PORTOCAVAL

ANASTOMOSIS
 The Hepatic Portal System

Figure 22.26
Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings
 Portal vein -- Development
• Two vitelline vein (infra-
hepatic part) - on either
side of developing
duodenum

• 3 transverse anastomoses
• (Cephalic and caudal –
ventral and middle –dorsal)

• Some part of these vein

disappear and remaining
part dev the portal vein

• Superior mesenteric &

Spleenic vein join
 Portal vein
 Collects blood from the abdominal part of alimentary
tract (excluding rectum and anal canal), spleen, pancreas
and gall bladder

 Drains into liver breaking up into sinusoids and draining

into the IVC (via hepatic veins)

 5 to 8 cm. long

 Superior mesenteric and splenic veins behind the neck of

pancreas( L2)
Runs upwards towards right
1.Behind the neck of pancreas
2.Behind the first part of duodenum
3.In the right free margin of lesser omentum
 Infraduodenal part
Ant: Neck of pancreas

Post:Inferior venacava

Retroduodenal part
Ant: D1, CBD
Gastroduodenal artery
.
Post: Inferior venacava
Supraduodenal part

Ant:
Hepatic artery
Bile duct

Posteriorly:

Inferior venacava
 Peculiarities of portal vein

1. Begins like vein from the capillary plexus of the gut

2. Ends like arteries by dividing into hepatic sinusoids

3. In addition to venous blood, it conveys the absorbed

products of the digested food

4. No valves

5. Acts as reservoir of blood – about 1/3rd of entire

volume of blood may be stored in portal system
Two streams of blood circulate through the
trunk of portal vein-

1. Blood from superior mesenteric -

conveyed by right branch of portal vein

2. Blood from splenic - carried by left

branch
 Formation
 Union of superior
mesenteric and
splenic veins
behind the neck of
pancreas(L2)
 Course

 Passes upwards and to

the right behind the
pancreas, 1st part of
duodenum

Enters within right free

margin of lesser
omentum

Reaches the porta

hepatis and terminates
by dividing into right and
left branch
Right branch(shorter and
vertical)
- receives cystic vein

Left branch(longer and

oblique)
- receives paraumbilical
vein
 Intra-hepatic part
After entering the liver, each branch divides and redivides.
Ends in the hepatic sinusoids, where portal venous blood
mixes with the hepatic arterial blood.

 Tributaries
Superior mesenteric vein
Splenic vein Formative tributaries
Right gastric vein
Left gastric vein Received by the trunk
of portal vein
Superior pancreaticoduodenal vein
Cystic vein Received by the two
Paraumbilical vein divisions of portal vein
Paraumbilical veins(portal system)
small veins that run in the falciform ligament,
and establish anastomoses between the portal
vein and the veins of the anterior abdominal wall
around the umbilicus
Superior
pancreaticoduodenall
vein

Paraumbilical vein

Superior mesenteric vein

Anastomosis
between portal and
systemic vein
(portosystemic/port
ocaval anastomosis)
These
anastomosis form
important routes
of collateral
circulation in
portal obstruction
Sites of portocaval anastomosis

1.At the umbilicus

B/W paraumbilical vein and the systemic
vein the anterior abdominal wall
+ In case of portal obstruction,
anastomosis around the umbilicus open
up and the veins enlarge that radiate
from the umbilicus like the spokes of the
wheel called caput medusae
Lateral thoracic vein Superior epigastric vein

Inferior epigastric vein

 …

2. At the lower
end of
oesophagus
oesophageal
tributaries of left
gastric vein (portal)
oesophageal
tributaries of
azygos vein
(systemic)
+ in portal
obstruction,
these veins are
distended
producing
oesophageal
varices
3. At the anal
canal

Superior rectal vein

(portal)
Middle and inferior
rectal veins
(systemic).
+ in portal
obstruction, the
radicles of
superior rectal
vein in the anal
canal are
distended
producing
piles/haemorrho
ids
4. At the bare area of
liver-
portal radicles (portal).
Retroperitoneal veins;
phrenic vein, intercostal
vein (systemic)
.
5.Behind the peritoneum
of the posterior
abdominal wall:
splenic and colic vein
(portal).
Left renal vein and
other tributaries of IVC
(systemic)
6.At the fissure for the
ligamentum venosum:

Rarely, the ductus venosus

remain patent and
connects the left branch
of the portal vein
directly to the IVC
 Applied anatomy
• Portal hypertension
– Normal pressure in the portal vein is about 5-10 mm of Hg
– Scarring and fibrosis in cirrhosis obstruct the portal vein
and its tributaries (above 40 mm of Hg)- portal
hypertension.
– The large volume of blood flowing from the portal system
to the systemic system produces dilation of veins at the
sites of portosystemic anastomosis eg.
• in the lower esophagus: esophageal varices

• Caput medusae around the umbilical

• Piles/haemorrhoids in the anal canal

Importance of Porto caval anastomosis:
In portal obstruction, back flow of blood through
radicles of caval system.

 Ascitic fluid accumulates in peritoneal cavity due to

venous stasis.

Thus, an indication of failure of communication

between portal vein and systemic veins.
In the lower esophagus: esophageal varices
Portal pressure: in portal vein 5- 15
mm Hg
Portal hypertension: pressure above
40 mm hg

Effects are:

Congestive splenomegaly
Ascites
Collateral circulation
Ascitic fluid accumulates in peritoneal cavity due to
venous stasis
RECENT TREATMENT OF PORTAL HYPERTENSION

TIPS--
Transjugular intrahepatic porto-systemic shunt—

Putting catheter in hepatic vein through internal

jugular vein under Radiological guidance

(catheter passes from internal jugular vein –

superior venacava- inferior venacava- then finally
to hepatic vein)– to dilate the portal branch
 Extra hepatic Biliary Apparatus

Contents -

•Hepatobiliary apparatus
•Pancreas
 Extra- hepatic Biliary apparatus

• Collects bile from the liver, stores in gall bladder

and transmit it to the second part of duodenum

• Consists of
1.The rt and lf hepatic ducts
2.The common hepatic duct
3.The gallbladder
4.The cystic duct
5.The common bile duct
 Gall bladder
• Pear-shaped reservoir of bile
• 7-10cm long,3cm broad
• Capacity -30 to 50ml

• Location: fossa on inferior

surface of rt lobe

• Parts
• Fundus, body, neck
• Fundus-
• Anterior, free, expanded portion
• Projects beyond the inferior border
• Comes in contact with ant abd wall

• Body
• Main part of gallbadder, tapers
posteriorly
• Upper surface-gallbladder fossa
• Lower surface-peritoneum

• Neck
• Funnel shaped
• Posteromedial part-Hartmannʼs pouch
 Calotʼs triangle/triangle of cystic artery
• Boundaries
• Above n lat- inferior surface of
liver
• Below n lat- cystic duct
• Med- common hepatic duct

• Content-cystic artery
• Imp guide for surgeon to
identify, divide n ligate cystic
artery n cystic duct during
cholecystectomy (surgical
removal of the gallbladder)
 Bile duct
• Union of cystic duct and
common hepatic ducts

• Behind head of pancreas-joins

with MPD form ampulla of vater
• Opens in major duodenal papilla

• Guarded by

Sphincter of Oddi
 SPHINCTER RELATED TO THE BILE
AND PANCREATIC DUCTS
1. SPHINCTER
CHOLEDOCHUS

2. SPHINCTER
PANCREATICUS

3. SPHINCTER AMPULLAE
OR SPHINCTER OF ODDI
ARTERIAL SUPPLY
 Nerve supply
• Through hepatic plexus (receive the fibers form
coelic plexus, right and left vagi and right phrenic
nerve)

– Sympathatic: from T7 to T9 (vasomotor and motor

to the sphincters)

– Parasympathatic: vagus (motor to the musculature

of the gall bladder and bile ducts, inhibitory to the
sphincters)
 Clinical anatomy
• Cholicystitis:
– Inflammation of the gall bladder

– Often associated with the cholelithiasis (formation of

stone in the gall bladder, cystic duct, or bile duct),
alcohol abuse, tumours of gall bladder

– Surgical removal of the gall bladder is called

cholicystectomy

– When a finger is placed just below the costal margin at

the tip of ninth costal cartilage (at the midclavicular
line), the patient feels sharp pain on inspiration. The
presence of sharp pain is referred to as Murphy’s sign
• Stone in gall bladder
Common site- Hartmannʼs pouch
Risk factors- fat, forty, fertile, female
• Referred pain-
1) Epigastrium (through vagus)
2) Over inferior angle of scapula
(through sympathetic –Greater
splanchnic nerve-T7)
3) Right shoulder (through phrenic
nerve- C4
• When gall stone tries to pass
through the bile duct it causes
intense, spasmodic pain called
biliary colic in the epigastrium
Tumors of pancreas-obstructive
jaundice
 development
• From the caudal end of foregut, an endodermal
hepatic bud arises during 3rd week of
development
• Connection betw hepatic bud and foregut
narrows-bile duct
• Outgrowth from bile duct-gallbladder and
cystic duct
• Mesoderm of septum transversum-
hematopoietic cell, connective tissue,
falciform ligament