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, cont.

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

H. Neck is continuous with cystic duct

Introduction, continued

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, cont.

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

GB in situ, anterior view

Common Bile Duct

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. Hartmanns 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

Hartmanns Pouch

Hartmanns 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, cont.

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, cont.

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