Dr. Tharwat S. Kandiel
ANATOMY
The gallbladder (or cholecyst, sometimes gall bladder) is a pear-shaped
organ that stores about 50 mL of bile (or "gall") until the body needs it for
digestion.
The gallbladder is about 7-10 cm long in humans and appears dark green
because of its contents (bile), rather than its tissue. It is connected to the liver
and the duodenum by the biliary tract.
The cystic duct leads from the gallbladder and joins with the common
hepatic duct to form the common bile duct.
The common bile duct then joins with the pancreatic duct, and enters the
duodenum through the hepatopancreatic ampulla at the major duodenal papilla.
Artery
Cystic artery
Vein
Cystic vein
Nerve
Celiac Ganglia, vagus
Precursor
Foregut
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Dr. Tharwat S. Kandiel
HISTOLOGY
The layers of the gallbladder are as follows:
 The gallbladder has a simple columnar epithelial lining characterized by
recesses called Aschoff's recesses (lacunae of Luschka) , which are pouches
inside the lining.
 Under the epithelium there is a layer of connective tissue.
 Beneath the connective tissue is a wall of smooth muscle that contracts in
response to cholecystokinin, a peptide hormone secreted by the duodenum.
 There is essentially no submucosa separating the connective tissue from
serosa and adventitia.
Function of GB
The gallbladder stores about 50 mL of bile , which is released when food
containing fat enters the digestive tract, stimulating the secretion of
cholecystokinin (CCK). The bile, produced in the liver, emulsifies fats and
neutralizes acids in partly digested food.
After being stored in the gallbladder, the bile becomes more concentrated
than when it left the liver, increasing its potency and intensifying its effect on
fats. Most digestion occurs in the duodenum.
ANOMALIES
 The gallbladder may be absent = 0.075%
 The gallbladder and cystic duct may be absence.
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Dr. Tharwat S. Kandiel
 The gallbladder is irregular in form or constricted across its middle; more
rarely, it is partially divided in a longitudinal direction.
 Two distinct gallbladders, each having a cystic duct that joined the hepatic
duct. (0.026%), The cystic duct may itself be doubled
 The gallbladder has been found on the left side (to the left of the ligamentum
teres) in subjects in whom there was no general tranposition of the thoracic
and abdominal viscera.
 The gallbladder may be intrahepatic or beneath the left lobe. Ectopic sites
include retrohepatic positions, or in the anterior abdominal wall or falciform
ligament, they may be suprahepatic or transversely position, floating, or
retroperitoneal. They may be in the midline anterior epigastric above the left
lobe or suprahepatic above the right hepatic lobe.
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Dr. Tharwat S. Kandiel
CHOLEDOCHAL CYST
Choledochal cysts are congenital anomalies of the bile ducts. They consist
of cystic dilatations of the extrahepatic biliary tree, intrahepatic biliary radicles,
or both.
Douglas is credited with the first clinical report in a 17-year-old girl who
presented with intermittent abdominal pain, jaundice, fever, and a palpable
abdominal mass.
Pathophysiology: The pathogenesis of choledochal cysts is most likely
multifactorial. Some aspects of the disease are consistent with a congenital
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Dr. Tharwat S. Kandiel
etiology, others with a congenital predisposition to acquiring the disease under
the right conditions.
The vast majority of patients with choledochal cysts have an anomalous
junction of the common bile duct with the pancreatic duct (anomalous
pancreatobiliary junction [APBJ]). An APBJ is characterized when the
pancreatic duct enters the common bile duct 1 cm or more proximal to where the
common bile duct reaches the ampulla of Vater. Miyano and Yamataka have
demonstrated such APBJs in more than 90% of their patients with choledochal
cysts.
The APBJ allows pancreatic secretions and enzymes to reflux into the
common bile duct. In the relatively alkaline conditions found in the common
bile duct, pancreatic proenzymes can become activated. This results in
inflammation and weakening of the bile duct wall. Severe damage may result in
complete denuding of the common bile duct mucosa.
From a congenital standpoint, defects in epithelialization and
recanalization of the developing bile ducts during organogenesis and congenital
weakness of the duct wall have also been implicated. The result is formation of a
choledochal cyst.
Anatomy: The following discussion of the pertinent anatomy of
choledochal cysts is based on the Todani classification published in 1977.
Type I choledochal cysts are most common and represent 80-90% of the
lesions. Type I cysts are dilatations of the entire common hepatic and common
bile ducts or segments of each. They can be saccular or fusiform in
configuration. Type I cysts can be divided into 3 subclassifications, including
type IA cysts, which are typically saccular and involve the entire extrahepatic
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Dr. Tharwat S. Kandiel
bile duct (common hepatic duct plus common bile duct) or the major portion of
the duct.
Type II choledochal cysts are relatively isolated protrusions or diverticula
that project from the common bile duct wall. They may be sessile or may be
connected to the common bile duct by a narrow stalk.
Type III choledochal cysts are found in the intraduodenal portion of the
common bile duct. Another term used for these cysts is choledochocele.
Type IVA cysts are characterized by multiple dilatations of the
intrahepatic and extrahepatic biliary tree. Most frequently, a large solitary cyst
of the extrahepatic duct is accompanied by multiple cysts of the intrahepatic
ducts. Type IVB choledochal cysts consist of multiple dilatations that involve
only the extrahepatic bile duct.
Type V choledochal cysts are defined by dilatation of the intrahepatic
biliary radicles. Often, numerous cysts are present with interposed strictures that
predispose the patient to intrahepatic stone formation, obstruction, and
cholangitis. The cysts are typically found in both hepatic lobes. Occasionally,
unilobar disease is found and most frequently involves the left lobe.
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Dr. Tharwat S. Kandiel
The patient may present at any age with
 Obstructive jaundice
 Cholangitis and
 Abd signs, with RUQ swelling in some cases
 It is a premalignant condition
 Diagnosis by US and MRI
 Radical excision of the cyst is the treatment of choice with Roux – en –Y
reconstruction.
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