove

helps define the region of the posterior liver and helps you identify the 4 main lobes

posteriorly, the ligamentum venosum separates the left lobe from everything else

hiatal hernia types

sliding and paraesophageal

widening of esophageal hiatus results in protrusion of stomach superiorly

sliding hernia

90% of hernia

part of stomach and distal esophagus (GE) intermittently slide up the thorax

GI tract

GI tract (pancreas, spleen, etc) → portal vein → liver

IVC

brings blood from liver → heart

portal triad blood flow

triad splits into the branches of common bile duct, proper hepatic artery, and portal vein

these branches supply L and R lobes of liver

hepatocytes

functional unit of liver is a lobule which has these

further organized into sinusoids that contain Kupffer cell

sinusoid region

does its work and eventually the extensions of hepatic vein will take blood from this region and take out

liver*

high level of malignancy metastases (20%+) *

portal vein

75% of blood flow to the liver is from this!

portal system

vascular arrangement where arteries or veins carry blood between capillary beds of 2 separate organs without going to the heart first

allows collection of nutrients and filtrates toxins in liver before exiting via hepatic veins to IVC and then the heart

examples of portal system

hepatic, renal, and hypophyseal (connects the hypothalamus with pituitary) portal system

hiatal hernia symptoms

GERD

chest discomfort

trouble swallowing

cough

incidental

hiatal hernia risk factor

age

obesity

persistent pressure (repeated vomiting/cough/strain)

congenital

hiatal hernia critical complication

strangulation of stomach resulting in ischemia/infarction (paraesophageal)

hiatal hernia anatomy

GE junction/fundus

portal vein

• originates behind neck of pancreas

• receives blood supply from superior mesenteric vein, inferior mesenteric vein, and splenic vein and gastric veins

  • these vessels contain venous return from the celiac trunk, SMA, and IMA

valveless

portal vein, SMV, IMV, and splenic vein

redundancy

systems of dual vessels (through IVC and portal veins) to take blood away from GI

cause symptoms if there’s a backup in the portal vein

liver disease

now sinusoids can’t work…

the blood can’t come out easily and backs up

and now IVC has to try to pick up the slack

portal vein tributaries

• splenic vein

• superior mesenteric

  • inferior mesenteric

other tributaries

left gastric vein, right gastric vein, paraumbilica veins

4 most important portosystemic anastomotic regions

lower esophagus, rectum, umbilicus, and bare area of liver

portal system drains

• what happens if there is a blockage?

the GI tract, spleen, pancreas, and gallbladder

if there is a blockage, venous return redundancy through caval and azygous system (bypass liver)

hemorrhoids

engorged rectal veins, backflow of blood from the superior rectal vein

if they enlarge in the GI region, this happens

esophageal vein varicoceles

if the veins enlarge in the esophageal region and there’s a risk of bursting. if they do burst → hemoptysis or other bleeding

lower esophageal (redundancy)

connection where venous and systemic blood connect

left gastric vein & esophageal vv

umbilical (redundancy)

connection where venous and systemic blood connect

paraumbilical veins & superior + inferior epigastric vv

rectal (redundancy)

connection where venous and systemic blood connect

superior rectal vein & middle + inferior rectal v

bare area of liver(redundancy)

connection where venous and systemic blood connect

right and left colic vv & retroperitoneal and lumbar vv

redundancy

for the ones above, if there is a backup in one of them, their “paired” one will have to work more

for ex, if the esophageal vv is backed up, the left gastric vein will work harder to cover

engorge and expand

if you have a vein under high pressure or prevent blood flow from happening, what will happen?

(what they do for drawing blood)

portal hypertension

a result of hepatic disease

liver

blood that is returning to the __, you can end up getting secondary malignancy (and track it)

tributaries/redundancies

preventing ischemia/more than one way to perfuse and filtrate

biliary system organs

liver, gallbladder, bile ducts that produce, store, and transport bile

bile

made by the liver cells, digests fats

flows through small ducts into the right and left hepatic ducts, join to form the common hepatic duct

gallbladder

bile is stored here, which is concentrated and then released through the cystic duct → common duct

common bile duct*

empties bile into the duodenum, controlled by the sphincter of Oddi to regulate flow and prevent reflux*

stones

can get stuck anywhere in the biliary tree

if it goes into the pancreatic duct → inflammation → pancreatitis (can be fatal) [gallstone pancreatitis]

if it gets stuck in the common hepatic duct = ERCP/MRCP (use stents, retrieve stones, use antibiotics, STOP EATING/NPO and fluids)

may need to do surgery (acute/controlled)

flow of biliary system

creation of bile goes downward from L and R hepatic duct (collection) into the common hepatic duct → (store) @ gallbladder (gallbladder can squeeze, then send stored bile into the common bile duct → duodenum)

some will continue flow down the common bile duct into the hepatopancreatic ampulla (of vater) → duodenum (2nd portion)

gallbladder parts

fundus, body, infundibulum, and neck

gallbladder function

receive, store, and concentrate bile that is secreted by the liver

• stores 30-55cc bile

ampulla

surrounded by smooth muscle sphincter (Oddi) preventing reflex of gastric content back into ampulla

joining of the two ducts

the amt of bile liver makes in a day

900cc bile/day