1. Gallbladder and Biliary System
Anatomy and Positioning

2. 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.

3. 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 ml or 1 qt of bile each day.

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

5. 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

6. 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.

7. 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.

8. Distal Common Bile Duct

9. 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.

10. Anatomic Relationships
PA to reduce OID
Supine for gallbladder drainage

11. 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.

12. 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

13. Radiographic Anatomy
Cystic duct
Neck
Body
Fundus

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

15. 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

16. 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

17. 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!

18. 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.

19. 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

20. 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.

21. 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.

22. 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.

23. 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)