GALLBLADDER

INTRODUCTION
The liver and gallbladder are the two accessory organs of the gastrointestinal tract, which
carry out a multifunctional role that aids digestion and homeostasis. The gallbladder is a small
hollow intraperitoneal organ found inferiorly to the liver and is involved in the storage and
release of bile into the duodenum.

LOCATION
The gallbladder (7–10 cm long) lies in the fossa for the gallbladder on the visceral surface of
the liver between the right and quadrate liver lobes. The superior part of the duodenum,
hepatic flexure and proximal transverse colon, are posteriorly related to it.
The relationship of the gallbladder to the duodenum is so intimate that the superior part of
the duodenum is usually stained with bile in the cadaver. Because the liver and gallbladder
must be retracted superiorly to expose the gallbladder during an open anterior surgical
approach (and atlases often depict it in this position), it is easy to forget that, in its natural
position, the body of the gallbladder lies anterior to the superior part of the duodenum, and
its neck and cystic duct are immediately superior to the duodenum.

SHAPE AND PARTS

The pear-shaped gallbladder can hold up to 50 mL of bile. The hepatic surface of the
gallbladder attaches to the liver by connective tissue of the fibrous capsule of the liver.
The gallbladder has three parts from lateral to medial:
• Fundus: the wide blunt end that usually projects from the inferior border of the liver at
the tip of the right 9th costal cartilage in the MCL. Peritoneum completely surrounds the
fundus of the gallbladder and binds its body and neck to the liver.
• Body: main portion that contacts the visceral surface of the liver, transverse colon, and
superior part of the duodenum. It lies in the gallbladder fossa of the liver.
• Neck (infundibulum): narrow, tapering end, opposite the fundus and directed toward the
porta hepatis; it typically makes an S-shaped bend and joins the cystic duct.
CYSTIC DUCT
The cystic duct (3–4 cm long) connects the neck of the gallbladder to the common hepatic
duct. The mucosa of the neck spirals into the spiral fold (spiral valve). The spiral fold helps
keep the cystic duct open; thus bile can easily be diverted into the gallbladder when the
distal end of the bile duct is closed by the sphincter of the bile duct and/or
hepatopancreatic sphincter, or bile can pass to the duodenum as the gallbladder contracts.
The spiral fold also offers additional resistance to sudden dumping of bile when the
sphincters are closed, and intra-abdominal pressure is suddenly increased, as during a
sneeze or cough.
The cystic duct passes between the layers of the lesser omentum, usually parallel to the
common hepatic duct, which it joins to form the common bile duct. The cystic duct, common
hepatic duct and part of the inferior border of the liver form the triangle of Calot.
FUNCTION OF THE GALL BLADDER
The main gallbladder function is to store and concentrate bile, which then gets distributed to
the duodenum through the biliary tract. While ingesting a meal, the presence of fats and
proteins in the intestines stimulates the release of cholecystokinin. This peptide hormone
causes simultaneous contraction of the body and relaxation of the neck of the gallbladder.
Once the pressure within the biliary tree increases, the sphincter of Oddi relaxes. Bile then
flows from the biliary tree directly into the duodenum.

BLOOD SUPPLY
The arterial supply of the gallbladder and cystic duct is from the cystic artery. The cystic
artery commonly arises from the right hepatic artery in the triangle between the common
hepatic duct, cystic duct, and visceral surface of the liver, the cystohepatic triangle (of
Calot). Variations occur in the origin and course of the cystic artery.
The venous drainage from the neck of the gallbladder and cystic duct flows via the cystic
veins. These small and usually multiple veins enter the liver directly or drain through the
hepatic portal vein to the liver, after joining the veins draining the hepatic ducts and
proximal bile duct.
The veins from the fundus and body of the gallbladder pass directly into the visceral surface
of the liver and drain into the hepatic sinusoids. Because this is drainage from one capillary
(sinusoidal) bed to another, it constitutes an additional (parallel) portal system.
The lymphatic drainage of the gallbladder is to the hepatic lymph nodes, often through
cystic lymph nodes located near the neck of the gallbladder. Efferent lymphatic vessels from
these nodes pass to the celiac lymph nodes.
The nerves to the gallbladder and cystic duct pass along the cystic artery from the celiac
(nerve) plexus (sympathetic and visceral afferent [pain] fibers), the vagus nerve
(parasympathetic), and the right phrenic nerve (actually somatic afferent fibers).
Parasympathetic stimulation causes contractions of the gallbladder and relaxation of the
sphincters at the hepatopancreatic ampulla. However, these responses are generally
stimulated by the hormone cholecystokinin (CCK), produced by the duodenal walls (in
response to the arrival of a fatty meal), and circulated through the bloodstream.
The sympathetic component arising from the celiac plexus inhibits contractions of the
gallbladder, it also conveys pain sensation.

CLINICALS
Jaundice
Jaundice is defined as a yellowish discoloration of the sclera, skin, and mucous membranes
due to an excessive amount of bilirubin (hyperbilirubinemia). Bilirubin is the end-product
resulting from the breakdown of erythrocytes. It is metabolized in the liver and released in
the gallbladder as part of bile. Therefore, excessive erythrocyte hemolysis, liver pathologies
and biliary tree obstruction can result in jaundice. Specific examples include Gilbert
syndrome, hepatitis, cirrhosis and carcinomas.
Jaundice becomes clinically evident only when serum bilirubin levels exceed 2 mg/dl. Apart
from yellowing, physical findings can include right upper quadrant pain, fever, anorexia,
malaise, acholic stools and dark coloured urine.

Gallstones
A gallstone is a concretion in the gallbladder, cystic duct, or bile duct composed chiefly of
cholesterol crystal. Gallstones (cholelithiasis) are much more common in females and their
incidence increases with age. However, in approximately 50% of persons, gallstones are
“silent” (asymptomatic). Over a 20-year period, two thirds of asymptomatic people with
gallstones remain symptom free.
The longer stones remain quiescent, the less likely symptoms are to develop. For gallstones to
cause clinical symptoms, they must obtain a size sufficient to produce mechanical injury to
the gallbladder or obstruction of the biliary tract (Townsend et al., 2012).
The distal end of the hepatopancreatic ampulla is the narrowest part of the biliary passages
and is the common site for impaction of gallstones. Gallstones may also lodge in the hepatic
and cystic ducts. A stone lodged in the cystic duct causes biliary colic (intense, spasmodic
pain). When the gallbladder relaxes, the stone may move back into the gallbladder.
If the stone blocks the cystic duct, cholecystitis (inflammation of the gallbladder) occurs
because of bile accumulation, causing enlargement of the gallbladder.
Another common site for impaction of gallstones is in an abnormal sacculation (Hartmann
pouch), that appears in diseased states at the junction of the neck of the gallbladder and the
cystic duct. When this pouch is large, the cystic duct arises from its upper left aspect, not from
what appears to be the apex of the gallbladder. Gallstones commonly collect in the pouch. If a
peptic duodenal ulcer ruptures, a false passage may form between the pouch and the
superior part of the duodenum, allowing gallstones to enter the duodenum.
Pain from an impaction of the gallbladder develops in the epigastric region and later shifts to
the right hypochondriac region at the junction of the 9th costal cartilage and the lateral
border of the rectus sheath. Inflammation of the gallbladder may cause pain in the posterior
thoracic wall, or right shoulder owing to irritation of the diaphragm. If bile cannot leave the
gallbladder, it enters the blood and causes jaundice.
Ultrasound and CT scans are common non-invasive techniques for locating stones. Gallstones
in Duodenum A gallbladder that is dilated and inflamed owing to an impacted gallstone in its
duct may develop adhesions with adjacent viscera. Continued inflammation may break down
(ulcerate) the tissue boundaries between the gallbladder and a part of the gastrointestinal
tract adherent to it, resulting in a cholecysto-enteric fistula. Because of their proximity to the
gallbladder, the superior part of the duodenum and the transverse colon are most likely to
develop a fistula of this type. The fistula would enable a large gallstone, incapable of passing
though the cystic duct, to enter the gastrointestinal tract. A large gallstone entering the small
intestine in this way may become trapped at the ileocecal valve, producing a bowel
obstruction (gallstone ileus). A cholecysto-enteric fistula also permits gas from the
gastrointestinal tract to enter the gallbladder, providing a diagnostic radiographic sign.