The gallbladder and bile ducts are described. The gallbladder is a pear-shaped organ located under the liver that stores and concentrates bile produced by the liver. It has a fundus, body, neck and connects to the common bile duct via the cystic duct. The common hepatic duct forms from the right and left hepatic ducts and joins the cystic duct to form the common bile duct. Blood supply is from the cystic artery and drainage is into the portal vein and hepatic veins. Diagnostic tests for gallbladder and bile duct issues include blood tests, ultrasound, CT, MRI, HIDA scan, and ERCP which also allows for therapeutic interventions like sphincterotomy and stone extraction.

1. Gallbladders & bile duct:

2. •Gallbladder
• The gallbladder is a hollow, pear-like-shaped organ that lies on the
cystic plate (gallbladder bed) under the surface of the liver.
• Anatomy
• Location
• Intraperitoneal organ
• Size and volume
• Length: 7–10 cm
• Width: 2.5 cm (at its widest point)
• Volume: 30–50 mL under normal conditions
• Can hold up to 300 mL if the cystic duct is obstructed

3. •Composition/structure
• Surface:
• Inferior or peritoneal.
• Superior or hepatic
• Fundus
• Body
• Infundibulum
• Narrow portion of the body that is continuous with the neck of the
gallbladder
• Neck
• Connects to the cystic duct → common hepatic duct → common bile
duct.
• Most common site of gallstone impaction

4. • biliary duct:
• Common hepatic duct
• The right and left hepatic ducts form the
common hepatic duct.
• Length : 4cm & 4mm diameter
• Cystic duct :Length: completely different.
• spirally-spiral valve of Heister

5. • •Common bile duct:
• 7-11 cm long , 5-10 mm in diameter. The
common bile duct is formed by Common
hepatic duct + Cystic duct
• 4 parts:
• 1- Supraduodenal about 2,5 cm long ,
• 2- Retroduodenal,
• 3- infraduodenal
• 4- and intraduodenal.
• 70% case Connects with the main pancreatic
duct extra wall of duodenum
• 2o% case the Connects with the main
pancreatic duct the wall of duodenum the
summit of major duodenal papilla.

6. •Arterial blood supply
• Gallbladder
• Cystic artery
• 90% Branch of the right hepatic artery
• Behind the common bile duct

7. Venous drainage:
• Superior surface of GB drains into
hepatic veins.
• Rest of GB is drained by one or two
cystic veins which enter into right
branch of portal vein.
• Lower part of bile duct drains into
portal vein.

8. Lymphatic drainage:
• Lymphatic drainage:
• Lymph of sub serosa &sub mucosal
• drained to Cystic lymph node
• locate in the neck of GB.
• Sub serosa vessel of GB Connected
• with sub capsular lymph channel of the liver.

9. • Innervation
• innervation
• Sympathetic: via the celiac plexus
• Parasympathetic: vagus nerve
• Sensory: fibers from Rt phrenic nerve

10. Gallbladder surgical physiology:
• Bile is a secretion produced by the liver and stored in the gallbladder
that aids in digestion, neutralization of gastric acid, fat absorption,
and excretion of bilirubin and cholesterol.
• Bile composition:
• Bile is mainly composed of
• water 97%,
• bile salts 1-2%,
• bile pigments ,cholesterol & fatty acid 1%.
• Secretion of bile by liver 40ml/hr.

11. Continue:
• The effect of cholecystokinin on the
gallbladder and the sphincter of Oddi.
• 1-Storage:
• A. During fasting, with the sphincter of
Oddi contracted and the gallbladder
filling.
• B. In response to a meal, the sphincter
of Oddi relaxed and the gallbladder
emptying.

12. Continue:
• 2- concentration of bile:
• Bile is secreted in liver, store and concentrate into the gallbladder,
• Na , Cl , Hco3 absorbed from bile.
• Bile is concentrated ( 5- 10)
• Bile salt , bile pigment , cholesterol and calcium.
• 3- secretion of mucus ( 20 ml in 24 hour )

13. • Congenital anomalies
• Developmentally, a diverticulum grows out from the ventral wall of
the foregut (primitive duodenum), which differentiates into the
hepatic ducts and the liver.
• A lateral bud from this diverticulum becomes the gallbladder and
cystic duct.
• Anomalies are found in 10% of subjects and these are of importance
to the surgeon during cholecystectomy.

14. 1.the gallbladder anomalies:
1. Congenital absence (agenesis) of the gallbladder:
occur 0,03%.
that important when pathologic process effected one are both GB
2. Duplication of the gallbladder: one in 4000.
A- Each GB connect to bile separately
B- shared
3. Left sided gallbladder :
drained to Lt hepatic duct OR CBD.
4. Posterior gallbladder

15. 5.Phrygian Cap
• The Phrygian cap is present in 2–6
per cent of cholecystograms and
may be mistaken for a pathological
• deformity of the organ.
6. Floating gall bladder
• The gall bladder may hang on a
mesentery, which makes it
• liable to undergo torsion

16. Bile duct anomalies:
1.Small ducts may drain directly from the liver into the body of the
gallbladder.
If present, but not recognized at the time of a cholecystectomy, a
bile leak with the accumulation of bile (biloma) may occur in the
abdomen.
2. Absence of the cystic duct:
the gallbladder opening directly into the side of the common
bile duct.

17. 3. choledochal cyst:
Cystic dilatation of the main bile ducts.

18. 4. Congenital biliary atresia :
biliary atresia, one of the causes of neonatal jaundice.
5.A long cystic duct:
travelling alongside the
common hepatic duct to open near the
duodenal orifice.
This occurs in 10% of cases.

19. • DIAGNOSTIC STUDIES
• Blood Tests
• When patients with suspected diseases of the gallbladder or the
• extrahepatic biliary tree are evaluated, a (CBC), LFT are routinely
• requested.
1. An elevated white blood cell (WBC) count may indicate or raise
suspicion of cholecystitis.
2. If associated with an elevation of
 bilirubin,
 alkaline phosphatase,
 and aminotransferase, cholangitis should be suspected.

20. • Blood Tests
3. Cholestasis, an obstruction to bile flow, is characterized by an
elevation of bilirubin (i.e., the conjugated form) and a rise in
alkaline phosphatase.
Serum aminotransferases may be normal or mildly elevated.
4. In patients with biliary colic or chronic cholecystitis, blood tests
will typically be normal.

21. u/s
• Initial investigation of choice in suspected in gallstones disease.
• Non invasive & • Painless
• Accurate identification of gall stones
• Not limited by jaundice or pregnancy
• Allows of GB size ,
• wall thickness ,
• inflammatory changes around GB
• Detects very small stones
• Accurate identification of dilated common bile ducts.

22. Endoscopic ultrasound:
• Endoscope with ultrasound transducer at tip
• Visualizes biliary tree from within stomach & duodenum
• Accurate to detect stones in CBD.

23. Plain radiography:
• X- RAY
1. 10-15 % of GB stones are radio opaque
2. Calcification (porcelain GB)
3. Bile lime
4. Air in bile duct.

24. IV & Oral cholecystography:
• IV Oral cholecystography
• Once considered the diagnostic procedure of choice for gallstones
• replaced by ultrasonography

25. Radioisotope scan:
• noninvasive evaluation of the liver, gallbladder, bile ducts, and
duodenum
• 99mTechnetium-labeled derivatives of
• iminodiacetic acid (HIDA) are injected IV.
• cleared by the Kupffer cells in the liver,
• and excreted in the bile.
• Uptake by the liver is detected within 10 minutes,
• the gallbladder, the bile ducts, and the duodenum are
• visualized within 60 minutes in fasting subjects

26. Ct scan:
• Computerized tomography:
• test of choice in suspected
• malignancy of the gallbladder,
• the extra hepatic biliary system,
• the tumor staging ,
• extent ,
• metastasis
• & lymph node

27. Percutaneous Transhepatic Cholangiography(PTC)
Intrahepatic bile ducts are accessed percutaneously with a
small needle under fluoroscopic guidance.
a guide wire is passed, and subsequently, a catheter is passed over the
wire .
Through the catheter, a cholangiogram
can be performed and therapeutic
interventions done,
such as biliary drain insertions
and stent placements.
Also tumors & stenosis

28. • MRI(Magnetic resonance Imaging)
• Provides anatomic details of liver, gallbladder, pancreas
• In many centers , MRI is first performed for diagnosis of biliary and
pancreatic duct pathology,

29. • ERCP : Endoscopic Retrograde
• Cholangiopancreatography
• Using a side-viewing endoscope,
• the common bile duct can be
• cannulated and a cholangiogram
• performed using fluoroscopy
• The procedure requires intravenous (IV)
• sedation for the patient.
• The advantages of ERCP include direct visualization of the ampullary
region and direct access to the distal common bile duct, with the
possibility of therapeutic intervention.

30. • CONTINUE…
• The test is rarely needed for uncomplicated gallstone
• disease, but for stones in the common bile duct, in particular,
• when associated with
• obstructive jaundice,
• cholangitis,
• or gallstone pancreatitis,
• ERC is the diagnostic and often therapeutic procedure of choice.
• Once the endoscopic cholangiogram has shown ductal stones,
Sphincterotomy and stone extraction can be performed,

31. • ERCP:
• Complications include:
• Pancreatitis
• Biliary tracts perforation
• Minor bleeding
• & cholangitis

32. Continue: