Anatomy and

Physiology of
Biliary Tree

Dr. Kamalakanta Das

MBBS, MS, FMAS, DCh

Embryology
Gallbladder develops with bile duct and liver during week 4 as ventral
bud (hepatic diverticulum) from caudal foregut
Hepatic diverticulum has two components: pars hepatica and pars
cystica
Pars hepatica gives rise to liver, common hepatic duct and
intrahepatic bile ducts
Pars cystica gives rise to cystic diverticulum, which gives rise to
gallbladder and cystic duct
Hepatic diverticulum elongates to form common bile duct
Above structures begin as solid cords, but by 8 weeks develop lumen

Embryological development of the liver, pancreas and biliary tree is triggered by

endodermal proliferation

Cardinale, V. etal.(2012) The biliary treea reservoir of multipotent stem cells

Nat.Rev.Gastroenterol.Hepatol. doi:10.1038/nrgastro.2012.23

Anatomy

Gall Bladder
Gallbladder is a pear-shaped sac, about 7 to 10
cm long
Average capacity of 30-50ml
Located in a fossa on the inferior surface of the
liver that is in line with the anatomic division of
the liver into right and left liver lobes

Surface markings: Murphys

Sign

tip of 9th cc
transpyloric plane
transverse colon
semilunar plane

The gallbladder is divided

into four anatomic areas :

The
The
The
The

fundus
corpus (body)
infundibulum
neck

Hartmans Pouch
Infundibulum of
gallbladder
Lies between body
and neck of
gallbladder
A normal variation
May obscure cystic
duct
If very large, may
see cystic duct
arising from pouch

The peritoneal
lining covering
the liver
covers the
fundus and
the inferior
surface of gall
bladder

Gall Bladder : visceral surface

Calots /
Hepatocystic
triangle

The triangle bounded by the common hepatic duct medialy, the

cystic duct inferiorly and the inferior surface of the liver superiorly

Contents of Calots
-

Mascagni's lymph node or Lund's node

Cystic artery
May also contain an aberrant / accessory Right
Hepatic Artery or anomalous sectoral bile ducts.

Histology
Lined by a single, highly-folded, tall columnar
epithelium that contains cholesterol and fat
globules
The mucus secreted into the gallbladder
originates in the tubulo-alveolar 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

What is the histological

difference from rest of the GI
tract?
Gallbladder lacks muscularis mucosa and
submucosa.

Blood supply
Cystic artery that supplies the gallbladder is usually a branch
of the right hepatic artery (>90% of the time).
When the cystic artery reaches the neck of the
gallbladder, it divides into anterior and posterior divisions

Anomalies

Veins &
Lymphatics
Venous return - small veins that enter directly into the liver,
or rarely to a large cystic vein that carries blood back to the
portal vein.
Lymphatics drain into nodes at the neck of the gallbladder. A
visible lymph node overlies the insertion of the cystic artery
into the gallbladder wall. Ultimately draining into celiac nodes.

Nerve supply
Parasympathetic
anterior vagal trunk
stimulates contraction of the gallbladder
and relaxes the ampullary sphincter.

Sypmathetic
T7-9
Afferents
T7-9

right phrenic nerve

Sub-diaphragmatic peritoneum
(C3-5)
(skin over shoulder is supplied
by supraclavicular (C3, 4)

Shoulder tip pain

Boass sign

Anomalies of
Gallbladder
Abnormal position:
Left sided (with or without situs inversus),
intrahepatic (5%), retroperitoneal,
suprahepatic; also within falciform
ligament, lesser sac or abdominal wall
Agenesis (absence)
Cysts
Diverticula
Hourglass gallbladder
Hypoplasia
Micro gallbladder
Multi-septate gallbladder
Phrygian cap : Inversion of distal fundus
into body,
to which it may
become adherent
Wandering gallbladder

Biliary Tree
The biliary tree is the anatomic term for the
path by which bile is secreted by the liver on
its way to the duodenum. It is referred to as a
tree because it begins with many small branches
which end in the common bile duct, sometimes
referred to as the trunk of the biliary tree.

Bile Ducts
R hepatic
L hepatic
Common
Hepatic
Cystic
CBD

L>R
CHD 1-4cm,
4mm diameter
CBD - 711cm, 5 - 6
mm , supra,
retro and panc
portion

The common hepatic duct

between the layers of
the
hepatoduodenal
ligament

4 cm
4 mm

The common bile duct

(choledochus)
8 -10 cm
2-6 mm

Cystic Duct

Cystic Duct
The cystic duct is about 1.5 in. (3.8 cm) long and connects the neck
of the gallbladder to the common hepatic duct to form the bile duct
Somewhat S-shaped and descends for a variable distance in the
right free margin of the lesser omentum.
The mucous membrane of the cystic duct is raised to form a spiral
fold that is continuous with a similar fold in the neck of the
gallbladder. The fold is commonly known as the 'spiral valves of
Heister
The function of the spiral valve is to keep the lumen constantly
open.

CBD
The common bile duct runs obliquely downward within the
lesser omentum (ant to portal vein and to the right of
hepatic artery), posterior to pylorus and then in the wall of
the duodenum for 1 to 2 cm (post to head of pancreas and
anterior to portal vein) before opening on a papilla of
mucous membrane ( 10 cm from pylorus )
There the pancreatic duct frequently joins it
Three main configurations:
In about 70% of people these ducts unite outside the
duodenal wall and traverse the duodenal wall as a single
duct.
In about 20%, they join within the duodenal wall and
have a short or no common duct, but open through the
same opening into the duodenum.
In about 10%, they exit via separate openings into the

Retro & infra-duodenal CBD

Pancreatic Ducts

Duct of Wirsung

Ampulla of Vater
Sphincter of Oddi

The sphincter of Oddi:

The proximal bile and pancreatic ducts and the common channel
are surrounded by circular and longitudinal smooth muscle, this
muscle complex is known as the sphincter of Oddi.

Accessory pancreatic duct

(Santorini)

minor duodenal papilla

Blood supply of the biliary tract

1. The cystic artery
2. The right hepatic artery
The posterior superior
pancreaticoduodenal artery

Major trunks running

along the medial and
lateral walls of the
common duct (3 o'clock
and 9 o'clock).

Aberrant hepatic duct(s) :

20%
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

Physiology

Bile
Bile is a yellow-green fluid that is made by the liver, stored in the
gallbladder and passes through the common bile duct into the
duodenum where it helps digest fat.
Bile is mainly composed of water, electrolytes, bile salts,
proteins, lipids, and bile pigments.
The pH of hepatic bile is usually neutral or slightly alkaline
The primary bile salts, cholate and chenodeoxycholate,
synthesized in the liver from cholesterol
conjugated with taurine and glycine, and act within the bile as
anions

Bile salts are excreted into the bile by the hepatocyte

In the intestines, about 80% of the conjugated bile
acids are absorbed in the terminal ileum.
The remainder is 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

Bilirubin
Production

Functions of
Gallbladder
Absorption & secretion
In the fasting state, approximately 80% of the bile secreted
by the liver is stored in the gallbladder (When digestion is
not taking place, the sphincter of Oddi remains closed)
It rapidly absorbs sodium, chloride, and water against
significant concentration gradients
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.

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.

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. When stimulated by eating, the gallbladder empties
50 to 70% of its contents within 30 to 40 minutes

Neurohormonal
Regulation

The vagus nerve stimulates contraction of the

gallbladder, and splanchnic sympathetic stimulation is
inhibitory to its motor activity.

Antral distention of the stomach causes both gallbladder

contraction and relaxation of the sphincter of Oddi.

VIP inhibits contraction and causes gallbladder relaxation

Somatostatin is a potent inhibitor of gallbladder

contraction

1 liter /day
40 mls/hour

capacity of about 50 ml

Thank You !!