Extrahepatic Biliary System

Question 1

Extrahepatic biliary system

Answer 1

1. Hepatic ducts
2. Cystic ducts
3. Common bile duct
4. Gall bladder

Question 2

Hepatic ducts: origin

Answer 2

Right and left hepatic ducts emerge from liver right and left lobes near porta hepatis right end and anterior to hepatic artery and portal vein branches

Question 3

Hepatic ducts: course

Answer 3

1. Both ducts unite forming common hepatic duct (3-4 cm long)
2. Descends in lesser omentum free border on hepatic artery right side and in front of portal vein

Question 4

Hepatic ducts: end

Answer 4

Common hepatic duct joins cystic duct at acute angle forming common bile duct

Question 5

Cystic duct

Answer 5

1. S-shaped duct
2. 3-4 cm long
3. Arises from gall bladder neck
4. Ends by joining common hepatic duct forming common bile duct

Question 6

Cystic duct spiral valve

Answer 6

Mucous membrane of cystic duct and gall bladder neck projects into their lumina to form spiral valve keeping them patent

Question 7

Common bile duct: formation

Answer 7

Union of common hepatic duct and cystic duct below porta hepatis

Question 8

Common bile duct: size

Answer 8

3-4 inches long and about 6 mm wide

Question 9

Common bile duct: parts

Answer 9

1. Supraduodenal part
2. Retroduodenal part
3. Infraduodenal part
4. Intraduodenal part

Question 10

Supraduodenal part

Answer 10

1. Passes in
   - Lesser omentum free border
   - In front of portal vein
   - On hepatic artery right side
2. Separated from IVC behind by Epiploic foramen

Question 11

Retroduodenal part

Answer 11

Lies behind 2nd inch of duodenum 1st part with gastroduodenal artery on its left side and portal vein behind separating them from IVC

Question 12

Infraduodenal part

Answer 12

Lies behind pancreas head (may be embedded in it) and in front of IVC

Question 13

Intraduodenal part

Answer 13

1. Common bile duct terminal part unites with main pancreatic duct forming ampulla of vater
2. Opens at major duodenal papilla in middle of Posteromedial aspect of duodenum 2nd part
3. Surrounded by sphincter of Oddi

Question 14

Common bile duct: applied anatomy

Answer 14

Common bile duct may be compressed in pancreas head cancer leading to obstructive jaundice

Question 15

Gall bladder: site

Answer 15

Lies in gallbladder fossa on inferior surface of liver right lobe just to right of quadrate lobe

Question 16

Gall bladder is fixed to the liver by:

Answer 16

1. Visceral peritoneum of liver inferior surface
2. Loose connective tissue containing cystic artery
3. Small veins from gall bladder to liver

Question 17

Gall bladder: shape

Answer 17

Pear shaped

Question 18

Gall bladder: size

Answer 18

3-4 inches long
3 cm wide
30-50ml capacity

Question 19

Gall bladder: function

Answer 19

Concentration (10 times) and storage of bile

Question 20

Gall bladder: parts

Answer 20

1. Fundus
2. Body
3. Neck

Question 21

Fundus relations

Answer 21

Protrudes below liver inferior border
1. Anterior: anterior abdominal wall
2. Posterior: transverse colon

Question 22

Body relations

Answer 22

1. Superior: liver inferior surface (gall bladder bed)
2. Inferior:
   - transverse colon
   - end of duodenum 1st part and beginning of 2nd part

Question 23

Neck relations

Answer 23

1. Uppermost and narrowest part
2. Give rise to cyctic duct
3. Its right wall presents dilation (Hartman’s pouch)
4. Superior: cystic artery separated it from liver
5. Inferior: 2nd inch of duodenum 1st part

Question 24

Gall bladder: surface anatomy

Answer 24

Fundus corresponds to tip of right 9th costal cartilage where:
1. Transpyloric plane
2. Right linea semilunaris
Or
3. Right lateral vertical plane
Crosses right costal margin (murphy’s point)

Question 25

Gall bladder: peritoneal covering

Answer 25

1. Fundus is completely covered with peritoneum as it projects below liver inferior border 2. Body and neck are only covered on their inferior surface

Question 26

Gall bladder: arterial supply

Answer 26

1. Cystic artery 2. Many small arteries: pass to gall bladder from its bed in liver

Question 27

Cystic artery

Answer 27

1. Right hepatic artery branch 2. Reaches gall bladder by passing in calot triangle between: - Cystic duct - Common hepatic duct - Liver inferior surface

Question 28

Gall bladder: venous drainage

Answer 28

Cystic veins: open directly into hepatic veins or into portal vein right branch

Question 29

Lymphatic drainage

Answer 29

1. Superior surface lymph vessels: communicate with liver lymph vessels 2. Remaining parts lymph vessels: pass to cystic node (at junction of cystic duct and common hepatic duct) and hepatic nodes (in porta hepatis along hepatic artery)

Question 30

Nerve supply

Answer 30

1. Parasympathetic 2. Sympathetic 3. Phrenic nerve

Question 31

Parasympathetic

Answer 31

Vagus nerve through coeliac plexus

Question 32

Sympathetic

Answer 32

Greater splanchnic nerves (T5-9) through coeliac plexus along hepatic artery

Question 33

Right phrenic nerve fibers

Answer 33

Through its communication with hepatic plexus, also reach gall bladder through hepatic plexus

Question 34

Applied anatomy: cholecystitis

Answer 34

Pain is felt in right hypochondrium and radiates to: 1. Shoulder tip (C3 and C4 give both phrenic and lateral supraclavicular nerves) 2. At back below scapula (T5-9 spinal segments give greater splanchnic nerve and supply the skin below scapula)

Question 35

Applied anatomy: Hartman’s pouch stone

Answer 35

Can cause obstruction of gall bladder neck and common hepatic duct leading to obstructive jaundice

Question 36

Gall bladder has double arterial supply

Answer 36

Which explains rarity of bladder gangrene in case of acute cholecystitis