Anatomy and Physiology of the Biliary System

Anatomy of the Gallbladder

• Pear-shaped sac, ~ 7-10 cm long

• 30-50 ml capacity, up to 300 ml when obstructed

• Fossa on the inferior surface of the liver, anatomic division into right and left liver lobes

• 4 anatomic areas:

– Fundus: rounded, blind end; 1-2 cm beyond liver margin; most smooth ms of the organ

– Body: main storage area; most of the elastic tissue; from fundus tapers into neck

– Neck: funnel-shaped; connects w/ the cystic duct; deepest part of the GB fossa into free
portion of the hepatoduodenal ligament

– Infundibulum (Hartmann’s pouch): formed by enlarged convexity of the neck

– Peritoneum: fundus & inferior surface

• Histology:

– Single, highly-folded, tall columnar epithelium containing cholesterol & fat globules

– Tubuloalveolar glands: mucus; in mucosa lining infundibulum & neck

– Lamina propria: supports epithelium

– Circular, longitudinal & oblique ms layers

– Subserosa: connective tissue, nerves, vessels, lymphatics & adipocytes

– Serosa: except where embedded

• Lacks muscularis mucosa & submucosa

• Arterial supply: Cystic artery

– branch of right hepatic a. (>90%) within hepatocystic triangle (triangle of Calot)

– At neck: anterior & posterior divisions

• Venous return:

– Small veins directly into liver

– Rarely, large cystic vein back to portal vein

 • Lymphatics: nodes at GB neck, cystic artery insertion in GB wall

Anatomy of the Extrahepatic Bile Ducts

• Right & left hepatic ducts, common hepatic duct (CBD), cystic duct, common bile
duct/choledochus

• CBD à 2nd portion of the duodenum through sphincter of Oddi

• Left hepatic duct:

– longer than right

– greater risk for dilatation during distal obstruction

• Common hepatic duct:

– 1-4 cm in length, 4mm in diameter

– In front of the portal v., right of hepatic a.

– Joined at an acute angle by cystic duct à CBD

• Cystic duct

– Variable length

– Variations of the cystic duct and its point of union w/ the common hepatic duct-
surgically important

Spiral valves of Heister = mucosal folds at the segment of cystic duct near GB neck; no valvular function

• Surgically significant variations in ductal anatomy

• Long, tortuous cystic duct.

• Cystic duct crosses common hepatic duct posteriorly and joins common duct on left side. This
junction is posterior in some patients.

• Very short or absent cystic duct, usually seen in severe, chronic inflammation.

• Long cystic duct with low insertion into common duct.

• Long cystic duct fused to common hepatic duct.

• Anomalous entry of right anterior or posterior segmental duct into cystic duct; it may also enter
the common hepatic duct.
Common bile duct :

• 7 to 11 cm in length, 5 cm to 10mm in diameter.

• Upper third (supraduodenal) = downward in the free edge in the hepatoduodenal ligament, to
the right of the hepatic artery, anterior to the portal vein.

• Middle third (retroduodenal) = behind the D1; diverges laterally from the portal vein and
hepatic artery.

• Lower third (pancreatic) = curves behind the head of the pancreas in a grove or traverses
through it & enters the 2nd portion of the duodenum and joins together w/ the pancreatic duct

• Runs obliquely downward within the wall for 1 to 2 cm before opening on the ampulla of Vater ~
10 cm distal to the pylorus.

• 3 configurations of the union of CBD & pancreatic duct:

– 70% - unite outside duodenal wall as a single duct

– 20% - within duodenal wall, w/ short or no common duct; open at same opening into
duodenum

– 10% - exit via separate openings into duodenum

– Sphincter of Oddi – a thick coat of circular smooth muscle surrounding the CBD at the
ampulla of Vater; controls bile flow into duodenum

• Histology:

– Columnar mucosa with numerous mucous glands in the CBD.

– Absent distinct ms layer in CBD

• Arterial supply: gastroduodenal and right hepatic arteries w/ major trunks running along the
medial and lateral walls of the CBD ( 3’o clock & 9’o clock).

• Nerve supply: density increases near Sphincter of Oddi; same as GB

• Ducts of Luschka

– drain directly from the liver into body of the GB

– If (+) & not recognized during cholecystectomy à bile leak, formation of biloma

Bile Formation and Composition

• Average adult with an average diet : 500 to 1000 ml of bile a day.

 – secretion: neurogenic, humoral and chemical stimuli.

– vagal stimulation: secretion of bile

– splanchnic nerve stimulation : ¯ bile flow.

• HCL, CHON, and Fatty acids à release of secretin from the duodenum à increased bile production
& flow

• Bile flow from the liver à hepatic ducts à common hepatic duct à duodenum.

Gallbladder Function

• Main functions: concentrate and store hepatic bile & deliver bile into duodenum in response to
a meal

• Absorption & Secretion

– Fasting state: 80% of the bile stored in GB

– GB mucosa: greatest absorptive power per unit area of any structure in the body

– Rapidly absorbs Na+, Cl- & H20 against significant concentration gradients à one
mechanism to prevent rise in pressure

– Other means of maintaining low pressure in the biliary tree:

• gradual relaxation

• emptying of the GB during fasting

– Epithelial cells secrete glycoproteins and hydrogen ions

– Mucosal glands in infundibulum & neck – mucus glycoproteins w/c protect mucosa from
lytic actions of bile & facilitate passage of bile through cystic duct (“white bile” in
hydrops of the GB)

• Transport of hydrogen ions by GB epithelium à acidification of bile à calcium solubility à no Ca2+

salts formed

Sphincter of Oddi

• 4-6 mm in length

• Basal resting pressure = 13 mm Hg above duodenal pressure

• Phasic contractions of 4/min, amplitude = 12-140 mm Hg

• Regulates flow of bile & pancreatic juice into duodenum

• Prevents regurgitation of duodenal contents into biliary tree

• Divert bile into GB

• Complex structure, functionally independent from the duodenal musculature

• Creates high-pressure zone b/w bile duct & duodenum

• Rise in CCKà relaxation à decreased amplitude of phasic contractions & reduced basal pressure à
increased bile flow into duodenum