THE GALLBLADDER

I. Introduction/General InformationA. Location:1. Epigastric region 2. Right hypochondriac region 3. On inferior surface of liver 4. Between quadrate and right lobes B. Pear-shaped, hollow structure

Location of Gallbladder

Gallbladder

Introduction/General Information, cont.

C. Fundus slants inferiorly, to the rightD. Attached to liver by loose (areolar) connective tissueE. Peritoneum covers free surfaces

The Gall Bladder and Bile DuctsFundus

Introduction, continued F. Normal measurements:7-10 cm long~ 6 cm diameter30 35 cc volumeG. Body and neck directed toward porta hepatis

Introduction, continued H. Neck is continuous with cystic duct

I. Cystic duct:1. joins common hepatic duct 2. superior and posterior to pylorus of stomach

The Gallbladder and Biliary System with Pancreas

Introduction, continued J. Common Bile Duct 1. 10-15 cm long 2. Courses through lesser omentum 3. Deep to pyloric sphincter 4. Narrow tube, 1-2 mm diameter5. Should be no more than 6 mm in diameter

CBD, continued 6. May be 8-10 mm in post-cholecystectomy patients7. Normally has smooth walls8. Joins with pancreatic duct9. On L.S., convergence is seen a. anterior to portal veinb. posterior to head of pancreas

Introduction, continued

K. Combined duct empties into duodenum @ ampulla of VaterL. Sphincter of Oddi guards duct, regulates bile flow Closed: bile goes into gallbladder Open: bile goes into duodenum

Ampulla of Vater with CBD and Pancreatic DuctAmpulla of Vater

II. Detailed AnatomyA. Fundus of GB: 1. may be palpated2. in angle between lateral border of right rectus abdominis and costal margin3. At level of elbow4. Most anterior visceral structure

Detailed Anatomy, cont.B. Body of Gallbladder1. Visceral surface of liver2. Deep to transverse colon or hepatic flexure of colon3. Descending portion of duodenum is medial

Anatomical Position of the GBGallbladderIVCLesser OmentumCommon Bile DuctGB in situ, anterior view

Detailed anatomy, continued C. Infections may spread to:1. duodenum, liver, colon, anterior abdominal wall, peritoneal cavity 2. Direct or via lymphatics3. Regions on the right half of the abdomen

Detailed anatomy, continued

4. Fistulas may develop: a. abnormal opening between two organs b. with duodenumc. Anastomoses with jejunum

Detailed anatomy, continued

E. Neck of gallbladder 1. continuous with cystic duct 2. characterized by a spiral valve (of Heister) 3. makes catheterization difficult

GB AnatomySpiral Valve (of Heister) in Cystic Duct

Detailed anatomy, continued F. Hartmanns Pouch1. Infundibulum of gallbladder2. Lies between body and neck of gallbladder3. A normal variation4. May obscure cystic duct 5. If very large, may see cystic duct arising from pouch

Hartmanns PouchHartmanns Pouch of the Gallbladder

Cystic Artery BranchesGastro-duodenal A.

Detailed anatomy, continued G. Cystic Duct1. 3-4 cm long2. Extends from neck of gallbladder to common hepatic duct 3. Joins with common hepatic duct inferior to porta hepatis4. Spiral valve may extend into neck of gallbladder

Cystic Duct

Detailed anatomy, continued H. Epiploic Foramen (of Winslow): an opening deep to lesser omentum leads to lesser peritoneal cavity separates Right portal vein and IVC important clinically

Epiploic Foramen Epiploic foramen

Lesser peritoneal cavityMidsagittal Section through Abdominopelvic Cavity

Detailed anatomy, continued

5. Surgically, foramen can be used to palpate CBD to check for stones6. Clinically significant because abscesses may spread via this foramen into lesser peritoneal cavity

Detailed anatomy, continued CBD has: hepatic artery on left and portal vein posterior descends in free margin of lesser omentum Retroduodenal (2nd) portion of CBD runs parallel to gastroduodenal artery GDA lies to left of CBD

Detailed anatomy, continued K. Last part of CBD 1. passes through pancreas 2. in tube or sulcus closely related to:a. IVCb. Portal Veinc. Gastroduodenal artery

Detailed anatomy, continued 3. On Transverse scans: a. CBD appears as rounded, fluid-filled structure b. anterior and lateral to portal vein

Biliary tract, continued

4. On Longitudinal Scans:1. the common hepatic duct crosses anterior to right portal vein 2. the CBD courses inferior to head of pancreas

Biliary tract, continued L. Blood supply to gallbladder:1. Cystic artery a. arises (~ 60% of the time) from right hepatic artery b. passes posterior to hepatic duct, then divides

Arterial Supply to the Gallbladder

Cystic artery Right hepatic arteryProper hepatic arteryCommon hepatic artery

Blood supply, continued c. Superficial branch, to peritoneal surface of GBd. Deep branch, to hepatic surface of GBe. May be doubled or tripled

Blood supply, continued

Right Hepatic ArteryCystic Artery, Superficial BranchCystic Artery, Deep Branch

Common Hepatic ArteryProper Hepatic Artery

Gastroduodenal Artery

Blood supply, continued 2. Small arteries supplying CBD a. arise from cystic artery b. posterior branch of superior pancreaticoduodenal artery3. May small veins drain directly into the liver

Detailed Anatomy, cont.M. GB must be distended with bile to be clearly visualized Phyrigian Cap Anatomical variation Fund is is folded back on itself not pathological

Detailed Anatomy, cont.O. Lymphatic drainage of GB1. Terminate @ celiac nodes2. Cystic node at neck of GBa. Actually a hepatic nodeb. Lies at junction of cystic & common hepatic ducts3. Other lymph vessels also drain into hepatic nodes

III. Gallbladder Diseases

A. Cholelithiasis & Cholecystitis 1. Cholecystitis = inflammation of GB2. Cholelithisis = Stone(s) in GB

CholelithiasisGB shows likely sites of stone formation/deposition

Gallbladder Diseases, continued

B. Failure to delineate GB1. Contracted (empty) due to ingestion of food, smoking2. Secondary to cholecystectomy

Gallbladder Diseases, continued C. Intraluminal defects1. GB Carcinomaa. US useful in diagnosis b. mass producing thickening and irregularity in wallc. Calculi found frequently

Gallbladder Diseases, continued 2. Polyps of GBa. Intraluminal echogenic projectionsb. do not change position with patientc. Must be differentiated from septations, mucosal folds 1. septations extend across lumen2. folds change configuration upon inspiration

Gallbladder diseases, continued 3. Viscid Bile, sludgea. Due to intermittent obstruction of CBD or cystic ductb. Seen in patients with bile stasis c. Produces linear, echogenic interface within GB

Diseases of the Biliary tract D. Obstructive jaundice: liver patterns a. On T.S., Parallel channel sign: 1. presence of two parallel tubular structures near portal vein 2. right portal vein with dilated right hepatic duct anterior

Biliary tract, continued b. On L.S., the double barrel or shotgun sign is seen 1. not always accurate2. seeing same vessels as parallel channel signc. As obstruction progresses, lobulated structures visible

5. Transparent Liver (5)1. Portal Cir. (13)