Gallbladder and Biliary System Anatomy and Positioning

Liver and GB Liver is the largest solid organ of the body weighing about about 3-4 lbs. It is located on in the RUQ. It is convex, the superior border conforms to the inferior surface of the right hemidiaphragm.

Liver The Liver has 4 lobes Faliciform Ligament Right lobe Left lobe Quadrant lobe Caudate lobe Faliciform Ligament Which divides the right lobe from the left The Liver produces about 800-1000 ml or 1 qt of bile each day.

Right and left hepatic ducts Bile Route Right and left hepatic ducts ▼ Common hepatic duct Common bile duct Pancreatic duct Duodenum 4

Gallbladder Gallbladder is located on the posterior, inferior wall of the liver. It is made up of three main parts Fundus: broad distal aspect Body Neck: proximal end

GB function Store bile produced by the liver Bile is formed by small lobules in the liver. It then travels to into the right/left hepatic ducts which unite to form the common hepatic duct From the common hepatic duct travels to the common bile duct. The common hepatic duct meets with the GB through the cystic duct. The cystic duct is 3-4 cm long. It contains spiral-shaped membranous folds called the spiral valve. It purpose is to prevent distention or collapse of the cyst duct. Bile is stored in the GB until needed for use in the digestion of fat.

Function of the GB When bile is needed to emulsify or break down dietary fat the GB contracts. Bile flows from the GB to the Common bile duct to the junction of the pancreatic duct (duct of Wirsung) It then travels through the Ampulla of Vater (hepatopancreatic ampulla) and through the sphincter of Oddi (hepatopancreatic sphincter) into the papilla of Vater (duodunal papilla) into the duodenum.

Distal Common Bile Duct

Gall Bladder The word ampulla means a rounded sac-like dilation of a duct or canal. In Latin it means flask. The word papilla means small nipple-shaped projection.

Anatomic Relationships PA to reduce OID Supine for gallbladder drainage

Main functions of the GB Storage of bile Concentration of bile: concentration (bile consistency) is monitored by hydrolysis – removal of water. If too much water is removed; cholesterol in the bile becomes too concentrated and form choleliths (stones). Contraction and release of bile for digestion.

Position of the GB The GB position in the abdomen is determined by body habitus. Hypersthenic – GB is high and more lateral. Sthenic/ Hyposthenic – GB is midway between the xiphoid and the lower lateral rib margin. Asthenic – GB is lower (at the crest) and midline

Radiographic Anatomy Cystic duct Neck Body Fundus

Radiographic anatomy Right hepatic duct Left hepatic duct Common hepatic duct Common bile duct Duodenum

GB and Biliary duct terminology Chole – bile, also used for GB Cysto – sac or bladder Angio – vessel or duct Graphy – write or study Gram – picture or film (image) Cholecystography – study of the GB Choleangiography – study of the biliary system (ducts) Cholecystocholangiogram – study of the GB and biliary system Cholecystectomy – removal of the GB

GB procedures OCG – Oral cholecystogram Operative Cholangiogram Laparoscopic Cholangiogram T-tube Cholangiogram (done post-op to either a operative or laparoscopic cholangiogram PTC Percutaneous Transhepatic Cholangiogram ERCP Endoscopic Retrograde Cholangiopancreatography

OCG Purpose is to study the anatomy and function of the GB. Ability of the liver to remove contrast media from the bloodstream Patency (openness) and condition of the biliary ducts Concentration and contracting ability of the GB Not done anymore!

Sonography Sonography has eliminated the need for OCG. Advantages Non-invasive Can detect small calculi in the ducts that are radiolucent No need for contrast media Less time consuming.

Operative exams Operative cholangiogram – done in conjunction with a cholecystectomy Used to visualize choleliths undetected during surgery Demonstrates the patency or openness of the ducts. Demonstrates the function of the hepatopancreatic ampulla (ampulla of vater) Visualize possible small lesions or strictures in the biliary ducts

Laparoscopic Cholecystectomy The GB is suctioned out via an endoscopic tube, the remnant cystic duct is cauterized. If stones are suspected, a T-tube maybe placed into the common bile duct. T-tube is placed in the duct and extended to outside the body for access. Contrast media can then be injected and checked by imaging at various times. If residual stones are detected they can be removed by a basket catheter.

Postoperative (T-tube or delayed) Cholangiogram Performed in radiology department T-tube placed in common bile duct during surgery and extending outside body clamped off Contrast media injected into T-tube catheter Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

ERCP (endoscopic retrograde cholangiopancreatography) Procedure: endoscopic inspection, cannulation, and injection of the biliary ducts with the use of a duodenoscope Endoscope Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

PTC Percutaneous Transhepatic Cholangiogram Transhepatic means through the liver A special “skinny” or Chiba needle is placed through the liver and into one of the biliary ducts (guidance is done through fluoroscopy) PTC has some risks: Liver hemorrhage Pneumothorax Bile escaping into the peritoneal (bile is corrosive and will irritate the periotoneal tissue causing peritonitis)