Download Relations of Gallbladder

Gall bladder and biliary tract
Learning Objectives
At the end of the lecture the student should be able to:
 Describe the location, size, relation and blood supply of gallbladder
 Know differences between Intra & Extra Hepatic Billiary Systems
 Have the knowledge of different components of Extra-hepatic biliary System
 Mentions the right & left hepatic ducts, common hepatic duct, cystic ducts, bile
duct
 Have the knowledge of clinical condition related to gallbladder
Gallbladder
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Pear-shaped sac lying on the visceral surface of the right lobe of the liver in a
fossa between the right and quadrate lobes.
7 to 10 cm long
Connected to intestinal through cystic duct.
Volume of gallbladder is 30 – 35 cc.
Gallbladder stores the bile secreted by liver and Gallbladder empties the bile into
duodenum.
Parts of Gallbladder
 Fundus: the wide end of the organ, projects from the inferior border of the liver
and is usually located at the tip of the right 9th costal cartilage in the
midclavicular line.
 Body: contacts the visceral surface of the liver, the transverse colon, and the
superior part of the duodenum.
 Neck: narrow and tapered; directed toward the porta hepatis; it makes an Sshaped bend and joins the cystic duct.
Relations of Gallbladder
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Upper Surface:
Attached to the liver by connective tissue and vessels.
Under Surface:
Covered by peritoneum, which is reflected on to it from the surface of the liver
Relations of Body of Gallbladder
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Upper surface: liver
Under surface: Commencement of the transverse colon; and farther back usually
with the upper end of the descending portion of the duodenum, but sometimes
with the superior portion of the duodenum or pyloric end of the stomach.
Relations of Neck of Gallbladder
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Neck is narrow, and curves upon itself like the letter S; at its point of connection
with the cystic duct it presents a well-marked constriction.
Usually follows a gentle curve, the convexity of which may be distended into a
dilatation known as the infundibulum, or Hartmann's pouch.
Relations of Fundus of Gallbladder
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The fundus is completely invested by peritoneum
The fundus is in relation to:
Front: Abdominal parieties, immediately below the ninth costal cartilage
Behind: Transverse colon.
Biliary Ducts and Gallbladder
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Biliary ducts convey bile from the liver to the duodenum.
Bile is produced continuously by the liver and stored and concentrated in the
gallbladder, which releases it intermittently when fat enters the duodenum.
Intra-Hepatic Biliary Duct System
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The canaliculi drain into the small interlobular biliary ducts and then into large
collecting bile ducts of the intrahepatic portal triad, which merges to form the
right and left hepatic ducts. The right and left hepatic ducts drain the right and left
(parts of the) liver, respectively. Shortly after leaving the porta hepatis, the right
and left hepatic ducts unite to form the common hepatic duct
Extra-Hepatic Biliary Duct System
The extra-hepatic bile duct system comprising of
1.
2.
3.
4.
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Common Hepatic Duct
Gallbladder
Cystic Duct
Bile Duct
The Right and Left Hepatic Ducts leave the porta hepatis and join together to
form Common Hepatic Duct which on left side join by Cystic Duct to form Bile
Duct which opens into 2nd part of duodenum
Right & Left Hepatic Ducts
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Two main trunks issue from the liver at the porta, one from the right, the other
from the left lobe.
The Right and Left Hepatic Ducts
Common Hepatic Duct, which
passes downward and to the right for about 4 cm., between the layers of the lesser
omentum, where it is joined at an acute angle by the cystic duct, and so forms the
common bile duct.
Cystic Duct
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About 4 cm. long, runs backward, downward, and to the left from the neck of the
gall-bladder, and joins the hepatic duct to form the common bile duct.
Cystic Duct
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Mucous membrane lining the cystic duct is thrown into a series of crescenteric
folds, from five to twelve in number, similar to those found in the neck of the
gall-bladder.
They form a valve like structure with in the cystic duct called as Spiral Valve
which control the flow of bile from gall bladder.
When the duct is distended, the spaces between the folds are dilated, so as to give
to its exterior a twisted appearance.
Bile Duct
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Bile Duct is formed by the junction of the cystic and hepatic ducts
About 7.5 cm. long.
Bile Duct is accompanied by the hepatic artery and portal vein in the right free
margin of lesser omentum and descends downwards and passing behind the first
part of duodenum and opens by piercing the mid point of wall of 2nd part of
duodenum.
Major Duodenal Papilla, Ampulla of Vater.
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The Bile Duct pierces the wall of 2nd part of duodenum along with pancreatic
duct . Both the ducts joined together with in the wall of duodenum and form a
short duct which is dilated to form Ampulla of Vater which opens on the Major
Duodenal Papilla.
Blood Supply of Gallbladder
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Arterial Supply: The extra hepatic part of biliary tract is supplied by
Right Hepatic Artery
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Cystic Artery
Superior Pancreatiocduodenal Artery
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The main arterial supply of the Gallbladder is the cystic artery, which is a branch
of right hepatic artery.
Sometimes an accessory cystic artery also supplies the Gallbladder which is a
branch of either the right, or the left or even the common hepatic artery.
Cystic artery supplying the Gallbladder is divided into two divisions at the neck
of the Gallbladder and named as
Superficial cystic artery
Deep cystic artery.
Arterial Supply of Gallbladder
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Arterial Supply of Gallbladder
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The superficial branch is supplying the lower surface of the organ which is
covered with the peritoneum
The deep branch is supplying those areas which are above and also not covered
with the peritoneum that is non-peritoneal.
Calot's Triangle
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Calot's Triangle is an anatomic space bordered by the
 Common hepatic duct medially,
 Cystic duct inferiorly
 Inferior edge of the liver superiorly.
The cystic artery normally passes through the triangle; this anatomic feature is
important during laparoscopic cholecystectomies.
Venous Drainage of Gallbladder
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The cystic veins, draining the neck of the gallbladder and cystic duct, enter the
liver directly or drain through the portal vein to the liver, after joining the veins
draining the hepatic ducts and upper bile duct
Venous Drainage of Gallbladder
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The veins from the fundus and body of the gallbladder pass directly into the
visceral surface of the liver and drain into the hepatic sinusoids.
Because this is drainage from one capillary (sinusoidal) bed to another, it
constitutes an addition (parallel) portal system.
Lymphatic Drainage of Gallbladder
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The lymphatic drainage of the gallbladder is to the hepatic lymph nodes , often
through cystic lymph nodes located near the neck of the gallbladder. Efferent
lymphatic vessels from these nodes pass to the celiac lymph nodes.
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The nerves to the gallbladder and cystic duct pass along the cystic artery from the
 Celiac nerve plexus (sympathetic and visceral afferent [pain] fibers
 Vagus nerve (parasympathetic)
 Right phrenic nerve (somatic afferent fibers).
Parasympathetic stimulation causes contractions of the gallbladder and relaxation
of the sphincters at the hepatopancreatic ampulla
Nerve Supply of Gallbladder
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Cholelithiasis
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Gallstone is a concretion in the gallbladder, cystic duct, or bile duct composed
chiefly of cholesterol crystals.
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More common in females
Incidence increases with age.
In approx. 50% of persons, gallstones are asymptomatic.
For gallstones to cause clinical symptoms, they must obtain a size sufficient to
produce mechanical injury to the gallbladder or obstruction of the biliary tract.
Sites for Impaction of Gallstones
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The distal end of the hepatopancreatic ampulla is the narrowest part of the biliary
passages and is the common site for impaction of gallstones.
The infundibulum of the gallbladder is another common site for impaction.
Gallstones may also lodge in the hepatic and cystic ducts.
A stone lodged in the cystic duct causes biliary colic (intense, spasmodic pain).
Cholecystitis
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When the gallbladder relaxes, the stone may pass back into the gallbladder.
If the stone blocks the cystic duct, cholecystitis (inflammation of the gallbladder)
occurs because of bile accumulation, causing enlargement of the gallbladder.
Pain develops in the epigastric region and later shifts to the right hypochondriac
region at the junction of the 9th costal cartilage and the lateral border of the rectus
sheath, indicated by the linea semilunaris.
Cholecystitis
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Inflammation of the gallbladder may cause pain in the posterior thoracic wall or
right shoulder owing to irritation of the diaphragm. If bile cannot leave the
gallbladder, it enters the blood and causes jaundice
Variations in the Cystic and Hepatic Ducts
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Occasionally, the cystic duct runs alongside the common hepatic duct and adheres
closely to it. The cystic duct may be short or even absent. In some people, there is
low union of the cystic and common hepatic ducts.
References
• Gray’s textbook of anatomy
• Internet
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