Anatomy Atlas

Gallbladder and biliary tree

Vesica biliaris et ductus biliares
Also: Gallbladder · Common bile duct · Cystic duct · Calot triangle
OrganHigh-yielddraftGI

Pear-shaped sac under the liver that stores and concentrates bile, with the extrahepatic bile ducts. Gallstone disease (biliary colic, cholecystitis, choledocholithiasis, cholangitis) is one of the most tested topics.

Core anatomy

Location

In the gallbladder fossa on the visceral surface of the liver. The fundus projects at the tip of the right 9th costal cartilage, where the lateral border of the right rectus abdominis meets the costal margin.

Parts
  • Fundus, body, neck (with Hartmann pouch, a common site of impacted stones)
  • Cystic duct (with spiral folds, the spiral valve of Heister) joins the common hepatic duct to form the common bile duct (CBD)
  • The CBD descends in the hepatoduodenal ligament, passes posterior to the 1st part of the duodenum, runs through or behind the head of the pancreas, and joins the main pancreatic duct to form the hepatopancreatic ampulla (of Vater), opening at the major duodenal papilla in the 2nd part of the duodenum. The sphincter of Oddi controls flow
  • Cystohepatic triangle (of Calot): cystic duct, common hepatic duct, and the inferior surface of the liver. It contains the cystic artery (usually from the right hepatic artery) and must be clearly identified in cholecystectomy (the "critical view of safety")
Relations

The fundus contacts the transverse colon; the body contacts the 1st and 2nd parts of the duodenum (the site of cholecystoenteric fistula in gallstone ileus).

Arterial supply

Cystic artery, usually from the right hepatic artery.

Venous drainage

Cystic veins and small veins directly into the liver.

Innervation

Celiac plexus (sympathetic, visceral pain in the epigastrium and RUQ), vagus, and the right phrenic nerve (referred pain to the right shoulder or scapula).

Mentioned in

Generated automatically from links in other entries.

Referred visceral painFront and back body outlines with numbered zones of referred pain. 1: the heart refers pain to the substernal region, left arm and jaw. 2: diaphragmatic irritation refers to the shoulder tip through C3–C5; on the left this is the Kehr sign of splenic rupture. 3: the stomach and duodenum (foregut) refer to the epigastrium. 4: the gallbladder refers to the right upper quadrant or epigastrium and to the right scapula. 5: the pancreas refers to the epigastrium and through to the back. 6: the small intestine and early appendicitis refer to the periumbilical region (midgut). 7: later appendicitis localizes to the right lower quadrant at McBurney point once the parietal peritoneum is inflamed. 8: the distal colon (hindgut) and bladder refer to the suprapubic region. 9: the kidney refers to the flank and costovertebral angle. 10: a ureteric stone causes pain from loin to groin.11223445678910Anterior · patient's right ←Posterior · patient's right →1Heart (angina, MI)Substernal, left arm, jaw (T1–T4)2DiaphragmShoulder tip (C3–C5, phrenic n.); left = Kehr sign3Stomach, duodenum (foregut)Epigastric4GallbladderRUQ or epigastric → right scapula5PancreasEpigastric, boring through to the back6Small intestine, early appendicitisPeriumbilical (midgut)7Appendicitis, laterRLQ (McBurney point) once parietal peritoneum is inflamed8Distal colon (hindgut), bladderSuprapubic9KidneyFlank, costovertebral angle10Ureter (stone)Loin to groin (testis or labium)

Swipe sideways to see the whole diagram →

Referred visceral pain. Visceral pain is poorly localized and felt in the dermatomes that share spinal segments with the organ's afferent fibers. Pain becomes sharp and localized once the parietal peritoneum is involved (appendicitis: periumbilical → RLQ). Zones are approximate and vary between people.
Original schematic, created for this atlas.
Stomach and liver with the celiac trunk and its branches, including the cystic artery
The gallbladder with the cystic artery (labelled at upper left).
Henry Vandyke Carter, Gray's Anatomy of the Human Body, 20th ed. (1918), Fig. 532. Source · Public domain (Public domain in the US: published before January 1, 1931 (per Wikimedia Commons))
Opened second part of the duodenum with probes in the common bile duct and pancreatic duct at the papilla
The common bile duct opening at the major duodenal papilla.
Henry Vandyke Carter, Gray's Anatomy of the Human Body, 20th ed. (1918), Fig. 1057. Source · Public domain (Public domain in the US: published before January 1, 1931 (per Wikimedia Commons))

Clinical correlations

Biliary colic and acute cholecystitis PANCE

Mechanism / lesion

Biliary colic: transient obstruction of the cystic duct by a stone. Acute cholecystitis: persistent obstruction with gallbladder inflammation. Risk factors ("5 F's"): female, fertile, forty, fat (obesity), fair; also rapid weight loss, pregnancy, estrogen and hemolysis (pigment stones).

Classic presentation

Colic: postprandial (fatty meal) RUQ/epigastric pain lasting less than about 6 hours, radiating to the right scapula. Cholecystitis: longer pain, fever, leukocytosis, Murphy sign.

Choledocholithiasis and ascending cholangitis PANCE

Mechanism / lesion

Stones in the common bile duct obstruct bile flow; superimposed infection causes cholangitis.

Classic presentation

Jaundice, elevated bilirubin and alkaline phosphatase. Cholangitis: Charcot triad (fever, RUQ pain, jaundice); Reynolds pentad adds hypotension and altered mental status. Needs antibiotics and urgent biliary drainage (ERCP).

Gallstone pancreatitis and gallstone ileus PANCE

Mechanism / lesion

A stone impacted at the ampulla blocks the pancreatic duct (pancreatitis). A large stone eroding through a cholecystoenteric fistula can obstruct the terminal ileum (gallstone ileus).

Classic presentation

Pancreatitis: epigastric pain radiating to the back with elevated lipase. Gallstone ileus: small bowel obstruction with pneumobilia and an ectopic stone (Rigler triad) in an older woman.

Courvoisier sign PANCE

Mechanism / lesion

Gradual distal CBD obstruction by malignancy (pancreatic head cancer, cholangiocarcinoma) distends a compliant gallbladder. Chronic gallstone disease causes a fibrotic, non-distensible gallbladder.

Classic presentation

A palpable, non-tender gallbladder with painless jaundice suggests malignancy rather than stones.

High-yield PANCE pearls

  • Ultrasound is first-line for RUQ pain / suspected cholecystitis; HIDA if ultrasound is equivocal (non-filling gallbladder = cholecystitis).
  • Charcot triad: fever, RUQ pain, jaundice → cholangitis → ERCP. Reynolds pentad adds hypotension + confusion.
  • Murphy sign: inspiratory arrest with RUQ palpation.
  • Courvoisier: painless jaundice + palpable non-tender gallbladder → pancreatic head cancer.
  • Calot triangle: cystic duct, common hepatic duct, liver edge; contains the cystic artery.

Imaging anatomy

X-ray

Most gallstones are not radiopaque (only about 10–15% are visible). Pneumobilia with gallstone ileus. Porcelain gallbladder (calcified wall). verify

CT

Less sensitive than ultrasound for gallstones. Useful for complications (perforation, emphysematous cholecystitis, abscess), malignancy, and pancreatitis.

MRI

MRCP noninvasively shows the biliary tree and CBD stones before choosing ERCP.

Ultrasound

First-line. Gallstones are echogenic with posterior acoustic shadowing and move with position. Acute cholecystitis: stones plus wall thickening (more than about 3 mm), pericholecystic fluid, gallbladder distension and a sonographic Murphy sign. A dilated CBD (more than about 6 mm, higher after cholecystectomy or with age) suggests obstruction. verify

Key views & landmarks
  • RUQ ultrasound
  • HIDA (cholescintigraphy) if ultrasound equivocal
  • MRCP / ERCP (therapeutic) for CBD stones

Physical exam

Surface landmarks

The gallbladder point: tip of the right 9th costal cartilage, at the lateral border of rectus abdominis (linea semilunaris).

Palpation

Palpate at the gallbladder point. A palpable gallbladder with jaundice suggests Courvoisier sign.

Murphy sign

Technique

Place fingers under the right costal margin at the gallbladder point and ask the patient to breathe in deeply.

Positive test

The patient stops inspiring abruptly (catches the breath) because of pain as the inflamed gallbladder descends onto the fingers.

Significance

Acute cholecystitis. Less sensitive in older adults.

Self-quiz

Q1.

A 42-year-old woman has 12 hours of constant RUQ pain after a fatty meal, fever of 38.5 °C, and leukocytosis. During palpation below the right costal margin she stops inhaling abruptly. What is the best initial imaging?

Show answer

B

Suspected acute cholecystitis (positive Murphy sign, fever) is evaluated first with RUQ ultrasound. HIDA is used if ultrasound is equivocal. ERCP is for CBD stones.

Q2.

A 70-year-old woman has fever, RUQ pain and jaundice, and she becomes hypotensive and confused. What is the definitive treatment after resuscitation and antibiotics?

Show answer

B

Reynolds pentad indicates severe ascending cholangitis. After antibiotics and fluids, the patient needs urgent biliary drainage (ERCP).

Q3.

A 66-year-old man has painless jaundice, weight loss, and a palpable, non-tender gallbladder. What is the most likely diagnosis?

Show answer

C

Courvoisier sign (painless jaundice + palpable non-tender gallbladder) suggests malignant distal CBD obstruction, most commonly pancreatic head carcinoma.

Q4.

Which structure is found within the cystohepatic triangle (of Calot)?

Show answer

B

The triangle (cystic duct, common hepatic duct, inferior liver surface) contains the cystic artery, which is ligated during cholecystectomy.

Q5.

An 80-year-old woman has small bowel obstruction. CT shows air in the biliary tree and a large gallstone in the bowel. Where is the stone most likely lodged?

Show answer

D

In gallstone ileus, a large stone erodes through a cholecystoenteric fistula (gallbladder body to the duodenum) and obstructs the terminal ileum, the narrowest part. Pneumobilia, obstruction and an ectopic stone form Rigler triad.

Flashcards

See also