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Anatomy, Abdomen and Pelvis: Gallbladder – StatPearls

Mark W. Jones; Sally Hannoodee; Michael Young.

Author Information and Affiliations

Last Update: October 31, 2022.

Introduction

The gallbladder is a pear-shaped organ located in the right upper quadrant of the abdomen. It measures approximately 7 cm to 10 cm in length and 4 cm in width. Even though the organ is small, it is a common cause of abdominal pain due to gallstones, which often require surgical removal of the organ. Anatomically, the gallbladder is located anteriorly on the undersurface of liver segments IV and V. There are many variants of the anatomy of the biliary system making exact knowledge of these anatomic possibilities crucial when performing gallbladder and biliary surgery. The gallbladder has an inferior peritoneal surface and a superior liver surface. It has no capsule however some authors describe an extension of the liver capsule (Glisson’s capsule) covering the exposed surface of the body of the gallbladder. The gallbladder fundus is wide, and as it continues into the main body, it narrows in diameter. The gallbladder body tapers into the infundibulum, which then connects to the neck and cystic duct.  At the distal portion of the gallbladder and into the cystic duct are spiral valves of Heister. These valves may be responsible to aide gallbladder emptying with neural and hormonal stimulation. In most people, there is an inferior outpouching of the gallbladder infundibulum or neck called Hartmann’s Pouch. Occasionally there is a paucity located at the top of the gallbladder fundus. This is called a Phrygian cap and has no pathologic or surgical significance.[1]

Embryology

By the end of the fourth week of embryogenesis, the hepatic diverticulum out pouches from the developing duodenum. The hepatic diverticulum goes on to become the biliary tree, while a second outpouching, known as the cystic diverticulum, immediately below develops into the gallbladder. Development of the biliary tree is extremely diverse in humans and leads to numerous variations of the biliary system.[2]

Blood Supply and Lymphatics

The gallbladder receives most of its blood supply from the cystic artery. The cystic artery is a branch of the right hepatic artery which arises from the common hepatic artery. Anatomic variants of this vascular supply are also frequently encountered. The common bile duct receives blood from the proper hepatic, the right gastric, the gastroduodenal, and the posterior superior pancreaticoduodenal arteries. These small vessels must be preserved during surgery to ensure adequate perfusion of the cystic and common bile ducts. Disruption of these vessels will increase rates of duct ischemia and leaks. There is no formal cystic vein. Venous drainage is by direct emptying into the gallbladder bed of the liver by short venules from the gallbladder into the liver parenchyma. Larger venous sinuses of the liver can also be encountered during cholecystectomy, and these can be problematic when trying to control bleeding. Subserosal and submucosal lymphatics drain the gallbladder to the cystic lymph node of Lund or node of Calot located in the Calot triangle. Cancer of the gallbladder often bypasses this lymph node and spreads directly to nodes located in the porta hepatis.[3]

Nerves

The gallbladder and cystic duct receive innervation from the following three nerves: 1) the right phrenic nerve conveys sensory information, 2) the hepatic branch of the right vagus nerve provides parasympathetic innervation, and 3) the celiac plexus provides sympathetic information. Gastric surgeries such as resections or bariatric procedures, or vagotomies done for peptic ulcer disease will de-innervate the gallbladder and cause dysfunctioning of the organ. This will, in turn, lead to the formation of gallstones and cholecystitis. Many times when such surgeries are performed, prophylactic cholecystectomies are done simultaneously to prevent cholecystitis.[4]

Surgical Considerations

The triangle of Calot is of surgical importance and has the following boundaries: 1) cystic duct on the right, 2) common hepatic duct on the left, and 3) the undersurface of the liver superiorly. The original definition of this triangle from 1891 listed the cystic duct, common hepatic duct and the cystic artery as boundaries. This has since been modified to allow better identification of landmarks for locating the cystic artery. Of surgical importance is that within the modern definition of the triangle of Calot runs the cystic artery and lymph node. Sometimes, the gallbladder neck is connected to the first part of the duodenum with loose fibrous bands known as the peritoneal cholecystoduodenal fold.

The left and right hepatic ducts join on the outside of the liver to form the common hepatic duct. The cystic duct joins the common hepatic duct after exiting the gallbladder to form the common bile duct. The short common bile duct travels inferiorly in the hepatoduodenal ligament along with the hepatic artery on the right and the portal vein posteriorly. The normal common bile duct diameter varies from 4 mm to 7 mm. Dilation of this duct usually indicates a distal obstruction from a common bile duct stone, benign stricture or neoplasm of the bile duct, pancreatic head, or ampulla Vater.

The distal end of the common bile duct is formed by the union of the pancreatic duct to form the common channel known as the ampulla of Vater. The ampulla of Vater is surrounded by a smooth muscle called the sphincter of Oddi, which prevents the reflux of duodenal secretions into the bile duct.

Microanatomy

The gallbladder wall is composed of several layers. The innermost layer is made up of columnar epithelium arranged in a microvillous formation, somewhat like the lining of the intestine. The other layers are the lamina propria, smooth muscularis, and serosa. Rotitansky-Aschoff sinuses are deep inclusions from the mucosal layer extending into the muscularis layer.[5]

Clinical Significance

The function of the gallbladder is to store bile (30 ml to 50 ml), which is released during the digestive and absorptive processes in the intestine. Contraction of the gallbladder with the release of bile into the biliary tree and duodenum is caused by gastric distension and fatty food content. This stimulates the secretion of cholecystokinin (CCK) from inclusion cells of the duodenum which causes contraction of the gallbladder. Disruption of neuro innervation, blockage of the cystic duct from gallstones, or other etiologies can cause symptoms of chronic or acute cholecystitis. Tests such as a nuclear HIDA (hepatobiliary) scan with CCK, or ultrasound are used to diagnose gallbladder disease. The gallbladder is distensible, and when the cystic duct is obstructed, it can enlarge to twice its size. This may result in infection requiring surgical removal.[6]

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Figure

The Liver, The gall-bladder and bile ducts laid open, Cystic duct, Spiral valves, Common bile duct. Contributed Gray’s Anatomy Plates

Figure

Diagram of the Calot triangle and local anatomy. Contributed by Rian Kabir, MD

References

1.

Hundt M, Wu CY, Young M. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Aug 8, 2022. Anatomy, Abdomen and Pelvis: Biliary Ducts. [PubMed: 29083810]

2.

Salazar MC, Brownson KE, Nadzam GS, Duffy A, Roberts KE. Gallbladder Agenesis: A Case Report. Yale J Biol Med. 2018 Sep;91(3):237-241. [PMC free article: PMC6153629] [PubMed: 30258310]

3.

Lung K, Lui F. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 25, 2022. Anatomy, Abdomen and Pelvis: Arteries. [PubMed: 30247834]

4.

Vernon H, Wehrle CJ, Alia VSK, Kasi A. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Nov 26, 2022. Anatomy, Abdomen and Pelvis: Liver. [PubMed: 29763190]

5.

Lee YJ, Moon JI, Choi IS, Lee SE, Sung NS, Kwon SW, Yoon DS, Choi WJ, Park SM. A large-cohort comparison between single incision laparoscopic cholecystectomy and conventional laparoscopic cholecystectomy from a single center; 2080 cases. Ann Hepatobiliary Pancreat Surg. 2018 Nov;22(4):367-373. [PMC free article: PMC6295377] [PubMed: 30588528]

6.

Rehfeld JF, Knop FK, Asmar A, Madsbad S, Holst JJ, Asmar M. Cholecystokinin secretion is suppressed by glucagon-like peptide-1: clue to the mechanism of the adverse gallbladder events of GLP-1-derived drugs. Scand J Gastroenterol. 2018 Dec;53(12):1429-1432. [PubMed: 30449207]

Disclosure: Mark Jones declares no relevant financial relationships with ineligible companies.

Disclosure: Sally Hannoodee declares no relevant financial relationships with ineligible companies.

Disclosure: Michael Young declares no relevant financial relationships with ineligible companies.

Ultrasound of the gallbladder with function

Ultrasound of the gallbladder with function is the only modern method of hardware diagnostics without internal intervention. This examination is painless and harmless, therefore it is applicable not only for adults, but also for children, as well as for pregnant women. Ultrasound with the definition of gallbladder function in real time visualizes both the organ itself and its structural elements.

Ultrasound transducers transmit a 3D image of the gallbladder and its ducts onto a screen. This allows you to detect the disease at an early stage. The reliability of the results of ultrasound and the affordability of the price make it indispensable in the field of diagnostics.

The classical ultrasound approach is used on a par with magnetic resonance imaging, but unlike the latter, it does not have harmful ionizing radiation. The acoustic transducer operates at 99.9% in receive mode and only 0.1% during operation. Such a minimal percentage of the impact of ultrasound on the body makes it absolutely safe.

Assessment of gallbladder function by ultrasound

In the process of reviewing the biliary system using ultrasound, the main normative indicators are determined:

• shape, size, volume, thickness of the walls of the gallbladder
• topographic location in the abdominal cavity
• contractility and evacuation capacity of the organ
• patency of the bile ducts
• presence of foreign bodies

900 24

In addition, the condition of the surrounding tissues is assessed. A competent specialist compares the normative indicators of ultrasound with the age of the patient, since they are different for different age categories.

Ultrasound of the contractile function of the gallbladder is carried out by real-time monitoring (express method). All these indicators allow an experienced specialist to accurately identify pathological changes. During the ultrasound of the abdominal cavity with the function of the gallbladder, diseases such as:

• cholestasis – bile stasis
• cholecystitis – inflammation of the gallbladder
• empyema – purulent inflammation
• gangrene – death of the walls of the organ bile flow
• cholelithiasis
• anomalies in the development of the biliary system
• benign and malignant neoplasms
• hematomas

Please note! Cholelithiasis in the latent (asymptomatic) phase is detected in 80% of patients during an ultrasound examination.

This is just a small list of diseases that are detected by ultrasound of the gallbladder with the definition of its contractility. A highly informative examination method, conducted by an experienced specialist, reveals even small changes in the organ. The accuracy of determining gallstone disease is 97-98%, the primary stage of gallbladder cancer is 87-88%. Early diagnosis facilitates treatment and prevents complications.

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Causes of diseases of the gallbladder and its ducts

The rhythm of our life often does not allow us to properly monitor our health. But at a minimum, we need to know what triggers diseases of the biliary system and what to avoid. So:

1. irregular, irrational diet with abuse of spicy, fried, smoked food
2. obesity
3. use of alcoholic beverages
4. long-term medication
5. injuries of the abdominal cavity

9001 4 frequent stress

All these factors lead to serious disturbances in digestive system. It is in such cases that determining the function of the gallbladder will help identify these problems.

Worth knowing! After the production of bile secretion by the liver, it immediately enters the gallbladder. And from there it is portioned out into the duodenum when taking fatty and heavy foods. Bile is an aggressive substance that irritates the intestinal mucosa. Violation of the evacuation function of the gallbladder causes a failure in the entire digestive tract.

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What are the indications?

Functional ultrasound of the gallbladder is performed for preventive and diagnostic purposes. Doctors recommend doing it at every annual dispensary registration.

Direct indications for instrumental examination are:

• unsatisfactory laboratory tests
• chronic lesions of the digestive tract
• suspicion of tumor formations
• accumulation of free fluid

90 002 Inherently ultrasound is prescribed before and after gallbladder removal surgery. And also in the course of dynamic observation in order to control the course and effectiveness of treatment of a previously identified disease.

Symptomatic indications of ultrasound include:

• regular paroxysmal pain on the right side under the ribs and radiating to the back, aggravated by eating heavy food, physical exertion chi
• frequent bitterness in the mouth, including after sleep
• yellowness of the skin and sclera
• discolored feces
• bright crimson tongue
• impaired appetite
• bloating due to intestinal overflow with gases

The symptoms are relative and applicable to other diseases of the gastrointestinal tract, so it is important to make a differential diagnosis. Often, gallbladder diseases are asymptomatic, which makes it difficult for medical diagnosis without additional examination methods. Doctors use an expression such as “The disease of well-being.” In 80% of patients undergoing ultrasound for prevention, cholelithiasis is determined

Interesting! Only 20% of cases of diseases of the gallbladder and its ducts are symptomatic at an early stage.

Ultrasound-guided gallbladder function is also studied to monitor therapeutic and diagnostic manipulations in this area.

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Contraindications for ultrasound of the gallbladder with determination of contractility function

Ultrasound of the gastrointestinal tract with function of the gallbladder is an advanced modern method of non-invasive scanning of this organ and its ducts. Instrumental examination has a minimum of relative contraindications. They are directly related to the contact of equipment sensors with the patient’s skin in the area of ​​the organ under study, i. e. violations of the integrity of the skin, manifested by:

• inflammatory processes
• purulent diseases
• burns
• wounds

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How to prepare for an ultrasound of the gallbladder and its ducts?

For the availability of an ultrasound examination and obtaining a high-quality three-dimensional image on the screen of an ultrasound machine, the patient is prescribed the following preparation: bread, legumes, milk, carbonated drinks).

• Avoid fatty meats and fish.
• In case of increased flatulence, take enzymatic preparations prescribed by the doctor (creon, festal) for three days before the procedure.
• Empty the bowels the night before.
• In case of constipation, use a cleansing enema, laxative rectal suppository or oral laxatives (drops, tablets).
• Avoid food intake 6-12 hours before.
• Do not smoke before the examination.

In case of determining the function of the gallbladder, take with you products that increase the secretion of bile.

Please note! Check with your doctor beforehand what kind of choleretic product it will be and in what quantity, in order to avoid an allergic reaction.

If you have previous biliary ultrasound results, you are advised to bring them with you. This will help to track the course of the disease in dynamics. In emergency cases, there is no advance preparation.

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Ultrasound examination of the gallbladder function

It is performed transabdominally (over the abdominal wall). During the procedure, the patient lies on his back on the couch, exposing his stomach. The doctor applies a special water-soluble gel to the right hypochondrium. The gel eliminates the air gap between the sensor and the patient’s skin, which allows ultrasound to penetrate deep into the tissues. Reflected from the organ under study, the acoustic wave will transmit data to the device.

By moving the sensor in accordance with the topography of the examined organ, the specialist displays an image of the gallbladder and bile ducts on the monitor of ultrasound equipment. After that, it determines all the normative indicators.

Sometimes, if necessary, the patient is asked to roll over on his left side and, taking a deep breath, hold his breath. Or, in a standing position, make several inclinations forward. In general, determining the function of the gallbladder under ultrasound control takes 15-20 minutes.

With additional ultrasound of the gallbladder with the definition of contractile function under load after the first stage, the subject takes a choleretic breakfast. It can be egg yolk, chocolate, cream, sour cream. 10 minutes later, the scan is repeated. This type of examination is carried out within 45-50 minutes.

After the procedure, the gel is removed with a disposable paper towel. Surfaces of the ultrasonic transducer in contact with the skin are treated and disinfected after each patient.

The results are interpreted immediately. The result of an ultrasound of the gallbladder and its ducts, the patient receives in his hands at the end of the examination.

Diseases of the gallbladder and its ducts is one of the most urgent problems of modern medicine today. According to the latest statistics in Moscow and the Moscow region, 22% of the population suffers from cholelithiasis. Of these, cholelithiasis in women over 40 years of age occurs 3-4 times more often than in men. Data on other diseases of the gallbladder and its ducts are also not encouraging. Cancers occur in 80% of chronic inflammation. Early diagnosis of diseases allows you to prescribe effective treatment and prevent complications.

Still have questions? You can ask them to the administrator at the phone number indicated on the site or order a call back.

Primary source medical center “Clinic ABC” / September 2018

Ultrasound of the liver, gallbladder, bile ducts

We invite you to sign up for Ultrasound of the liver, gallbladder and bile ducts in our diagnostic center – “BC Clinic » in Moscow. BS Clinic specialists have extensive experience and expert knowledge in the field of deciphering ultrasound indicators.

Ultrasound of the liver, gallbladder and bile ducts is a comprehensive examination of the organs, which is prescribed for any complaints of abdominal pain, as well as in case of disorders of the gastrointestinal tract.

Using ultrasound of the liver, gallbladder and bile ducts, doctors diagnose:

• anomalies in the structure of organs
• acute and chronic hepatitis
• cholecystitis
• cholelithiasis
• cirrhosis
• pathologies of the biliary tract
• hemangiomas
• calcifications
• steatosis
• cysts and cystic formations
• hepatomas (cancer)
• metastases in oncological diseases
• parasitic infections
• inflammatory processes
• infectious diseases
• traumatic lesions,
• Presence/absence of stones and polyps in the gallbladder and ducts
• the presence of free fluid in the abdominal cavity and small pelvis – as a sign of a number of diseases
• thrombosis of arteries or veins

Indications for recording an ultrasound scan of the liver, gallbladder and bile ducts ribs

• nausea, vomiting, belching, bitter taste in the mouth
• Appearance of a yellow tint on the skin or sclera of the eyes
• dark urine and light stool
• skin itching up to microbruising, regular allergic rashes, eczema
• high temperature
• obesity and metabolic syndrome
• alcohol abuse
• regular use of medicines
• high levels of amylase and bilirubin in the blood
• radiation and chemotherapy
• trauma to the abdomen.

Also, ultrasound of the liver, gallbladder and bile ducts is carried out at the required frequency, if the diseases of these organs have already been diagnosed and control over the course of the disease is necessary, and in addition to identify the effectiveness of the therapy.

Methods of ultrasound diagnostics

Ultrasound is used to study the lobes of the liver (right and left), its components, bile ducts, small and large vessels in the liver, as well as surrounding tissues.

When performing an ultrasound of the liver, gallbladder and bile ducts, the doctor looks at the following indicators:

• location relative to other organs
• anatomy of the liver
• body size
• shape and contours
• nature of focal formations
• uniformity
• echogenicity
• state of channels inside the liver
• condition of blood vessels.

Contraindications for ultrasound procedure

This procedure has no contraindications, since the nature of the manipulation is safe, does not carry the risk of radiation exposure and does not involve surgical intervention.

How is the procedure for ultrasound of the liver, gallbladder and bile ducts

The patient lies on his back, or on the right / left side, occasionally the examination is performed while sitting. The doctor applies an ultrasound gel on the abdomen and moves the sensor over the surface of the area under study, thus obtaining an image of the organ from different angles. It is recommended to adhere to the following sequence: the study begins with longitudinal sections from the upper abdomen.
Upon completion, all data are entered into the study protocol, which the doctor, along with the images, hands over to the patient.

Ultrasound of the liver, gallbladder and bile ducts in Moscow can be done inexpensively and quickly by contacting BC Clinic.

Advantages

The examination procedure is absolutely painless and quite informative. It allows you to quickly obtain reliable data on the state and functioning of the liver, gallbladder and ducts, thus identifying a dangerous disease at an early stage.