Gross anatomy and histology of extrahepatic biliary apparatus

it describes different parts of extrahepatic biliary apparatus and their clinical significance.

1. Gross anatomy and histology of
extrahepatic biliary apparatus.
Dr. Laxman Khanal
Associate Professor, Department of Human Anatomy
BPKIHS, Dharan, Nepal

2. Q. Cystic artery is the branch of:
a. Hepatic artery properb. Right hepatic artery
c. Left hepatic arteryd. common hepatic artery
Q. Gall bladder is located in:
a.Inferior surface of right lobe of liver
b.Posterior surface of right lobe of liver
c.Inferior surface of left lobe of liver
d.Posterior surface of left lobe of liver
Q.Clinically GB pain is referred to:
a.Inferior angle of Rtscapula
b.Tip of Rtshoulder
c.Stomach region
d.All of the above

3. What is extrahepatic biliary apparatus (EHBA)?
Theextrahepaticbiliaryapparatusreceivesthebilefromliver,stores
andconcentratesitinthegallbladder,andtransmitsittothesecond
partoftheduodenumwhenrequired.
Consistsoffivecomponents:
1. Right and left hepatic ducts
2. Common hepatic duct
3. Gallbladder
4. Cystic duct
5. Bile duct or common bile duct
Anatomicalknowledgeaboutitis
importanttounderstandvariousdisease
processessuchascholelithiasisand
cholecystitisandalsotounderstandthe
surgicalprocesslikecholecystectomy.

4. Rtlobe
Rtlobe
Lt lobe
Lt lobe
•Gallbladder is located in fossa for gallbladder in right lobe of liver.
•It is attached to the liver by right and left hepatic duct.
•Fundus of gallbladder is extended below the lower margin of liver.
Portahepatisisthepointof
initiationofEHBA.

5. Components of EHBA
Extendsbelowthelower
marginofliverandliesatthe
tipofRt9
th
costalcartilageof
thecostalmargin.

6. Hartmann’s pouch:
Prone to lodgment of stone
50 ml
Functions of GB
1.Storage of bile
2.Concentration of bile
3.Acidification of bile
Bileisanemulsifying
agentwhichfacilitates
pancreaticlipasefor
hydrolysisoflipid.
Gall bladder

7. Peritoneal covering of gallbladder
Covered by peritoneum except for the surface resting on liver.

8. Microanatomy of gall bladder
Mucous membrane
•lined by columnar epithelium (cholangiocyte)
•Forms folds (Rugae)
•Similar to villi (but no goblet cells)
•No Muscularis mucosa
Muscle layer (smooth muscle fibers)
Serous (peritoneal) layer
•Lined by mesothelium
Poorly developed submucosa layer

9. Epiploic foramen
Lesser sac

10. Supra duodenal part
Retro duodenal part
Infra duodenal part
Intra duodenal part

11. Hepatopancreaticampulla
(ampullaofVater)
1.Sphinctercholedochus
2.Sphincterpancreaticus
3.Sphincterampullae
(sphincterofOddi)
Major duodenal papilla
Fore gut-midgut
transition point

12. CCK
+
_

13. Blood supply of biliary system
Common hepatic artery
Rtgastric artery
Gastroduodenal artery
Hepatic artery proper
Cystic artery
Artery: cystic artery
Vein: cystic vein
Lymph: cystic LN
Nerve: cystic plexus
Sympathetic: T7-T9
Parasympathetic: Vagus nerve

14. Blood supply of bile duct
1.Descending branch of cystic artery
2.Ascending branch of sup pancreaticoduodenal artery

15. Blood supply of GB
and Calot’striangle
Contentsof Calot’striangle:
1.Cystic artery & vein
2.Cystic LN
Boundariesof calot’striangle
1.Undersurface of liver (sup)
2.CHD (left side)
3.Cystic duct (right side)
Ligationofcysticarteryinthistriangle
istheoneofthecrucialstepsin
surgicalremovalofgallbladder.
•Alsocalledascystohepatictriangle

16. Moynihan’s Hump
Or
Caterpillar’s turn

17. Gall stone (cholelithiasis)
•Gallstonesarepresentinapproximately10%ofpeopleovertheage
of40andaremorecommoninwomen.
•Theyarepredominantlyamixtureofcholesterolandbilepigment.
•Theymayundergocalcification,whichcanbedemonstratedonplain
radiographs.
•Thegallbladdercannotemptynormallyandcontractionsofthe
gallbladderwallproduceseverepain.
•Ifpainpersistsacholecystectomy(removalofthegallbladder)maybe
necessary.

18. Cholesterol stone Pigment stoneMixed stone

20. Cholecystitis
•Inflammation of the gall bladder is called as cholecystitis.
•Most commonly caused by cholelithiasiswhich causes obstruction of
bile duct or cystic duct.
•Symptoms
Biliary colic
Jaundice
Murphy’s sign positive
Murphy’s sign
Deep pressure at GB point at the
height of inspiration
Patient feels stabbing pain
Catch in breath

21. Cholecystectomy