Transcript THE GALLBLADDER

THE GALLBLADDER
I. Introduction/General Information
A. 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, con’t.
C. Fundus slants inferiorly, to the right
D. Attached to liver by loose (areolar)
connective tissue
E. Peritoneum covers free surfaces
The Gall Bladder and Bile Ducts
Fundus
Introduction, continued …
F. Normal measurements:
7-10 cm long
~ 6 cm diameter
30 – 35 cc volume
G. 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 diameter
5. Should be no more than 6 mm in
diameter
CBD, continued …
6. May be 8-10 mm in postcholecystectomy patients
7. Normally has smooth walls
8. Joins with pancreatic duct
9. On L.S., convergence is seen
a. anterior to portal vein
b. posterior to head of pancreas
Introduction, continued …
K. Combined duct empties into duodenum
@ ampulla of Vater
L. Sphincter of Oddi guards duct, regulates
bile flow
1. Closed: bile goes into gallbladder
2. Open: bile goes into duodenum
Ampulla of Vater with CBD and Pancreatic Duct
Ampulla of Vater
II. Detailed Anatomy
A. Fundus of GB:
1. may be palpated
2. in angle between lateral border of right
rectus abdominis and costal margin
3. At level of elbow
4. Most anterior visceral structure
Detailed Anatomy, con’t.
B. Body of Gallbladder
1. Visceral surface of liver
2. Deep to transverse colon or hepatic
flexure of colon
3. Descending portion of duodenum
is medial
Anatomical Position of the GB
IVC
Gallbladder
Lesser Omentum
Common Bile Duct
GB 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 lymphatics
3. Regions on the right half of the abdomen
Detailed anatomy, continued …
4. Fistulas may develop:
a. abnormal opening between two
organs
b. with duodenum
c. 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 Anatomy
Spiral Valve
(of Heister) in
Cystic Duct
Detailed anatomy, continued …
F. Hartmann’s Pouch
1. Infundibulum of gallbladder
2. Lies between body and neck of
gallbladder
3. A normal variation
4. May obscure cystic duct
5. If very large, may see cystic duct arising
from pouch
Hartmann’s Pouch
Hartmann’s Pouch of
the Gallbladder
Cystic Artery Branches
Gastroduodenal A.
Detailed anatomy, continued …
G. Cystic Duct
1. 3-4 cm long
2. Extends from neck of gallbladder to
common hepatic duct
3. Joins with common hepatic duct
inferior to porta hepatis
4. Spiral valve may extend into neck of
gallbladder
Cystic Duct
Detailed anatomy, continued …
H. Epiploic Foramen (of Winslow):
1. an opening deep to lesser
omentum
2. leads to lesser peritoneal cavity
3. separates Right portal vein and IVC
4. important clinically
Epiploic Foramen
Epiploic foramen
Lesser peritoneal
cavity
Midsagittal Section through
Abdominopelvic Cavity
Detailed anatomy, continued …
5. Surgically, foramen can be used to
palpate CBD to check for stones
6. Clinically significant because
abscesses may spread via this
foramen into lesser peritoneal cavity
Detailed anatomy, continued …
I. CBD has:
1. hepatic artery on left and portal vein
posterior
2. descends in free margin of lesser
omentum
J. Retroduodenal (2nd) portion of CBD
1. runs parallel to gastroduodenal artery
2. 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. IVC
b. Portal Vein
c. 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

Right hepatic artery
 Proper hepatic artery
Common hepatic artery


Cystic artery
Blood supply, continued …
c. Superficial branch, to
peritoneal surface of GB
d. Deep branch, to hepatic
surface of GB
e. May be doubled or tripled
Blood supply, continued …



Right Hepatic Artery
Cystic Artery, Superficial
Branch
Cystic Artery, Deep
Branch
Proper Hepatic
Artery
Common Hepatic
Artery
Gastroduodenal
Artery
Blood supply, continued …
2.
Small arteries supplying CBD
a. arise from cystic artery
b. posterior branch of superior
pancreaticoduodenal artery
3. May small veins drain directly into
the liver
Detailed Anatomy, con’t….
M. GB must be distended with bile to be
clearly visualized
N. Phyrigian Cap
1. Anatomical variation
2. Fund is is folded back on itself
3. not pathological
Detailed Anatomy, con’t….
O. Lymphatic drainage of GB
1. Terminate @ celiac nodes
2. Cystic node at neck of GB
a. Actually a hepatic node
b. Lies at junction of cystic
& common hepatic ducts
3. Other lymph vessels also drain
into hepatic nodes
III. Gallbladder Diseases
A. Cholelithiasis & Cholecystitis
1. Cholecystitis = inflammation of GB
2. Cholelithisis = Stone(s) in GB
Cholelithiasis

GB shows likely
sites of stone
formation/deposition
Gallbladder Diseases, continued …
B. Failure to delineate GB
1. Contracted (empty) due to ingestion of
food, smoking
2. Secondary to cholecystectomy
Gallbladder Diseases, continued …
C. Intraluminal defects
1. GB Carcinoma
a. US useful in diagnosis
b. mass producing thickening and
irregularity in wall
c. Calculi found frequently
Gallbladder Diseases, continued …
2. Polyps of GB
a. Intraluminal echogenic projections
b. do not change position with patient
c. Must be differentiated from
septations, mucosal folds
1. septations extend across lumen
2. folds change configuration
upon inspiration
Gallbladder diseases, continued …
3. Viscid Bile, “sludge”
a. Due to intermittent obstruction of
CBD or cystic duct
b. 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 accurate
2. seeing same vessels as
parallel channel sign
c. As obstruction progresses,
lobulated structures visible