The liver secret necessary for digestion moves through the gallbladder to the intestinal cavity through the bile ducts. Various diseases provoke changes in the functioning of the bile ducts. Interruptions in the work of these pathways affect the performance of the whole organism. The bile ducts differ in their structural and physiological features.

Interruptions in work bile ducts affect the performance of the whole organism

What is the gallbladder for?

The liver is responsible for the secretion of bile in the body, and what function does the gallbladder perform in the body? The biliary system is formed by the gallbladder and its ducts. development in it pathological processes threatens with serious complications and affects the normal life of a person.

The functions of the gallbladder in the human body are:

• accumulation of bile fluid in the cavity of the organ;
• thickening and preservation of hepatic secretions;
• excretion through the bile ducts into the small intestine;
• protecting the body from irritants.

The production of bile is carried out by the cells of the liver and does not stop day or night. Why does a person need a gallbladder and why is it impossible to do without this link when transporting hepatic fluid?

The excretion of bile occurs constantly, but the processing of the food mass with bile is required only in the process of digestion, which is limited in duration. Therefore, the role of the gallbladder in the human body is to accumulate and store the secret of the liver until the right time. The production of bile in the body is an uninterrupted process and it is formed many times more than the volume of the pear-shaped organ allows. Therefore, bile splitting occurs inside the cavity, the removal of water and some substances necessary in other physiological processes. Thus, it becomes more concentrated, and its volume is significantly reduced.

The amount that the bubble will throw out does not depend on how much it produces the largest gland - the liver, which is responsible for the production of bile. The value in this case is played by the amount of food consumed and its nutritional composition. The passage of food through the esophagus serves as a signal to start work. To digest fatty and heavy foods, more secretions will be required, so the organ will contract more strongly. If the amount of bile in the bladder is insufficient, then the liver is directly involved in the process, where the secretion of bile never stops.

The accumulation and excretion of bile is carried out as follows:

Therefore, the role of the gallbladder in the human body is to accumulate and store the secret of the liver until the right time.

• the common hepatic duct passes the secret to the bile duct, where it accumulates and is stored until the right moment;
• the bubble begins to contract rhythmically;
• the bladder valve opens;
• the opening of the intracanal valves is provoked, the sphincter of the major duodenal papilla relaxes;
• bile goes to the intestines through the common bile duct.

In cases where the bubble is removed, the biliary system does not cease to function. All work falls on the bile ducts. The innervation of the gallbladder or its connection with the central nervous system occurs through the hepatic plexus.

Gallbladder dysfunction affects the well-being and can cause weakness, nausea, vomiting, skin itching and others. unpleasant symptoms. In Chinese medicine, it is customary to consider the gallbladder not as separate body, but as a component of the same system with the liver, which is responsible for the timely release of bile.

The meridian of the gallbladder is considered Jansky, i.e. paired and runs throughout the body from head to toes. The meridian of the liver, which belongs to the Yin organs, and the gallbladder are closely related. It is important to understand how it spreads in human body so that the treatment of organ pathologies with the help of Chinese medicine is effective. There are two channel paths:

• external, passing from the corner of the eye through the temporal region, forehead and back of the head, then descending to the armpit and lower along the front of the thigh to ring finger legs;
• internal, starting in the area of ​​​​the shoulders and going through the diaphragm, stomach and liver, ending with a branch in the bladder.

Stimulation of points on the meridian of the biliary organ helps not only to improve digestion and improve its work. Impact on the points of the head eliminates:

• migraines;
• arthritis;
• diseases of the visual organs.

Also, through the points of the body, you can improve cardiac activity, but with help. Areas on the legs - muscle activity.

The structure of the gallbladder and biliary tract

The gallbladder meridian affects many organs, which indicates that the normal functioning of the biliary system is extremely important for the functioning of the whole organism. The anatomy of the gallbladder and biliary tract is a complex system of channels that ensure the movement of bile inside the human body. To understand how the gallbladder works, its anatomy helps.

What is the gallbladder, what is its structure and functions? This organ has the shape of a sac, which is located on the surface of the liver, more precisely, in its lower part.

In some cases, during fetal development, the organ does not come to the surface of the liver. The intrahepatic location of the bladder increases the risk of developing cholelithiasis and other diseases.

The shape of the gallbladder has a pear-shaped outline, a narrowed top and an expansion at the bottom of the organ. There are three parts in the structure of the gallbladder:

• narrow neck, where bile enters through the common hepatic duct;
• body, widest part;
• the bottom, which is easily determined by ultrasound.

The organ has a small volume and is able to hold about 50 ml of fluid. Excess bile is excreted through the small duct.

The walls of the bubble have the following structure:

1. Serous outer layer.
2. epithelial layer.
3. Mucous membrane.

The mucous membrane of the gallbladder is designed in such a way that the incoming bile is very quickly absorbed and processed. In the folded surface there are many mucous glands, the intensive work of which concentrates the incoming fluid and reduces its volume.

The anatomy of the gallbladder and biliary tract is a complex system of channels that ensure the movement of bile inside the human body.

The anatomy of the biliary tract includes two types of ducts: extrahepatic and intrahepatic bile ducts.

The structure of the biliary tract outside the liver consists of several channels:

1. Cystic duct that connects the liver to the bladder.
2. The common bile duct (CBD or common bile duct), which begins at the junction of the hepatic and cystic ducts and leads to the duodenum.

The anatomy of the biliary tract distinguishes between the sections of the common bile duct. First, bile from the bladder passes through the supraduodenal section, passes into the retroduodenal section, then enters the duodenal section through the pancreatic section. Only along this path can bile get from the organ cavity to the duodenum.

How the gallbladder works

The process of movement of bile in the body is triggered by small intrahepatic tubules, which unite at the exit and form the hepatic left and right ducts. Then they form into an even larger common hepatic duct, from where the secret enters the gallbladder.

How does the gallbladder work, and what factors affect its activity? During periods when digestion is not required, the bladder is in a relaxed state. The work of the gallbladder at this time is to accumulate a secret. Eating provokes the launch of many reflexes. The pear-shaped organ is also included in the process, which makes it mobile due to the beginning contractions. By this point, it already contains processed bile.

The required amount of bile is released into the common bile duct. Through this channel, the liquid enters the intestine and promotes digestion. Its function is to break down fats through its constituent acids. In addition, the processing of food with bile leads to the activation of enzymes required for digestion. These include:

• lipase;
• aminolase;
• trypsin.

Bile appears in the liver. Passing through the choleretic channel, it changes its color, structure and decreases in quantity. Those. bile is formed in the bladder, which is different from the liver secretion.

The concentration of incoming bile from the liver occurs by removing water and electrolytes from it.

The principle of the gallbladder is described in the following paragraphs:

1. Collection of bile produced by the liver.
2. Condensation and storage of a secret.
3. The direction of the liquid through the duct into the intestine, where food is processed and broken down.

The organ begins to work, and its valves open only after the person receives food. The gallbladder meridian, on the contrary, is activated only in the late evening from 11 am to 1 am.

Diagnostics of the bile ducts

Failure of the biliary system occurs most often due to the formation of any obstacle in the channels. The reason for this may be:

• cholelithiasis
• tumors;
• inflammation of the bladder or bile ducts;
• strictures and scars that can affect the common bile duct.

Identification of diseases occurs with the help of a medical examination of the patient and palpation of the right hypochondrium, which allows you to establish a deviation from the norm in the size of the gallbladder, laboratory tests of blood and feces, as well as using hardware diagnostics:

Ultrasonography shows the presence of stones and how many have formed in the ducts.

1. X-ray. Not able to give specifics about the pathology, but helps to confirm the presence of a suspected pathology.
2. ultrasound. Ultrasonography shows the presence of stones and how many have formed in the ducts.
3. ERCP (endoscopic retrograde cholangiopancreatography). Combines X-ray and endoscopic examination and is the most effective method studies of diseases of the biliary system.
4. CT. With cholelithiasis, this study helps to clarify some details that cannot be determined with ultrasound.
5. MRI. Similar to CT method.

In addition to these studies, a minimally invasive method for detecting blockage of the choleretic ducts, laparoscopy, can be used.

Causes of diseases of the bile ducts

Violations in the functioning of the bladder have various causes and can be triggered by:

Any pathological changes in the ducts disrupt the normal outflow of bile. Expansion, narrowing of the bile ducts, thickening of the walls of the common bile duct, the appearance of various formations in the canals indicates the development of diseases.

The narrowing of the lumen of the bile ducts disrupts the return flow of secretions to the duodenum. The causes of diseases in this case can be:

• mechanical trauma caused during surgery;
• obesity;
• inflammatory processes;
• the appearance of cancerous tumors and liver metastases.

Strictures in the bile ducts cause cholestasis pain in the right hypochondrium, jaundice, intoxication, fever. The narrowing of the bile ducts leads to the fact that the walls of the channels begin to thicken, and the area above - to expand. Blockage of the ducts leads to stagnation of bile. It becomes thicker, creating ideal conditions for the development of infections, so the appearance of strictures often precedes the development of additional diseases.

The expansion of the intrahepatic bile ducts occurs due to:

Expansion of the intrahepatic bile ducts occurs due to the formation of stones

Changes in the bile ducts accompany the symptoms:

• nausea;
• gagging;
• soreness of the right side of the abdomen;
• fever;
• jaundice;
• rumbling in the gallbladder;
• flatulence.

All this indicates that the biliary system is not working properly. There are some of the most common diseases:

1. ZhKB. The formation of stones is possible not only in the bladder, but also in the ducts. The patient in many cases for a long time there is no discomfort. Therefore, stones may go unnoticed for several years and continue to grow. If the stones block the bile ducts or injure the walls of the canal, then the developing inflammatory process is difficult to ignore. Pain, high fever, nausea and vomiting will not allow this to be done.
2. Dyskinesia. This disease is characterized by a decrease in the motor function of the bile ducts. Violation of the flow of bile occurs due to a change in pressure in various fields channels. This disease can develop independently, as well as accompany other pathologies of the gallbladder and its ducts. A similar process causes pain in the right hypochondrium and heaviness that occurs a couple of hours after eating.
3. Cholangitis. It is usually caused by acute cholecystitis, but the inflammatory process can also occur on its own. Symptoms of cholangitis include: fever, excessive sweating, pain in the right side, nausea and vomiting, jaundice develops.
4. Acute cholecystitis. Inflammation is of an infectious nature and proceeds with pain and fever. At the same time, the size of the gallbladder increases, and deterioration occurs after eating fatty, heavy meals and alcoholic beverages.
5. Cancer tumors of channels. The disease often affects the intrahepatic bile ducts or pathways at the gates of the liver. With cholangiocarcinoma, yellowing appears skin, itching in the liver, fever, nausea and other symptoms.

In addition to acquired diseases, congenital developmental anomalies, such as aplasia or hypoplasia of the gallbladder, can complicate the work of the bladder.

Anomalies of the gallbladder

Anomaly in the development of the gallbladder ducts is diagnosed in almost 20% of people. Much less often you can find a complete absence of channels designed to remove bile. Congenital malformations entail disruption of the biliary system and digestive processes. Majority birth defects does not pose a serious threat and is treatable, severe forms of pathologies are extremely rare.

Anomalies of the ducts include the following pathologies:

• the appearance of diverticula on the walls of the channels;
• cystic lesions of the ducts;
• the presence of kinks and partitions in the channels;
• hypoplasia and atresia of the biliary tract.

According to their characteristics, anomalies of the bubble itself are conditionally divided into groups depending on:

• localization of the gall;
• changes in the structure of the body;
• deviations in form;
• quantities.

An organ can be formed, but have a different normal location and host:

• in right place but across;
• inside the liver;
• under the left hepatic lobe;
• in the left hypochondrium.

Pathology is accompanied by violations of bladder contractions. The organ is more susceptible to inflammatory processes and the formation of stones.

The "wandering" bubble can occupy various positions:

• inside the abdominal region, but almost not in contact with the liver and covered with abdominal tissues;
• completely separated from the liver and communicating with it through a long mesentery;
• With total absence fixation, which increases the likelihood of kinks and torsion (lack of surgical intervention leads to the death of the patient).

It is extremely rare for doctors to diagnose a newborn with a congenital absence of the gallbladder. Gallbladder agenesis can take several forms:

1. Complete absence of the organ and extrahepatic bile ducts.
2. Aplasia, in which, as a result of underdevelopment of the organ, there is only a small, incapable of functioning process and full-fledged ducts.
3. Hypoplasia of the bladder. The diagnosis suggests that the organ is present and able to function, but some of its tissues or areas are not fully formed in the child in the prenatal period.

Functional kinks go away on their own, while true ones require medical intervention.

Agenesis in almost half of the cases leads to the formation of stones and the expansion of the large bile duct.

An abnormal, non-pear-shaped form of the gallbladder appears due to constrictions, kinks in the neck or body of the organ. If the bubble, which should be pear-shaped, resembles a snail, then a kink has occurred that violated the longitudinal axis. The gallbladder collapses to the duodenum, and adhesions form at the point of contact. Functional excesses pass on their own, and the true ones require medical intervention.

If the pear-shaped shape changes due to constrictions, then the vesical body narrows in places or completely. With such deviations, stagnation of bile occurs, provoking the appearance of stones and accompanied by severe pain.

In addition to these shapes, the pouch may resemble the Latin S, a ball, or a boomerang.

A bifurcation of the gallbladder weakens the organ and leads to dropsy, calculi and inflammation of the tissues. The gallbladder may be:

• multi-chamber, while the bottom of the organ is partially or completely separated from its body;
• bilobed, when two separate lobules join one bladder neck;
• ductular, two bubbles with their ducts function simultaneously;
• triplication, three organs united by a serous membrane.

How are bile ducts treated?

In the treatment of blockage of the ducts, two methods are used:

• conservative;
• operational.

The main one in this case is surgical intervention, and conservative means are used as auxiliary.

Sometimes, a calculus or a mucous clot can leave the duct on its own, but this does not mean that the problem is completely eliminated. The disease in the absence of treatment will return, so it is necessary to deal with the cause of the appearance of such stagnation.

In severe cases, the patient is not operated on, but his condition is stabilized, and only after that the day of the operation is appointed. To stabilize the condition, patients are prescribed:

• starvation;
• installation of a nasogastric tube;
• antibacterial drugs in the form of antibiotics with a wide range actions;
• droppers with electrolytes, protein preparations, fresh frozen plasma and others, mainly to detoxify the body;
• antispasmodic drugs;
• vitamin remedies.

To accelerate the outflow of bile, non-invasive methods are resorted to:

• extraction of calculi with a probe, followed by drainage of channels;
• percutaneous puncture of the bladder;
• cholecystostomy;
• choledochostomy;
• percutaneous hepatic drainage.

Normalization of the patient's condition allows you to apply operational methods treatment: laparotomy, when the abdominal cavity is fully opened or laparoscopy, performed using an endoscope.

In the presence of strictures, endoscopic treatment allows you to expand the narrowed ducts, insert a stent and ensure that the channels are provided with a normal lumen of the ducts. Also, the operation allows you to remove cysts and cancerous tumors that usually affect the common hepatic duct. This method is less traumatic and allows even cholecystectomy. Opening the abdominal cavity is resorted to only in cases where laparoscopy does not allow for the necessary manipulations.

Congenital malformations, as a rule, do not require treatment, but if the gallbladder is deformed or omitted due to some kind of injury, what should I do? Displacement of the organ while maintaining its performance does not worsen health, but with the appearance of pain and other symptoms, it is necessary:

• observe bed rest;
• drink enough liquid (preferably without gas);
• adhere to a diet and foods approved by the doctor, cook correctly;
• take antibiotics, antispasmodics and analgesics, as well as vitamin supplements and choleretic drugs;
• attend physiotherapy, do physiotherapy exercises and massage for relief.

Despite the fact that the organs of the biliary system are relatively small, they do a great job. Therefore, it is necessary to monitor their condition and consult a doctor when the first symptoms of diseases appear, especially if there are any congenital anomalies.

Video

What to do if a stone appears in the gallbladder.

One of the main places in the biliary tract system is occupied by the gallbladder - an unpaired organ that serves as a kind of "accumulator" of bile secreted by the liver. Subsequently, this bile is transported to the small intestine. This process occurs under the influence of the hormone cholecystokinin - it provokes contraction and subsequent emptying of the gallbladder.

What is the human gallbladder made of?

The human gallbladder in the biliary tract system is an unpaired hollow pear-shaped organ, approximately 7-10 x 2-3 cm in size, with a capacity of 40-70 ml. However, it is easily stretched and can freely, without damage, contain up to 200 ml of liquid.

The gallbladder has a characteristic dark green color and is located on inner surface liver in the fossa of the gallbladder. it depends on the gender, age and physique of the person. In men, it is located on a line drawn from the right nipple to the navel; in women, it is determined by the line connecting the right shoulder to the navel. In some cases, the gallbladder can be partially or completely located inside the liver tissue (intrahepatic location) or, conversely, be completely suspended on its mesentery, which sometimes causes it to twist around the mesentery.

Rare congenital anomalies include the absence of the gallbladder, as well as its partial or complete doubling.

Below you will learn what the gallbladder consists of and how it works. transport systems.

The structure of the gallbladder includes 3 parts - the bottom, body and neck:

• Bottom heading towards lower section the liver and protrudes from under it, being the part visible from the front, which can be examined using ultrasound diagnostic methods.
• Body is the longest and most extended part. At the point of transition of the body to its neck (the narrowest part), a bend is usually formed, so the neck is at an angle to the body of the gallbladder and goes to the gates of the liver.
• Neck continues into the cystic duct, the lumen of which is on average 3 mm, and the length is from 3 to 7 cm. The cystic and hepatic ducts form a common bile duct, which has a lumen of 6 mm and a length of up to 8 cm. When the mouth is blocked, the lumen of the common bile duct may increase up to 2 cm in diameter without any pathology.

A feature of the structure of the gallbladder is that the common bile duct unites with the main duct of the pancreas and through the sphincter of Oddi opens into the duodenum in the Vater (large) papilla.

Look at the photo of the structure of the gallbladder to better understand what parts it consists of:

Walls and membranes of the gallbladder

The wall of the gallbladder consists of mucous, muscular and connective tissue membranes, and the lower surface is covered with a serous membrane:

• mucous membrane It is represented by a loose network of elastic fibers and contains mucus-forming glands, which are mainly located in the cervical region of the gallbladder. The mucosa contains numerous small folds giving it a velvety look. In the region of the neck 1-2, the transverse folds are of considerable height and, together with the folds in the cystic duct, form a valve system called the Heister valve.
• Muscular membrane The gallbladder is made up of bundles of smooth muscle and elastic fibers. In the neck region, muscle fibers are located mainly circularly (in a circle), forming a kind of pulp - the sphincter of Lutkens, which regulates the flow of bile from the gallbladder into the cystic bile duct and vice versa. Between the bundles of muscle fibers in the wall of the gallbladder there are multiple gaps - Aschoff's passages. Poorly drained, they can be a place of stagnation of bile, formation of stones, foci of chronic infection.
• Connective tissue sheath consists of elastic and collagen fibers. In the body of the gallbladder, the muscular and connective tissue membranes do not have a clear distinction. Sometimes, having passed to the serous membrane, the fibers form narrow tubular passages with blindly ending ends - Lushka's passages, which play a role in the occurrence of microabscesses in the gallbladder wall.

Changes in the walls and transport systems of the gallbladder

An overdistended gallbladder with a pathologically altered wall often has a pocket of Hartmann, in which, as a rule, accumulate gallstones. Sometimes when the walls of the gallbladder change, this pocket reaches enough large sizes, which greatly complicates the detection of the confluence of the cystic duct into the common hepatic duct.

Transport systems of the gallbladder:

• The gallbladder is supplied by the cystic artery, which arises from the right hepatic artery. Venous flows from the gallbladder along several venous trunks through the main tissue of the liver into the portal vein and partially into the right branch of the portal vein through the extrahepatic vessels.
• Lymph outflow occurs both in the liver and in the extrahepatic lymphatic vessels.
• Innervation (supply of organs and tissues with nerves, which ensures their connection with the central nervous system) of the gallbladder is carried out through the solar plexus, the vagus nerve and the right-sided phrenic nerve bundle. These nerve endings regulate the contraction of the gallbladder, relaxation of the corresponding sphincters and provoke pain in diseases.

Thanks to muscle fibers, the gallbladder is able to contract together with the biliary tract, throwing bile into the duodenum under a pressure of 200-300 mm of water column!

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gallbladder, vesica fellea (biliaris), is a bag-shaped reservoir for bile produced in the liver; it has an elongated shape with wide and narrow ends, and the width of the bubble gradually decreases from the bottom to the neck. The length of the gallbladder ranges from 8 to 14 cm, the width is 3-5 cm, the capacity reaches 40-70 cm 3. It has a dark green color and a relatively thin wall.

In the gallbladder, the bottom of the gallbladder, fundus vesicae felleae, is distinguished - its most distal and widest part, the body of the gallbladder, corpus vesicae felleae, - middle part and the neck of the gallbladder, collum vesicae felleae, is the proximal narrow part from which the cystic duct departs, ductus cysticus. The latter, having joined with the common hepatic duct, forms the common bile duct, ductus choledochus.

The gallbladder lies on the visceral surface of the liver in the gallbladder fossa, fossa vesicae felleae, which separates the anterior right lobe from a square lobe of the liver. Its bottom is directed forward to the lower edge of the liver in the place where a small notch is located, and protrudes from under it; the neck is turned towards the gate of the liver and lies along with the cystic duct in the duplication of the hepatoduodenal ligament. At the place of transition of the body of the gallbladder into the neck, a bend is usually formed, so the neck is lying at an angle to the body.

The gallbladder, being in the fossa of the gallbladder, adjoins to it with its upper surface, devoid of peritoneum, and connects to the fibrous membrane of the liver. Its free surface, facing down into the abdominal cavity, is covered with a serous sheet of the visceral peritoneum, passing to the bladder from the adjacent areas of the liver. The gallbladder can be located intraperitoneally and even have a mesentery. Usually, the bottom of the bladder protruding from the liver notch is covered with peritoneum on all sides.

The structure of the gallbladder.

The structure of the gallbladder. The wall of the gallbladder consists of three layers (with the exception of the upper extraperitoneal wall): the serosa, tunica serosa vesicae felleae, the muscular membrane, tunica muscularis vesicae felleae, and the mucous membrane, tunica mucosa vesicae felleae. Under the peritoneum, the wall of the bladder is covered with a thin loose layer of connective tissue - the subserous base of the gallbladder, tela subserosa vesicae felleae; on the extraperitoneal surface, it is more developed.

The muscular membrane of the gallbladder, tunica muscularis vesicae felleae, is formed by one circular layer of smooth muscles, among which there are also bundles of longitudinally and obliquely arranged fibers. The muscular layer is less pronounced in the bottom area and stronger in the cervical region, where it directly passes into the muscular layer of the cystic duct.

The mucous membrane of the gallbladder, tunica mucosa vesicae felleae, is thin and forms numerous folds, plicae tunicae mucosae vesicae felleae, giving it the appearance of a network. In the region of the neck, the mucous membrane forms several oblique spiral folds, plicae spirales, one after the other. The mucous membrane of the gallbladder is lined with a single-row epithelium; in the neck in the submucosa there are glands.

Topography of the gallbladder.

Topography of the gallbladder. The bottom of the gallbladder is projected on the anterior abdominal wall in the angle formed by the lateral edge of the right rectus abdominis muscle and the edge of the right costal arch, which corresponds to the end of the IX costal cartilage. Syntopically, the lower surface of the gallbladder is adjacent to the anterior wall of the upper part of the duodenum; on the right it is adjacent to the right bend colon.

Often the gallbladder is connected to the duodenum or to the colon by a peritoneal fold.

Blood supply: from the gallbladder artery, a. cystica, branches of the hepatic artery.

Bile ducts.

There are three extrahepatic bile ducts: the common hepatic duct, ductus hepaticus communis, the cystic duct, ductus cysticus, and the common bile duct, ductus choledochus (biliaris).

The common hepatic duct, ductus hepaticus communis, is formed at the gates of the liver as a result of the confluence of the right and left hepatic ducts, ductus hepaticus dexter et sinister, the latter are formed from the intrahepatic ducts described above. duct coming from the gallbladder; thus arises the common bile duct, ductus choledochus.

Cystic duct, ductus cysticus, has a length of about 3 cm, its diameter is 3-4 mm; the neck of the bladder forms two bends with the body of the bladder and with the cystic duct. Then, as part of the hepatoduodenal ligament, the duct goes from top to right down and slightly to the left and usually merges with the common hepatic duct at an acute angle. The muscular membrane of the cystic duct is poorly developed, although it contains two layers: longitudinal and circular. Throughout the cystic duct, its mucous membrane forms a spiral fold, plica spiralis, in several turns.

Common bile duct, ductus choledochus. embedded in the hepatoduodenal ligament. It is a direct continuation of the common hepatic duct. Its length is on average 7-8 cm, sometimes reaching 12 cm. There are four sections of the common bile duct:

1. located above the duodenum;
2. located behind the upper part of the duodenum;
3. lying between the head of the pancreas and the wall of the descending part of the intestine;
4. adjacent to the head of the pancreas and passing obliquely through it to the wall of the duodenum.

The wall of the common bile duct, in contrast to the wall of the common hepatic and cystic ducts, has a more pronounced muscular membrane, which forms two layers: longitudinal and circular. At a distance of 8-10 mm from the end of the duct, the circular muscle layer is thickened, forming the sphincter of the common bile duct, m. sphincter ductus choledochi. The mucous membrane of the common bile duct does not form folds, except for the distal area, where there are several folds. In the submucosa of the walls in the non-hepatic bile ducts, there are mucous glands of the bile ducts, glandulae mucosae biliosae.

The common bile duct connects with the pancreatic duct and flows into a common cavity - the hepato-pancreatic ampulla, ampulla hepatopancreatica, which opens into the lumen of the descending part of the duodenum at the top of its major papilla, papilla duodeni major, at a distance of 15 cm from the pylorus. The size of the ampoule can reach 5×12 mm.

The type of confluence of the ducts may vary: they may open into the intestine by separate mouths, or one of them may flow into another.

In the region of the major papilla of the duodenum, the mouths of the ducts are surrounded by a muscle - this is the sphincter of the hepatic-pancreatic ampulla (sphincter of the ampulla), m. sphincter ampullae hepatopancreaticae (m. sphincter ampulae). In addition to the circular and longitudinal layers, there are separate muscle bundles that form an oblique layer that combines the sphincter of the ampulla with the sphincter of the common bile duct and with the sphincter of the pancreatic duct.

Topography of the bile ducts. The extrahepatic ducts lie in the hepatoduodenal ligament along with the common hepatic artery, its branches, and the portal vein. At the right edge of the ligament is the common bile duct, to the left of it is the common hepatic artery, and deeper than these formations and between them - portal vein; in addition, lymphatic vessels, nodes and nerves lie between the sheets of the ligament.

The division of the proper hepatic artery into the right and left hepatic branches occurs in the middle of the length of the ligament, and the right hepatic branch, heading upward, passes under the common hepatic duct; at the place of their intersection, the gallbladder artery departs from the right hepatic branch, a. cystica, which goes to the right and up to the area of ​​\u200b\u200bthe angle (gap) formed by the confluence of the cystic duct with the common hepatic duct. Next, the gallbladder artery passes along the wall of the gallbladder.

Innervation: liver, gallbladder and bile ducts - plexus hepaticus (truncus sympathicus, nn. vagi).

Blood supply: liver - a. hepatica propria, and its branch a. cystica approaches the gallbladder and its ducts. In addition to the artery, v. portae, collecting blood from unpaired organs in the abdominal cavity; passing through the system of intraorgan veins, leaves the liver through vv. hepaticae. falling into v. cava inferior. From the gallbladder and its ducts deoxygenated blood drains into the portal vein. Lymph is drained from the liver and gallbladder into nodi lymphatici hepatici, phrenici superior et inferior, lumbales dextra, celiaci, gastrici, pylorici, pancreatoduodenales, anulus lymphaticus cardiae, parasternales.

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For many decades, priority invasive research methods, such as oral cholecystocholangiography, intravenous and infusion cholegraphy, percutaneous, transhepatic, laparoscopic cholecystocholangiography, and endoscopic retrograde pancreatoangiography, have been widely and effectively used to study the biliary tract.

The information content of radiological methods has increased significantly with the introduction into clinical practice computed tomography and magnetic resonance. However, along with high information content, these methods are complex, expensive, unsafe for the patient's health, and have a wide range of contraindications.

When examining the biliary tract, echography in the hands a good specialist in a matter of minutes in 95-97% of cases he can correctly answer the task set by the clinician, i.e. differentiate obstructive jaundice from parenchymal jaundice, determine the level and cause of duct obstruction. In this regard, it should be widely used, especially at the initial stage of the diagnostic process, and for the purpose of selecting patients for complex invasive research methods.

Indications:

- as a screening method in the study of newborns with icteric syndrome;

- all indications for .

The bile ducts are divided into intra- and extrahepatic.

The extrahepatic bile ducts include: cystic, common hepatic, common bile.

Cystic duct- removes bile from the gallbladder, has an average length of 4.5 cm, a width of 0.3-0.5 cm. Usually, at the gates of the liver, within the hepatic duodenal ligament, it connects to the common hepatic duct. Its relationship with the common hepatic duct can vary up to its independent flow into the duodenum.

common hepatic duct It is formed from the confluence of the right and left hepatic ducts in the right part of the gate of the liver in front of the bifurcation of the portal vein.

The length of the duct varies from 2 to 10 cm, the width is from 0.3 to 0.7 cm. The common hepatic duct is formed at the gates of the liver and is, as it were, a continuation of the left hepatic flow, located in front of the bifurcation of the portal vein.

The common bile duct is formed from the confluence of the common hepatic and cystic ducts and is a continuation of the common hepatic duct. Depending on the anatomical location The common bile duct is divided into 4 parts:

- supraduodenal - over the duodenum;

- retroduodenal - behind the upper part of the intestine;

- retropancreatic - behind the head of the pancreas;

- intramural - perforates back wall descending part of the duodenum.

The length of the duct varies from 2 to 12 cm (average 5-8 cm), and the width is 0.5-0.9 cm.

Before entering the pancreatic tissue, the duct expands somewhat, and then, passing through the pancreatic tissue, narrows, especially at the confluence with the duodenum. In its last section, the common hepatic duct merges with the pancreatic duct, forming a common ampulla, or opens separately into the duodenum. It should be noted that there may be a variety of anatomical variations in its location.

Research methodology

In the special literature, there is a lot of data on the high possibilities of echography in visualizing intra- and especially extrahepatic ducts. The data obtained by the author on more than 216,000 thousand studies of the gallbladder and biliary tract indicate rather modest possibilities of the ultrasound method on present stage its development in the identification and visualization of normal extrahepatic bile ducts. It seems that the researchers wishful thinking. One of the main reasons for the low information content of ultrasound examination of the extrahepatic bile ducts is the rather wide variability of the topographic and anatomical picture of the study at the hilum and, which practically does not make it possible to isolate and offer a specific projection of the ultrasound beam, which provides identification and complete visualization of the ducts in one scan. The informativeness of the method is significantly increased if ultrasonic device equipped with Doppler Color, which allows you to differentiate the portal vein and the proper hepatic artery from the common bile duct.

The ducts are carried out after the detailed, gallbladder, pancreas and vessels of the portal and inferior vena cava in the position of the patient on the back and left side at the moment of holding the breath at the height of inspiration or when the abdomen protrudes, on the back with an inflatable rubber pillow placed under the lower back, as a result of which the liver moves down and the bile ducts become closer to the anterior abdominal wall.

In some patients, good duct imaging results can be obtained two to three minutes after the patient is in the vertical position. In this case, the transverse colon is shifted down and frees the gates of the liver.

Many methods of ultrasonic scanning of the extrahepatic bile ducts have been proposed, however, it should be remembered that there is no universal method. Each specialist with experience develops his own individual methodological approach to identifying extrahepatic bile ducts. In practice, the generally accepted classical scanning techniques are used - longitudinal, transverse and oblique.

The frequency of detection of extrahepatic bile ducts (in normal and pathological conditions) mainly depends on the resolution of the device, the scanning method, the patient's preparation and, of course, on the experience of the specialist. top scores in the identification of extrahepatic bile ducts, we obtained a combination of linear, convex and sector sensors with a frequency of 3.5-5 MHz. As already noted, the intrahepatic bile ducts are not located normally, it is rarely possible to locate the left and right common hepatic ducts in the form of narrow tubular formations that merge in the form of a V. The left hepatic duct is located in the hilum of the liver above the portal vein, its length is 1.5-2.5 cm and diameter 0.3-0.5 cm.

The right hepatic duct is also located in the hilum of the liver above the right branch of the portal vein, its length is 0.5-1.5 cm, diameter is 0.2-0.5 cm. distance from the gate of the liver.

The length of the common hepatic duct ranges from 2 to 10 cm with a diameter of 0.3-0.7 cm, in children under 14 years of age it is 2.5 cm long and up to 0.3 cm in diameter. The cystic duct is rarely detected and only in the immediate vicinity of the gallbladder neck. Sonographically, the length of the duct is on average 4-5 cm, and the diameter is up to 0.25 cm.

Its connection with the common hepatic duct, which usually occurs in the hepatoduodenal ligament, is almost rarely seen. Ultrasound visualization of the common bile duct is also difficult due to the fact that anatomical study in the hepatoduodenal ligament does not allow to obtain an image of the entire duct in the plane of one section. In practice, in the vast majority of cases, only an echographic picture of its segments can be obtained.

In the specialized literature, many techniques for detecting the common bile duct are described. In particular, V. Demidov proposes to find the portal vein and its bifurcation during longitudinal scanning, a mark is made in its projection on the skin of the abdomen, and a cross section of the common bile duct is found in the region of the head of the pancreas, and in this area a mark is also made on the skin of the abdomen.

In the zone of these two connected points, a thorough scanning is carried out with the help of a line, and, according to the author, in most cases it is possible to detect the common bile duct in almost its entire length. In our practice, ultrasound of the common bile duct was started from the pancreatic head, where its cross section can almost always be detected as a rounded anechoic formation with a diameter of 0.5-0.6 cm. Without losing connection with the found oval formation (transverse duct scan), the probe is slowly rotated in or out clockwise until an elongated echo-negative common bile duct track is obtained from the transverse scan. Normally, the common bile duct is a thin-walled tubular non-pulsating formation, in contrast to the hepatic artery proper, which is usually located more medially from the right branch of the portal vein and runs more horizontally in relation to the common bile ducts. There is no need to talk about its true length; in most cases, only its segments are located. The diameter is almost the same throughout its entire length and should not exceed 5 mm.

The ultrasound specialist should remember that if the common bile duct in the areas of topographic examination in the hilum of the liver (this is the right free edge of the hepatoduodenal ligament) above the portal vein is not distinguished and there is no clinical interest for its search, then it should be considered echographically normal, and there is no need to waste time looking for it.

The reasons that prevent good visualization of the common bile duct can be very different. Among them:

- technical - low resolution of the device, lack of technical capabilities, that is, the optimal set of sensors that could combine various methods scanning;

- poor preparation of the patient - the presence of gases in the transverse colon, a shadow from the contents of the duodenum, covering the gate of the liver;

- location anomaly;

— reasons associated with the presence of volumetric structural and liquid formations;

- shadows from gallbladder stones;

- scars on the anterior abdominal wall;

- lack of experience of a specialist, etc.

Despite certain difficulties of a subjective and objective nature, echography in most cases provides quick and valuable information about the norm and pathology of the extrahepatic bile ducts and is the method of choice.

Pathology

Malformations

Atresia of the bile ducts

Severe pathology, which is rare and diagnosed in the neonatal period. The main symptom that makes the doctor resort to the study of the biliary tract is jaundice, which manifests itself in a child at the time of birth and rapidly progresses. Atresia of the bile ducts can manifest itself focally when the ducts of a part of the liver are affected; on the echogram, the bile ducts are presented as thin echogenic, often tortuous, strands. If there is atresia only of the distal parts, their overlying areas are dilated and visible as anechoic tortuous tubes. With a diffuse lesion, when the pathology covers all the intrahepatic bile ducts, and sometimes extrahepatic ones, a lot of intertwining thin echogenic lines are located in the liver parenchyma.

Echography in this pathology is highly informative, it allows to determine the degree of underdevelopment of the gallbladder and biliary tract, to differentiate from physiological and hemolytic jaundice, septic diseases, postpartum hepatitis and other neonatal diseases, and to select patients for invasive research methods.

Anomaly in the development of the cystic duct

It is extremely rare and refers to various types of connection of the cystic duct with the hepatic ducts, these are also bends, narrowings, expansions and additional cystic ducts. To identify this pathology, echography is little - or almost uninformative. Diagnosis is carried out by invasive methods. Of particular interest for echography is the absence of the cystic duct.

No cystic duct

Occurs rarely. In this case, the gallbladder often has a rounded shape, instead of the cystic duct, an echogenic cord is located, and an anechoic path is located in the wall, associated with the common bile duct, the functioning of which is clearly visible when taking a choleretic breakfast. In the presence of calculi, they easily enter the common bile duct and, accumulating, significantly and tortuously expand it, which leads to obstructive jaundice.

Anomalies in the development of the main bile ducts

There are anomalies of the bile ducts, hypoplasia of the bile ducts, congenital perforation of the common bile duct and cystic dilation of the bile ducts, which have little effect on bile secretion in childhood and appear only at an older age.

Sonographic interest is only cystic dilatation of the bile ducts. This pathology includes: cystic simultaneous expansion of both extra- and intrahepatic bile ducts (Caroli disease). It manifests itself in the form of uneven focal or diffuse dilatations of the ducts, which are easily diagnosed echographically, although they can sometimes be confused with liver metastases.

It should be noted that congenital dilatation of the ducts, especially in adults, is difficult to differentiate from that with compression of the ducts. cancerous tumor, enlarged lymph nodes or blockage by a stone. In these cases, it is almost always possible to find the cause, since obstructive jaundice is present.

This anomaly is usually associated with fibrotic changes liver, causing hepatomegaly and portal hypertension.

Common bile duct cysts

Can be noted as an expansion along the entire length of the duct, lateral expansion common bile duct (congenital diverticulum) associated with it by a leg of various widths (we observed this pathology in 5 patients), and in the form of choledochocele - dilatation of only the intraduodenal part of the common bile duct, which is located as an oval-elongated, hypoechoic, with uneven contours formation associated with the wall of the duodenum.

bile duct stones

One of the most common pathologies of intra- and extrahepatic ducts is stones. The issue of echodiagnostics of intrahepatic duct stones is difficult, because due to the difficulty of specifying the location and depth of the location of the duct with the stone, these patients rarely undergo surgical treatment, perhaps because the clinic is rarely present. They are a find of an echographer. They can be very difficult to distinguish from calcifications of the liver parenchyma, which can be located anywhere. The only one hallmark with a stone of 10-15 mm, an echo-negative path and an expanded section of the duct are located behind it.

Stones of the common hepatic bile ducts

The stones of the common hepatic ducts are more often located closer to the gates of the liver, that is, at the point of transition to the common bile duct; they are usually small in size (up to 0.5 - 0.7 cm), round or oval in shape, often with even contours, highly echogenic, but rarely leave acoustic shadow in contrast to large calcifications of the liver parenchyma. A section of the dilated duct (echo-negative path) is located near the stone.

With complete blockage of the duct, its proximal and ducts of the third order of this share. It should be noted that it is very difficult to determine which lobe of the hepatic duct is affected. According to our data, the left common hepatic duct is more often affected.

Common bile duct stones

In most cases, stones enter the common bile duct from the gallbladder and rarely (1-5%) form directly in the duct.

The frequency of lesions is up to 20% of the total number of patients with cholelithiasis. Duct stones can be single or multiple, of different sizes and shapes, but more often rounded, of different echogenicity and rarely leave an acoustic shadow. The duct may be distally or proximally dilated; with partial blockage of the duct, transient obstruction is caused, with complete blockage - stable obstructive jaundice. When a stone blocks the terminal section of the duct, bile hypertension occurs, leading to significant expansion of the extrahepatic and partially intrahepatic ducts.

In these cases, jaundice may temporarily disappear.

Cholangitis

Acute or chronic inflammation of the intra- and extrahepatic biliary tract.

The main reason for the occurrence- this is cholestasis with choledocholithiasis and infected bile. Inflammation of the bile ducts clinical practice common, but difficult and rarely diagnosed. Echographically, with cholangitis, the ducts are unevenly linearly expanded, the walls with a catarrhal form are homogeneously thickened, weakly echogenic (edematous), with purulent - unevenly thickened, echogenic and dilated. Sometimes in their lumen it is possible to locate echogenic contents - purulent bile. With this form, there is always a specific clinical picture: fever to fibril, chills, heaviness and dull pain in the right hypochondrium, nausea, possibly vomiting.

In connection with damage to the liver parenchyma and cholestasis, jaundice appears.

With progression, small abscesses can form in the walls of the bile ducts, and multiple ulcers can form in the liver parenchyma. different sizes abscesses.

In the process effective treatment you can observe the narrowing of the lumen of the ducts, the thinning of the wall, the disappearance of the contents from the lumen.

Primary sclerosing cholangitis

A rare disease characterized by segmental or diffuse narrowing of the extra- and intrahepatic ducts, leading to severe cholestasis and cirrhosis of the liver. Sonographic picture: the echogenicity of the ducts or periportal zones is significantly increased, the walls of the common bile duct are thickened.

The liver has a motley picture - a combination of zones of low and high echogenicity.

Tumors of the bile ducts

From benign tumors adenomas, papillomas, myomas, lipomas, adenofibromas, etc. can be found. An echogram can reveal a tumor-like formation of different sizes and echogenicity localized in the projection of the extrahepatic bile ducts, but more often in the projection of the choledochus, without specifying histological forms, the differentiation of which is carried out using targeted biopsy area of ​​the tumor.

bile duct cancer

It is very rare (0.1-0.5%), but more common than gallbladder cancer. More common are cholangiocarcinoma and adenocarcinoma, which can be localized in any part of the extrahepatic bile ducts. It is more often noted in the region of the Vater papilla, at the junction of the hepatic duct with the cystic duct and at the junction of both hepatic ducts. Sonographic diagnosis is difficult due to the small size of the cancer. There are two forms of tumor growth: exophytic and endophytic.

In the exophytic form, the tumor grows in the lumen of the duct and quickly obturates it. At the initial stage, on the echogram, it is located in the form of a focal tumor-like, often echogenic, small-sized formation that bulges into the lumen of the duct, with its expansion before and after the tumor.

In the endophytic form, the duct gradually narrows due to the thickening of its wall and becomes blocked, also leading to obstructive jaundice.

Given the slow growth and late metastasis to the regional lymph nodes and liver, extrahepatic duct cancer appears late, when obstructive jaundice is noted.

Mechanical jaundice

Thus, echography in the study of the bile ducts is a priority method that allows you to quickly answer many questions related to the norm and pathology of the bile ducts.

MINISTRY OF HEALTH OF THE REPUBLIC OF BELARUS

BELARUSIAN STATE MEDICAL UNIVERSITY

DEPARTMENT OF OPERATIONAL SURGERY AND TOPOGRAPHIC ANATOMY

V. F. VARTANYAN, P. V. MARKAUTSAN

OPERATIONS ON THE GALL BLADDER AND BILID DUCTS

Teaching aid

UDC 616.361/.366-089(075.8) BBK 54.13 i 73

Approved by the Scientific and Methodological Council of the University as a teaching aid on June 14, 2006, Protocol No. 7

Reviewers: Assoc. S. N. Tikhon, prof. A. V. Prokhorov

Vartanyan, V. F.

In 18 Operations on the gallbladder and bile ducts: textbook.-method. allowance / V. F. Vartanyan, P. V. Markautsan. - Minsk: BSMU, 2007 - 16 p.

ISBN 978-985-462-763-2.

Anatomical issues are discussed, as well as general principles surgical treatment of diseases of the gallbladder and extrahepatic bile ducts used in clinical practice.

Designed for senior students of all faculties.

Anatomy of the gallbladder

Holotopia. The gallbladder (GB) and ducts are projected into the right hypochondrium and proper epigastric region.

Skeletotopia. The bottom of the gallbladder is most often projected in the corner formed by the outer edge of the right rectus abdominis muscle and the costal arch, at the level of the anterior end of the IX costal cartilage (at the place where the cartilage of the X rib merges with it). The GB can also be projected at the place where the costal arch is crossed by a line connecting the top of the right axillary cavity with the navel.

Syntopia. Above and in front of the gallbladder is the liver, on the left is the pylorus, on the right is the hepatic flexure of the colon, the transverse colon (or the initial section of the duodenum 12). The bottom of the gallbladder usually comes out from under the anterior-lower edge of the liver by 2–3 cm and adjoins the anterior abdominal wall.

The gallbladder ( vesica fellea) has a pear-shaped shape (Fig. 1), is located on the visceral surface of the liver in the corresponding hole (fossa vesicae felleae), separating the anterior section of the right lobe of the liver from the square. The gallbladder is covered by the peritoneum, usually on three sides (mesoperitoneally). Much less often, intrahepatic (extraperitoneal) and intraperitoneal (maybe mesentery) its location takes place. Anatomically, the bottom is distinguished in the gallbladder (fundus vesicae felleae), the wide part is the body (corpus vesicae felleae) and the narrow part is the neck (collum vesicae felleae). The length of the gallbladder varies from 8 to 14 cm, the width is 3–5 cm, and the capacity reaches 60–100 ml. In the gallbladder, before it passes into the cystic duct, there is a kind of protrusion of the wall in the form of a pocket (Hartmann's pocket), which is located below the rest of the bladder cavity.

Rice. 1. Scheme of the gallbladder:

1 - bottom; 2 - body; 3 - neck; 4 - common bile duct; 5 - cystic duct; 6 - Hartmann pocket

The wall of the gallbladder consists of a mucous membrane (tunica mucosa vesicae felleae),

muscular (tunica muscularis vesicae felleae), subserous (tela subserosa vesicae felleae) and serous (tunica serosa vesicae felleae) layers.

The mucous membrane is presented a large number spiral folds, lined with a single layer of prismatic border epithelium and has a good resorption capacity. It is quite sensitive to various extreme events in the body, which is morphologically manifested by its swelling and desquamation.

The muscle layer consists of bundles of muscle fibers running in the longitudinal and circular directions. There may be gaps between them, through which the mucous membrane can directly fuse with the serous one (Rokitansky-Ashoff sinuses). These sinuses play important role in the pathogenesis of the development of biliary peritonitis without perforation of the gallbladder: when the gallbladder is overstretched, bile seeps through the mucous and serous membranes directly into abdominal cavity.

Luschke's burrows may be located on the upper surface of the GB (Fig. 2). They start from the small intrahepatic ducts of the liver and reach the mucous membrane. During cholecystectomy, these passages gape and cause the outflow of bile into the free abdominal cavity, which, as a rule, necessitates drainage of this cavity and the bed of the gallbladder.

Rice. 2. The structure of the HP:

1 - Luschke's moves; 2 - intrahepatic duct; 3 - muscle layer of the gallbladder; 4 - sine of Rokitansky–Ashoff

The blood supply to the gallbladder (Fig. 3) is carried out by the cystic artery (a. systica), which departs from the right branch of the hepatic artery and, approaching the neck of the bladder, is divided into two branches going to the upper and bottom surface. To find it, one can distinguish the so-called Kahlo triangle, the walls of which are the cystic and common hepatic ducts, and the base is the cystic artery.

The lymphatic network of the gallbladder vessels has its own characteristics. Lymph through two collectors enters the lymph nodes, one of which is located on the left side of the bladder neck, the second - directly at the edge

12 duodenal ulcer. These nodes at inflammatory process in the gallbladder can increase in size and compress the common bile duct.

Rice. 3. Blood supply to the gallbladder:

1 - Kahlo's triangle; 2 - cystic artery; 3 - cystic duct; 4 - common hepatic duct; 5 - common bile duct

Innervation of the gallbladder, ducts, sphincters is carried out from the celiac, lower diaphragmatic plexuses, as well as from the anterior trunk vagus nerve. Therefore, often diseases of the stomach and duodenum, as well as irritation of the vagus nerve during sliding hernia esophageal opening of the diaphragm lead to dysfunction of the sphincter of Oddi and inflammatory changes in the gallbladder, and vice versa.

Anatomy of the extrahepatic bile ducts

The neck of the gallbladder passes into the cystic duct (ductus cysticus), which usually connects at an acute angle to the common hepatic duct (ductus hepaticus communis), resulting in the formation of the common bile duct (ductus choledochus). The folds of the mucous membrane in the cystic duct are located along the bile flow, which makes it difficult for it to move retrogradely (like a valve).

The diameter of the ductus cysticus is 3 mm, ductus hepaticus communis -

4–5 mm and ductus choledochus 6–8 mm. The common bile duct is on average 6–8 cm long. It runs along the right edge of the hepatoduodenal ligament. Next to it is hepatic artery, and between them and behind - the portal vein. Ductus choledochus (Fig. 4) consists of four sections: pars supraduodenalis (from the beginning to the duodenum 12), pars retroduodenalis (behind the horizontal part of the intestine), pars pancreatica (in the thickness of the pancreas), pars duodenalis (in the intestinal wall). common bile