The gallbladder is a pear-shaped sac, about 7 to 10 cm long, with an average

capacity of 30 to 50 mL. When obstructed, the gallbladder can distend

markedly and contain up to 300 mL. The gallbladder is located in a fossa on
the inferior surface of the liver. A line from this fossa to the inferior vena cava
divides the liver into right and left liver lobes.
The gallbladder is divided into four anatomic areas: the fundus, the corpus
(body), the infundibulum, and the neck. The fundus is the rounded, blind end
that normally extends 1 to 2 cm beyond the livers margin. It contains most of
the smooth muscles of the organ, in contrast to the body, which is the main
storage area and contains most of the elastic tissue. The body extends from
the fundus and tapers into the neck, a funnel-shaped area that connects with
the cystic duct. The neck usually follows a gentle curve, the convexity of
which may be enlarged to form the infundibulum or Hartmanns pouch. The
neck lies in the deepest part of the gallbladder fossa and extends into the
free portion of the hepatoduodenal ligament.

The same peritoneal lining that covers the liver covers the fundus and
the inferior surface of the gallbladder. Occasionally, the gallbladder has a
complete peritoneal covering and is suspended in a mesentery off the inferior
surface of the liver, and rarely, it is embedded deep inside the liver
parenchyma (an intrahepatic gallbladder).
The gallbladder is lined by a single, highly folded, tall columnar epithelium
that contains cholesterol and fat globules. The mucus secreted into the
gallbladder originates in the tubuloalveolar glands found in the mucosa lining
the infundibulum and neck of the gallbladder, but are absent from the body
and fundus. The epithelial lining of the gallbladder is supported by a lamina
propria. The muscle layer has circular longitudinal and oblique fibers, but
without well-developed layers. The perimuscular subserosa contains
connective tissue, nerves, vessels, lymphatics, and adipocytes. It is covered
by the serosa except where the gallbladder is embedded in the liver. The
gallbladder differs histologically from the rest of the gastrointestinal.

The cystic artery that supplies the gallbladder is usually a branch of the right
hepatic artery (>90% of the time). The course of the cystic artery may vary,
but it nearly always is found within the hepatocystic triangle, the area bound
by the cystic duct, common hepatic duct, and the liver margin (triangle of
Calot). When the cystic artery reaches the neck of the gallbladder, it divides
into anterior and posterior divisions. Venous return is carried either through
small veins that enter directly into the liver or, rarely, to a large cystic vein
that carries blood back to the portal vein. Gallbladder lymphatics drain into

nodes at the neck of the gallbladder. Frequently, a visible lymph node overlies
the insertion of the cystic artery into the gallbladder wall. The nerves of the
gallbladder arise from the vagus and from sympathetic branches that pass
through the celiac plexus.
The preganglionic sympathetic level is T8 and T9. Impulses from the liver,
gallbladder, and the bile ducts pass by means of sympathetic afferent fibers
through the splanchnic nerves and mediate the pain of biliary colic. The
hepatic branch of the vagus nerve supplies cholinergic fibers to the
gallbladder, bile ducts, and liver. The vagal branches also have peptidecontaining nerves containing agents such as substance P, somatostatin,
enkephalins, and vasoactive intestinal polypeptide.
Bile Ducts
The extrahepatic bile ducts consist of the right and left hepatic ducts, the
common hepatic duct, the cystic duct, and the common bile duct or
choledochus. The common bile duct enters the second portion of the
duodenum through a muscular structure, the sphincter of Oddi. The left
hepatic duct is longer than the right and has a greater propensity for
dilatation as a consequence of distal obstruction. The two ducts join to form a
common hepatic duct, close to their emergence from the liver. The common
hepatic duct is 1 to 4 cm in length and has a diameter of approximately 4
mm. It lies in front of the portal vein and to the right of the hepatic artery.
The common hepatic duct is joined at an acute angle by the cystic duct to
form the common bile duct. The length of the cystic duct is quite variable. It
may be short or absent and have a high union with the hepatic duct, or long
and run parallel, behind, or spiral to the main hepatic duct before joining it,
sometimes as far as at the duodenum. Variations of the cystic duct and its
point of union with the common hepatic duct are surgically important (Fig. 322). The segment of the cystic duct adjacent to the gallbladder neck bears a
variable number of mucosal folds called the spiral valves of Heister. They do
not have any valvular function but may make cannulation of the cystic duct
difficult.
The extrahepatic bile ducts consist of the right and left hepatic ducts, the
common hepatic duct, the cystic duct, and the common bile duct or
choledochus. The common bile duct enters the second portion of the
duodenum through a muscular structure,the sphincter of Oddi.3 The left
hepatic duct is longer than the right and has a greater propensity for
dilatation as a consequence of distal obstruction. The two ducts join to form a
common hepatic duct, close to their emergence from the liver. The common
hepatic duct is 1 to 4 cm in length and has a diameter of approximately 4
mm. It lies in front of the portal vein and to the right of the hepatic artery.
The common hepatic duct is joined at an acute angle by the cystic duct to

form the common bile duct. The length of the cystic duct is quite variable. It
may beshort or absent and have a high union with the hepatic duct, or long
and run parallel, behind, or spiral to the main hepatic duct before joining it,
sometimes as far as at the duodenum. Variations of the cystic duct and its
point of union with the common hepatic duct are surgically important (Fig. 322). The segment of the cystic duct adjacent to the gallbladder neck bears a
variable number of mucosal folds called the spiral valves of Heister. They do
not have any valvular function but may make cannulation of the cystic duct
difficult.
The extrahepatic bile ducts are lined by a columnar mucosa with numerous
mucous glands in the common bile duct. A fibroareolar tissue containing
scant smooth muscle cells surrounds the mucosa. A distinct muscle layer is
not present in the human common bile duct. The arterial supply to the bile
ducts is derived from the gastroduodenal and the right hepatic arteries, with
major trunks running along the medial and lateral walls of the common duct
(sometimes referred to as 3 oclock and 9 oclock). These arteries
anastomose freely within the duct walls. The density of nerve fibers and
ganglia increases near the sphincter of Oddi, but the nerve supply to the
common bile duct and the sphincter of Oddi is the same as for the
gallbladder.1,2

Anomalies
The classic description of the extrahepatic biliary tree and its arteries applies
only in about one third of patients.4 The gallbladder may have abnormal
positions, be intrahepatic, be rudimentary, have anomalous forms, or be
duplicated. Isolated congenital absence of the gallbladder is very rare, with a
reported incidence of 0.03%. Before the diagnosis is made, the presence of an
intrahepatic bladder or anomalous position must be ruled out. Duplication of the
gallbladder with two separate cavities and two separate cystic ducts has an
incidence of about one in every 4000 persons. This occurs in two major varieties:
the more common form in which each gallbladder has its own cystic duct that
empties independently into the same or different parts of the extrahepatic biliary
tree, and as two cystic ducts that merge before they enter the common bile
duct. Duplication is only clinically important when some pathologic processes
affect one or both organs. A left-sided gallbladder with a cystic duct emptying
into the left hepatic duct or the common bile duct and a retrodisplacement of the
gallbladder are both extremely rare. A partial or totally intrahepatic gallbladder
is associated with an increased incidence of cholelithiasis.

Small ducts (of Luschka) may drain directly from the liver into the body of the
gallbladder. If present, but not recognized at the time of a cholecystectomy, a bile
leak with the accumulation of bile (biloma) may occur in the abdomen. An accessory
right hepatic duct occurs in about 5% of cases. Variations of how the common bile
duct enters the duodenum are described in earlier, in the Bile Ducts section.

Anomalies of the hepatic artery and the cystic artery are quite common, occurring
in as many as 50% of cases.5 In about 5% of cases, there are two right hepatic
arteries, one from the common hepatic artery and the other from the superior
mesenteric artery. In about 20% of patients, the right hepatic artery comes off the
superior mesenteric artery. The right hepatic artery may course anterior to the
common duct. The right hepatic artery may be vulnerable during surgical
procedures, in particular when it runs parallel to the cystic duct or in the mesentery
of the gallbladder. The cystic artery arises from the right hepatic artery in about
90% of cases, but may arise from the left hepatic, common hepatic,
gastroduodenal, or superior mesenteric arteries (Fig. 32-4).
PHYSIOLOGY
Bile Formation and Composition
The liver produces bile continuously and excretes it into the bile canaliculi.
The normal adult consuming an average diet produces within the liver 500 to
1000 mL of bile a day. The secretion of bile is responsive to neurogenic,
humoral, and chemical stimuli. Vagal stimulation increases secretion of bile,
whereas splanchnic nerve stimulation results in decreased bile flow.
Hydrochloric acid, partly digested proteins, and fatty acids in the duodenum
stimulate the release of secretin from the duodenum that, in turn, increases
bile production and bile flow. Bile flows from the liver through to the hepatic
ducts, into the common hepatic duct, through the common bile duct, and
finally into the duodenum. With an intact sphincter of Oddi, bile flow is
directed into the gallbladder.
Bile is mainly composed of water, electrolytes, bile salts, proteins, lipids, and
bile pigments. Sodium, potassium, calcium, and chlorine have the same
concentration in bile as in plasma or extracellular fluid. The pH of hepatic bile
is usually neutral or slightly alkaline, but varies with diet; an increase in
protein shifts the bile to a more acidic pH. The primary bile salts, cholate and
chenodeoxycholate, are synthesized in the liver from cholesterol. They are
conjugated there with taurine and glycine and act within the bile as anions
(bile acids) that are balanced by sodium. Bile salts are excreted into the bile
by the hepatocyte and aid in the digestion and absorption of fats in the
intestines.
In the intestines, about 80% of the conjugated bile acids are absorbed in the
terminal ileum. The remainder is dehydroxylated (deconjugated) by gut
bacteria, forming secondary bile acids deoxycholate and lithocholate. These
are absorbed in the colon, transported to the liver, conjugated, and secreted
into the bile. Eventually, about 95% of the bile acid pool is reabsorbed and
returned via the portal venous system to the liver, the so-called
enterohepatic circulation. Five percent is excreted in the stool, leaving the
relatively small amount of bile acids to have maximum effect.

 Cholesterol and phospholipids synthesized in the liver are the principal lipids
found in bile. The synthesis of phospholipids and cholesterol by the liver is, in
part, regulated by bile acids. The color of the bile is due to the presence of
the pigment bilirubin diglucuronide, which is the metabolic product from the
breakdown of hemoglobin and is present in bile in concentrations 100 times
greater than in plasma. Once in the intestine, bacteria convert it into
urobilinogen, a small fraction of which is absorbed and secreted into the bile.
Gallbladder Function
The gallbladder, the bile ducts, and the sphincter of Oddi act together to
store and regulate the flow of bile. The main function of the gallbladder is to
concentrate and store hepatic bile and to deliver bile into the duodenum in
response to a meal. Absorption and Secretion. In the fasting state,
approximately 80% of the bile secreted by the liver is stored in the
gallbladder. This storage is made possible because of the remarkable
absorptive capacity of the gallbladder, as the gallbladder mucosa has the
greatest absorptive power per unit area of any structure in the body. It rapidly
absorbs sodium, chloride, and water against significant concentration
gradients, concentrating the bile as much as 10-fold and leading to a marked
change in bile composition. This rapid absorption is one of the mechanisms
that prevent a rise in pressure within the biliary system under normal
circumstances. Gradual relaxation as well as emptying of the gallbladder
during the fasting period also plays a role in maintaining a relatively low
intraluminal pressure in the biliary tree.
The epithelial cells of the gallbladder secrete at least two important products
into the gallbladder lumen: glycoproteins and hydrogen ions. The mucosal
glands in the infundibulum and the neck of the gallbladder secrete mucus
glycoproteins that are believed to protect the mucosa from the lytic action of
bile and to facilitate the passage of bile through the cystic duct. This mucus
makes up the colorless white bile seen in hydrops of the gallbladder
resulting from cystic duct obstruction. The transport of hydrogen ions by the
gallbladder epithelium leads to a decrease in the gallbladder bile pH. The
acidification promotes calcium solubility, thereby preventing its precipitation
as calcium salts.
Motor Activity.
Gallbladder filling is facilitated by tonic contraction of the sphincter of
Oddi, which creates a pressure gradient between the bile ducts and the
gallbladder. During fasting, the gallbladder does not simply fill passively. In
association with phase II of the interdigestive migrating myenteric motor
complex in the gut, the gallbladder repeatedly empties small volumes of bile
into the duodenum. This process is mediated at least in part by the hormone

motilin. In response to a meal, the gallbladder empties by a coordinated

motor response of gallbladder contraction and sphincter of Oddi relaxation.
One of the main stimuli to gallbladder emptying is the hormone
cholecystokinin (CCK). CCK is released endogenously from the duodenal
mucosa in response to a meal.7 When stimulated by eating, the gallbladder
empties 50% to 70% of its contents within 30 to 40 minutes. Over the
following 60 to 90 minutes, the gallbladder gradually refills. This is correlated
with a reduced CCK level. Other hormonal and neural pathways also are
involved in the coordinated action of the gallbladder and the sphincter of
Oddi. Defects in the motor activity of the gallbladder are thought to play a
role in cholesterol nucleation and gallstone formation.