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Collects bile from the liver, stores it in the gallbladder, and transmits it to the second part of the duodenum.
Components:
Right and Left Hepatic Ducts
Common Hepatic Duct
Gallbladder
Cystic Duct
Bile Duct
Emerge at the porta hepatis from respective lobes of the liver.
Arrangement of structures at porta hepatis (posterior to anterior):
Branches of the portal vein
Proper hepatic artery
Hepatic ducts
Formed by the union of the right and left hepatic ducts near the right end of the porta hepatis.
Descends about 3 cm, then joins the cystic duct to form the bile duct.
Accessory hepatic ducts present in ~15% of individuals, usually from right lobe.
They may terminate in the gallbladder, common hepatic duct, or upper bile duct.
Cause postoperative bile leakage after cholecystectomy, so surgical drainage is advised
Volume 2, BD Chaurasia’s Human …
.Shape: Pear-shaped reservoir of bile.
Location: Fossa on the inferior surface of the right lobe of liver, extending from the right end of the porta hepatis to the inferior border of the liver.
Parts:
Fundus – projects beyond inferior liver border, opposite 9th costal cartilage.
Body – lies in fossa on liver, adherent superiorly to liver (non-peritoneal), peritoneum covers inferior surface related to transverse colon and duodenum.
Neck – narrow upper end; continues into cystic duct.
Hartmann’s pouch: mucosal outpouching at posteromedial wall; common site for gallstone lodgment.
Calot’s triangle: bounded by cystic duct (inferiorly), common hepatic duct (medially), and inferior surface of liver (superiorly); contains cystic artery and lymph node of Lund.
Storage of bile and its release into the duodenum when required.
Absorption of water and concentration of bile (up to 10×).
Regulation of biliary pressure by contracting or relaxing in coordination with the sphincter of Oddi.
Pathophysiology: Disturbance in concentration function → bile salt absorption → cholesterol precipitation → gallstone formation
Volume 2, BD Chaurasia’s Human …
.Gallstones (Cholelithiasis): may lodge in Hartmann’s pouch or cystic duct.
Cholecystitis: pain referred to epigastrium, right shoulder, or inferior angle of right scapula (phrenic nerve C3–C5).
Accessory ducts: source of postoperative bile leakage.
Cystic artery – usually from right hepatic artery; variable, so careful dissection required.
Length: About 3–4 cm long and 3 mm in diameter.
Course: Joins the common hepatic duct at an acute angle to form the bile duct.
Lumen: Irregular due to spiral folds of mucosa called valves of Heister, which help maintain the duct’s patency and prevent sudden collapse during bile passage.
Histology:
Lined by columnar epithelium.
Mucosa folded into spiral ridges.
Muscular layer continuous with gallbladder musculature.
Formation: Union of common hepatic duct and cystic duct.
Length: About 8 cm.
Parts and Course:
Supraduodenal Part – lies in the free margin of the lesser omentum.
Anteriorly: Liver
Posteriorly: Portal vein, epiploic foramen
Left side: Hepatic artery
Retroduodenal Part – behind the first part of the duodenum.
Anteriorly: Duodenum
Posteriorly: Inferior vena cava
Left: Gastroduodenal artery
Infraduodenal Part – embedded in a groove on the posterior surface of the head of the pancreas.
Intraduodenal Part – oblique course through the duodenal wall; unites with pancreatic duct to form the hepatopancreatic ampulla (of Vater).
Opens at the major duodenal papilla, 8–10 cm distal to the pylorus.
Sphincter Choledochus (of Boyden):
Surrounds terminal part of the bile duct above the junction with pancreatic duct.
Always present; keeps bile duct closed when gallbladder fills.
Opens during fatty meal intake under hormonal influence (cholecystokinin).
Sphincter Pancreaticus:
Surrounds terminal part of the pancreatic duct; variably developed.
Sphincter Ampullae (of Oddi):
Surrounds hepatopancreatic ampulla; regulates bile and pancreatic juice flow into the duodenum.
Coordinates with gallbladder contraction and relaxation of sphincter choledochus.
Cystic artery (chief source) — branch of right hepatic artery; supplies gallbladder, cystic duct, hepatic ducts, and upper bile duct.
Posterior superior pancreaticoduodenal artery — supplies lower bile duct.
Right hepatic artery — minor supply to mid-portion of bile duct.
Superior surface of gallbladder → veins drain directly into liver.
Rest of gallbladder → cystic veins → right branch of portal vein.
Lower bile duct → drains directly into portal vein.
Upper part (gallbladder, cystic duct, hepatic ducts):
→ Cystic node (in Calot’s triangle) → upper hepatic nodes (on anterior border of epiploic foramen).
Lower bile duct:
→ Lower hepatic nodes → pancreaticosplenic nodes.
Sympathetic: From coeliac plexus → pain and vasomotor control.
Parasympathetic: From vagus nerve → motor to gallbladder and relaxation of sphincters.
Sensory (referred pain): via phrenic nerve (C3–C5) → pain referred to right shoulder and inferior angle of right scapula.
Biliary Obstruction:
Blockage of bile flow due to gallstones or carcinoma of pancreas.
Results in obstructive jaundice: pale stools, dark urine, yellow sclera, and pruritus.
Cholelithiasis (Gallstones):
Formed by cholesterol or pigment stones due to bile stasis or infection.
Lodgement in cystic duct → colicky pain, vomiting, and cholecystitis.
Cholecystitis:
Inflammation of gallbladder; pain referred to epigastrium, right shoulder, or inferior angle of right scapula.
Calot’s Triangle (Cystohepatic Triangle):
Boundaries:
Inferior → Cystic duct
Medial → Common hepatic duct
Superior → Inferior surface of liver
Contents: Cystic artery and cystic lymph node.
Importance: Landmark during cholecystectomy.
Biliary Investigation Techniques:
Ultrasound – to detect gallstones.
ERCP (Endoscopic Retrograde Cholangiopancreatography) – to visualize bile and pancreatic ducts.
Hormonal Control:
Cholecystokinin-pancreozymin (CCK-PZ) released from duodenal mucosa → contracts gallbladder and relaxes sphincters.
Referred Pain:
Stretching of bile duct or gallbladder → pain in epigastrium and right shoulder (due to diaphragmatic peritoneal innervation).
The gallbladder wall has three main layers (no submucosa and no muscularis mucosae).
Lined by simple columnar epithelium with tall absorptive cells containing microvilli.
Epithelium rests on a lamina propria made of loose connective tissue rich in capillaries.
The mucosa shows numerous folds and ridges, forming a honeycomb pattern when contracted.
Rokitansky–Aschoff sinuses: Small mucosal outpouchings that extend into the muscular layer; often seen in chronic cholecystitis.
Function: Absorbs water and electrolytes to concentrate bile.
Composed of irregularly arranged bundles of smooth muscle fibers (no distinct circular or longitudinal orientation).
Contraction is controlled by cholecystokinin (CCK), causing expulsion of bile.
Superior (hepatic) surface: Non-peritoneal; attached to liver by areolar tissue (adventitia).
Inferior surface: Covered by peritoneum (serosa).
Contains blood vessels, lymphatics, and autonomic nerves.
Absorptive function: Active sodium and water absorption concentrate bile up to 10 times.
Mucus secretion: Protects mucosa from concentrated bile acids.
Storage: 30–60 mL bile reservoir under fasting conditions.
Response to meals: Gallbladder contracts due to CCK-PZ, while sphincter of Oddi relaxes, allowing bile flow into duodenum.
Derived from the hepatic diverticulum — an endodermal outgrowth from the caudal part of the foregut (4th week).
Hepatic Diverticulum:
Grows into ventral mesentery toward the septum transversum.
Divides into two parts:
Pars hepatica (cranial part): Forms liver parenchyma and hepatic ducts.
Pars cystica (caudal part): Forms gallbladder and cystic duct.
Common Hepatic Duct:
Formed from the stalk of the hepatic diverticulum.
Bile Duct:
Initially a common channel from hepatic diverticulum to duodenum.
Later, rotation of duodenum moves the opening dorsally, placing the bile duct posterior to the first part of duodenum and in contact with the pancreatic duct.
Epithelium: Derived from endoderm of foregut.
Connective tissue and muscle: Derived from splanchnic mesoderm.
Agenesis of Gallbladder: Complete absence; rare.
Double Gallbladder: Two sacs, often with separate cystic ducts.
Accessory Hepatic Ducts: May open into gallbladder or bile duct — important surgically.
Abnormal Termination of Bile Duct: May open into duodenum separately from pancreatic duct.
Atresia or Stenosis: Failure of recanalization of biliary ducts → neonatal obstructive jaundice.
Embryological correlation: Persistence of fetal solid phase of ducts may lead to biliary atresia (infantile jaundice).
Surgical note: Awareness of variations in cystic duct or accessory ducts prevents bile leakage after cholecystectomy.
Functional correlation: Hormone CCK-PZ (from duodenal mucosa) coordinates bile expulsion during digestion of fats.
The gallbladder both stores and concentrates bile; this concentration predisposes to gallstone formation (cholelithiasis).
The cystic artery commonly arises from the right hepatic artery, but its origin and relation to the bile ducts are highly variable—this is vital knowledge during cholecystectomy.
Pain of cholecystitis is often referred to the epigastrium, right shoulder, or inferior angle of the right scapula, due to the phrenic nerve (C3–C5) innervation.
Murphy’s sign: Tenderness and arrest of inspiration when palpating under the right costal margin (indicates cholecystitis).
Courvoisier’s law: Distended, palpable gallbladder with jaundice suggests malignant obstruction (e.g., carcinoma of head of pancreas), not stones.
Referred pain from gallbladder or bile duct is mediated via the right phrenic nerve, hence perceived in the supraclavicular region.
The Calot’s triangle is bounded by:
Cystic duct (inferiorly)
Common hepatic duct (medially)
Inferior surface of liver (superiorly)
It contains the cystic artery and cystic lymph node (Lund’s node).
ERCP (Endoscopic Retrograde Cholangiopancreatography) is used to visualize and assess bile duct patency.
Gallstones may erode through the gallbladder wall into the duodenum, causing intestinal obstruction at the ileocaecal junction (gallstone ileus).
Cholecystokinin-pancreozymin (CCK-PZ), secreted from the duodenum after fatty meals, causes gallbladder contraction and sphincter relaxation.
Typhoid bacilli can persist in the gallbladder, producing a chronic carrier state.
A fat, fair, fertile, forty-year-old female complains of spasmodic pain in the right hypochondrium, radiating to the epigastrium and right shoulder.
Questions & Explanations:
Cause of pain: Gallstones obstructing the cystic duct → distension of gallbladder (cholelithiasis).
Radiation: Referred via phrenic nerve to epigastrium and right shoulder.
Murphy’s sign: Pain and inspiratory arrest when pressing below the right costal margin—positive in acute cholecystitis.
During open cholecystectomy, the surgeon encounters severe bleeding.
Questions & Explanations:
Bleeding source: Usually the cystic artery.
Control: Can compress proper hepatic artery (in anterior wall of epiploic foramen) between thumb and finger.
Alternate procedure: Laparoscopic cholecystectomy is now standard.
A patient with jaundice and distended gallbladder.
Interpretation:
Suggests malignant obstruction (e.g., carcinoma of the head of pancreas).
Follows Courvoisier’s law — extrinsic obstruction causes dilatation, intrinsic (stone) does not.
A patient develops intestinal obstruction due to a gallstone.
Explanation:
Gallstone erodes through gallbladder into duodenum, travels through small intestine, and lodges at ileocaecal junction → gallstone ileus.
Postoperative bile leakage after cholecystectomy.
Cause:
Unrecognized accessory hepatic duct injured during surgery.
Solution: Adequate drainage to prevent bile peritonitis.
A 45-year-old woman presents with fever, vomiting, and severe right hypochondrial pain radiating to the right shoulder. Pain worsens after fatty meals.
Explanation:
Inflammation of the gallbladder due to cystic duct obstruction by gallstone.
Referred pain: via right phrenic nerve (C3–C5) to right shoulder.
Murphy’s sign: Positive.
Anatomical basis: Gallbladder in contact with visceral surface of liver → inflammation may spread to hepatic capsule causing localized peritonitis.
A patient develops obstructive jaundice with clay-colored stool and dark urine.
Explanation:
Gallstone lodged in the common bile duct (CBD).
Anatomical effect: Bile cannot enter duodenum → bilirubin regurgitates into blood.
Key site: Distal CBD near hepatopancreatic ampulla.
Investigation: ERCP or MRCP imaging.
A 60-year-old male presents with progressive jaundice, pale stool, and weight loss, but no pain.
Explanation:
Tumor compresses the intrapancreatic part of the bile duct, obstructing bile flow.
Courvoisier’s sign: Painless, palpable gallbladder due to extrinsic obstruction.
Referred pain: May appear in the back due to pancreatic involvement.
A 52-year-old woman with gallstones develops fever with chills, jaundice, and right upper quadrant pain (Charcot’s triad).
Explanation:
Infection and inflammation of the bile duct (ascending cholangitis).
Pathway: Gallstone obstructs CBD → bacterial infection from duodenum.
Complication: Sepsis, hepatic abscess.
A 3-week-old baby presents with persistent jaundice and pale stools since birth.
Explanation:
Failure of recanalization of bile ducts (developmental anomaly).
Consequence: Bile accumulation → hepatomegaly and neonatal cholestasis.
Treatment: Surgical (Kasai portoenterostomy).
Following open cholecystectomy, a patient shows persistent bile drainage from the wound.
Explanation:
Accidental injury to an accessory hepatic duct or cystic duct stump leak.
Anatomical note: Accessory ducts commonly arise from the right lobe and open into the gallbladder or hepatic ducts.
A gallstone lodged in the cystic duct compresses the common hepatic duct, leading to jaundice without CBD stones.
Explanation:
Due to close proximity between cystic and common hepatic ducts.
May cause fistula formation between the two ducts.
A patient develops biliary colic and transient jaundice after fatty meals.
Explanation:
Spasm or fibrosis of the sphincter of Oddi prevents bile flow.
Effect: Back pressure → gallbladder distension and pain.
Hormonal link: Lack of proper response to cholecystokinin.
An elderly woman develops intestinal obstruction after long-standing gallstones.
Explanation:
Stone erodes through gallbladder wall → enters duodenum → lodges at ileocaecal junction.
Anatomical sequence: Gallbladder → duodenum → small intestine → obstruction.
A post-traumatic patient develops acute peritonitis with bile-stained fluid in the abdomen.
Explanation:
Rupture of gallbladder or bile duct leads to leakage into peritoneal cavity.
Consequence: Chemical peritonitis due to bile salts.
After gallbladder removal, patient complains of right upper abdominal pain and dyspepsia.
Explanation:
Residual stone in CBD or sphincter spasm of Oddi.
Clinical note: Need imaging (ERCP) to identify retained stones.
During laparoscopic cholecystectomy, sudden bleeding obscures the surgical field.
Explanation:
Cystic artery runs in Calot’s triangle, and variations are common.
Preventive step: Always identify cystic artery before clipping.
Pain radiating from right hypochondrium to inferior angle of right scapula.
Explanation:
Due to irritation of diaphragmatic peritoneum, supplied by the phrenic nerve (C3–C5).
Sensory fibers refer pain to C4 dermatome (shoulder region).
Patient develops severe fever, leukocytosis, and tense palpable gallbladder.
Explanation:
Suppurative infection of the gallbladder due to cystic duct obstruction.
Complication: Gangrene or perforation.
Sudden severe pain in right hypochondrium radiating to right shoulder, often after a fatty meal.
Explanation:
Spasm of the smooth muscle of the gallbladder wall or bile duct due to transient obstruction by stone.
Duration: Usually short-lived (<6 hours).
The extrahepatic biliary apparatus consists of:
Right and left hepatic ducts
Common hepatic duct
Cystic duct
Gallbladder
Bile duct (common bile duct)
Stores and concentrates bile.
Contracts during digestion (especially after fatty meals) under the action of cholecystokinin (CCK) to release bile into the duodenum.
Supraduodenal
Retroduodenal
Infraduodenal (within the pancreatic groove)
Intraduodenal (within the wall of duodenum)
A muscular sphincter surrounding the ampulla of Vater (terminal part of bile and pancreatic ducts).
Regulates bile and pancreatic juice flow into the duodenum.
Relaxes under the influence of CCK-PZ.
The common bile duct and the main pancreatic duct (duct of Wirsung) unite to form the ampulla of Vater, which opens at the major duodenal papilla.
Boundaries:
Inferior → Cystic duct
Medial → Common hepatic duct
Superior → Inferior surface of the liver
Contents: Cystic artery and cystic lymph node (of Lund).
Surgical importance: Landmark during cholecystectomy.
A small diverticulum of the gallbladder neck where gallstones commonly lodge.
Situated between the neck of gallbladder and cystic duct.
In the presence of jaundice and a palpable gallbladder, the cause is malignant obstruction (e.g., carcinoma of the head of pancreas), not gallstones.
Elicited by pressing under the right costal margin during inspiration.
Arrest of inspiration due to pain indicates acute cholecystitis.
Chiefly from the cystic artery, a branch of the right hepatic artery.
Lies within Calot’s triangle.
The lower bile duct receives blood from the posterior superior pancreaticoduodenal artery.
Upper surface → directly into liver substance.
Lower surface → via cystic veins into portal vein.
Cystic lymph node (Lund’s node) → hepatic nodes → celiac nodes.
Sympathetic fibers: from celiac plexus (pain sensation).
Parasympathetic fibers: from vagus nerve (motor to gallbladder, relax sphincters).
Sensory fibers: via phrenic nerve → referred pain to right shoulder and scapular region.
Emulsification of fats.
Neutralization of gastric acid in the duodenum.
Excretion of bilirubin and cholesterol.
Aids in absorption of fat-soluble vitamins (A, D, E, K).
Small mucosal diverticula that extend into the muscular wall of the gallbladder.
Commonly seen in chronic cholecystitis.
Derived from the pars cystica of the hepatic diverticulum (endodermal outgrowth from the foregut).
Muscles and connective tissue from splanchnic mesoderm.
Agenesis or duplication of gallbladder.
Accessory hepatic ducts.
Abnormal termination of bile duct.
Atresia or stenosis (failure of recanalization).
Congenital absence or obliteration of bile ducts due to failure of recanalization.
Leads to neonatal jaundice and cholestasis.
Gallstones in the bile duct (choledocholithiasis).
Carcinoma of the head of pancreas.
Stricture or atresia of bile ducts.
Parasite infestation (Clonorchis sinensis).
Lies posterior to the first part of duodenum, then passes through the head of pancreas to open into the second part of duodenum at the major duodenal papilla.
1. The cystic artery is a branch of:
a. Right hepatic artery
b. Left hepatic artery
c. Coeliac trunk
d. Common hepatic artery
✅ Answer: a. Right hepatic artery
2. The capacity of the gallbladder is approximately:
a. 50–150 mL
b. 30–60 mL
c. 150–300 mL
d. 350–500 mL
✅ Answer: b. 30–60 mL
3. The cystic duct joins which of the following ducts?
a. Common hepatic duct
b. Right hepatic duct
c. Left hepatic duct
d. None of these
✅ Answer: a. Common hepatic duct
4. Pain of gallstones is referred to all the following areas except:
a. Tip of right shoulder
b. Epigastric region
c. Inferior angle of left scapula
d. Inferior angle of right scapula
✅ Answer: c. Inferior angle of left scapula
5. Which of the following structures lies within Calot’s triangle?
a. Portal vein
b. Cystic artery
c. Right hepatic vein
d. Inferior vena cava
✅ Answer: b. Cystic artery
6. The sphincter of Oddi surrounds which structure?
a. Cystic duct
b. Hepatopancreatic ampulla
c. Common hepatic duct
d. Gallbladder neck
✅ Answer: b. Hepatopancreatic ampulla
7. Hartmann’s pouch is found in which part of the gallbladder?
a. Fundus
b. Body
c. Neck
d. None
✅ Answer: c. Neck
8. The gallbladder develops from:
a. Pars hepatica
b. Pars cystica
c. Hepatic bud
d. Ventral pancreas
✅ Answer: b. Pars cystica
9. Referred pain from the gallbladder is carried by which nerve?
a. Intercostal
b. Phrenic
c. Vagus
d. Sympathetic from celiac plexus
✅ Answer: b. Phrenic nerve
10. The common bile duct opens into the duodenum at the:
a. Minor duodenal papilla
b. Major duodenal papilla
c. Foramen of Winslow
d. Ampulla of Vater
✅ Answer: b. Major duodenal papilla
1 – a
2 – b
3 – a
4 – c
5 – b
6 – b
7 – c
8 – b
9 – b
10 – b
Right and left hepatic ducts, common hepatic duct, cystic duct, gallbladder, and common bile duct.
It stores and concentrates bile and expels it into the duodenum when required for fat digestion.
Approximately 30–60 mL.
At the tip of the ninth costal cartilage, where it meets the right lateral border of the rectus abdominis.
Boundaries:
Inferiorly – cystic duct
Medially – common hepatic duct
Superiorly – inferior surface of the liver
Contents: cystic artery and cystic lymph node (of Lund).
A small diverticulum at the neck of the gallbladder where gallstones commonly lodge.
Supraduodenal, retroduodenal, infraduodenal (in pancreatic groove), and intraduodenal parts.
At the major duodenal papilla in the second part of the duodenum.
A dilation formed by the union of the common bile duct and main pancreatic duct, guarded by the sphincter of Oddi.
Sphincter choledochus (Boyden) – surrounds terminal bile duct.
Sphincter pancreaticus – around pancreatic duct.
Sphincter ampullae (Oddi) – around hepatopancreatic ampulla.
Sympathetic: from celiac plexus
Parasympathetic: from vagus nerve
Sensory: via right phrenic nerve (causing referred pain to right shoulder/scapula)
By the cystic artery, a branch of the right hepatic artery.
A distended, palpable gallbladder with jaundice suggests malignant obstruction (e.g., carcinoma of head of pancreas) rather than stones.
On deep inspiration, pressing under the right costal margin causes sharp pain and inspiratory arrest — a sign of acute cholecystitis.
From the pars cystica of the hepatic diverticulum (endodermal outgrowth from foregut).
Congenital failure of recanalization of bile ducts, leading to neonatal obstructive jaundice.
Cholecystokinin-pancreozymin (CCK-PZ) released from duodenal mucosa after fatty meals.
Mucosal diverticula that extend into the muscular layer of the gallbladder, seen in chronic cholecystitis.
It must be carefully identified and ligated within Calot’s triangle during cholecystectomy to prevent hemorrhage.
Pain from gallbladder inflammation is referred to the right shoulder and inferior angle of right scapula through phrenic nerve fibers (C3–C5).
Emulsification of fats
Aids in absorption of fat-soluble vitamins (A, D, E, K)
Neutralizes gastric acid
Excretes cholesterol and bilirubin
Formation of gallstones due to imbalance between bile salts, cholesterol, and phospholipids, often in fat, fair, fertile, forty females.
Superior surface: non-peritoneal, attached to liver.
Inferior surface: covered by peritoneum related to duodenum and transverse colon.
Posterior superior pancreaticoduodenal artery.
Surgical removal of the gallbladder; most often done laparoscopically.
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