Gallbladder

Picture series by Mai

Figure 32-1. Anterior aspect of the biliary
anatomy. a = right hepatic duct; b = left hepatic
duct; c = common hepatic duct; d = portal vein; e
= hepatic artery; f = gastroduodenal artery; g = left
gastric artery; h = common bile duct; i = fundus of
the gallbladder; j = body of gallbladder; k =
infundibulum; l = cystic duct; m = cystic artery; n
= superior pancreaticoduodenal artery. Note the
situation of the hepatic bile duct confluence
anterior to the right branch of the portal vein, and
the posterior course of the right hepatic artery
1310 behind the common hepatic duct.
Figure32-2.
Variationsofthecysticductanatomy.A.L
owjunctionbetweenthecysticductandco
mmonhepaticduct.B.Cysticductadher-
ent to the common hepatic duct. C.
High junction between the cystic and
the common hepatic duct. D. Cystic
duct drains into right hepatic duct. E.
Long cystic duct that joins common
hepatic duct behind the duodenum. F.
Absence of cystic duct. G. Cystic duct
crosses posterior to common hepatic
duct and joins it anteriorly. H. Cystic
duct courses anterior to common
hepatic duct and joins it posteriorly.
Figure 32-4. Variations in the arterial supply to the
gallbladder. A. Cystic artery from right hepatic artery,
about 80% to 90%. B. Cystic artery from right hepatic
artery (accessory or replaced) from superior
mesenteric artery, about 10%. C. Two cystic arter- ies,
one from the right hepatic, the other from the
common hepatic artery, rare. D. Two cystic arteries,
one from the right hepatic, the other from the left
hepatic artery, rare. E. The cystic artery branch- ing
from the right hepatic artery and running anterior to
the com- mon hepatic duct, rare. F. Two cystic
arteries arising from the right hepatic artery, rare.
Figure 32-8. Schematic diagram of per- cutaneous
transhepatic cholangiogram and drainage for obstructing
proximal cholangio- carcinoma. A. Dilated intrahepatic
bile duct is entered percutaneously with a fine needle. B.
Small guidewire is passed through the needle into the
duct. C. A plastic catheter has been passed over the wire,
and the wire is subsequently removed. A cholangiogram
is performed through the catheter. D. An external
drainage catheter in place. E. Long wire placed via the
catheter and advanced past the tumor and into the
duodenum. F. Internal stent has been placed through the
tumor.
Figure 32-5. The effect of
cholecystokinin on the Figure 32-6. An ultrasonography
gallbladder and the sphincter of the gallbladder. Arrows indi-
of Oddi. A. During fasting, cate the acoustic shadows from
with the sphincter of Oddi stones in the gallbladder.
contracted and the gallbladder
filling. B. In response to a
meal, the sphincter of Oddi
relaxed and the gallbladder
emptying.
Figure 32-8. Schematic diagram of per- cutaneous
transhepatic cholangiogram and drainage for obstructing
proximal cholangio- carcinoma. A. Dilated intrahepatic
bile duct is entered percutaneously with a fine needle. B.
Small guidewire is passed through the needle into the
duct. C. A plastic catheter has been passed over the wire,
and the wire is subsequently removed. A cholangiogram
is performed through the catheter. D. An external
drainage catheter in place. E. Long wire placed via the
catheter and advanced past the tumor and into the
duodenum. F. Internal stent has been placed through the
tumor.
Figure 32-12. The three major
components of bile plotted on trian-
gular coordinates. A given point
represents the relative molar ratios of
bile salts, lecithin, and cholesterol.
The area labeled “micellar liquid”
shows the range of concentrations
found consistent with a clear micellar
solution (single phase), where
cholesterol is fully solubilized. The
shaded area directly above this region
corresponds to a metastable zone,
supersaturated with cholesterol. Bile
with a composition that falls above
the shaded area has exceeded the
solu- bilization capacity of
cholesterol and precipitation of
cholesterol crystals occurs.
FIGURE 54-21 Triangle of Solubility.
With the three major components of
bile that determine cholesterol
solubility and stability, each can be
quantified by molar percentage to
show a relative ratio to the other two.
Cholesterol is completely soluble in
only the small area in the left lower
corner, where a clear micellar solu-
tion exists, below the closed circles.
Just above this, in the area between the
open and closed circles, cholesterol is
supersaturated but stable and thus
crystallized only with stasis. In the
remainder of the triangle, cholesterol
is significantly supersaturated and
unstable. In this region, crystals form
immediately.
Figure 32-17. Percutaneous cholecystostomy. A pigtail
catheter has been placed through the abdominal wall, the
right lobe of the liver, and into the gallbladder.
Figure 32-22. Classification of
choledochal cysts. Type I, fusiform or
cystic dilations of the extrahepatic
biliary tree, is the most common type,
making up >50% of the choledochal
cysts. Type II, saccular diverticulum
of an extrahepatic bile duct. Rare,
<5% of choledochal cysts. Type III,
bile duct dilatation within the
duodenal wall (choledochoceles),
makes up about 5% of choledochal
cysts. Types IVa and IVb, mul- tiple
cysts, make up 5% to 10% of
choledochal cysts. Type IVa affects
both extrahepatic and intrahepatic bile
ducts, whereas type IVb cysts affect
the extrahepatic bile ducts only. Type
V, intrahepatic biliary cysts, is very
rare and makes up 1% of choledochal
cysts.
Figure 32-26. Bismuth-Corlette classification of bile duct
tumors.
Figure 32-28. A through F.
Percutaneous transhepatic
cholangiography and
placement of a biliary
drainage catheter. The
catheter has been passed
through the tumor area
(distal cholangiocarcinoma)
that is obstructing the distal
common bile duct and into
the duodenum.