biliary tree and gallbladder

largest gland in body

liver

liver is divided into large right lobe and smaller left lobe at

falciform ligament

two minor lobes are on medial side of right lobe

caudate-posterior

quadrate-inferior

hilum called __ is situated transversely between two minor lobes

porta hepatis

convey blood to liver

portal vein and hepatic artery

both portal vein and hepatic artery enter __ and branch out through __

porta hepatis

liver substance

liver receives blood from

portal system

the hepatic veins convey blood from

liver sinusoids to IVC

numerous functions of liver and biliary system including formation of

bile

amount of bile secreted each day

1-3 pints or ½ to 1 liter

bile is an

excretion and secretion

aid in emulsification and assimilation of fats

secretion

channel of elimination for waste products of red blood cell destruction

excretion

bile collected from __

the two main hepatic ducts emerge at the __ and join to form the __ which unites with the cystic duct to form the __

porta hepatis

common hepatic duct

common bile duct

The common bile duct joins the pancreatic duct to enter together into an enlarged chamber called the

hepatopancreatic ampulla

another name for hepatopancreatic ampulla

ampulla of vater

ampulla opens into descending portion of the

duodenum

the distal end is controlled by the __ as it enters the duodenum

choledochal sphincter

The hepatopancreatic ampulla is controlled by a circular muscle called the

sphincter of the hepatopancreatic ampulla

sphincter of Oddi.

During periods between digestion, the sphincter remains closed/contracted, so most of the bile is routed into the

gallbladder for concentration and storage

During digestion, the sphincter relaxes to

permit the bile to flow into the duodenum.

The ampulla of Vater opens on an elevation on the duodenal mucosa called the

major duodenal papilla

a thin walled, pear shaped ,musculomembranous sac

gallbladder

capacity of gallbladder

2 ounces

gallbladder concentrates bile by

absorption of water content

gallbladder stores bile

during interdigestive periods

gallbladder evacuates bile

during digestion

The muscular contraction of the gallbladder is activated by a hormone called

cholecystokinin

cholecystokinin is secreted by __

duodenal mucosa

cholecystokinin releases into blood when

fatty or acid chyme passes into the intestine

gallbladder has a __ continuous with cystic duct

narrow neck

body (main)

fundus (broad lower portion)

position of gallbladder varies with

body habitus

an elongated gland on the posterior abdominal wall

pancreas

head of pancreas extends inferiorly and is enclosed within the curve of

duodenum at level of L2-L3

the body and tail of pancreas pass transversely behind __ and in front of __, with tail ending at __

stomach

left kidney

spleen

pancreas is an ___ gland

exocrine and endocrine

exocrine cells of pancreas are arranged in

lobules with a duct system

pancreas exocrine produces

pancreatic juice to act on proteins, fats, and carbohydrates

endocrine portion of pancreas consists of

islets of langerhans

islets of langerhans produce the hormones

insulin and glucagon

The digestive juice secreted by the exocrine glands is conveyed into the

pancreatic duct and then into duodenum

The pancreatic duct often unites with the common bile duct to form a single passage via the __ which opens directly into the

hepatopancreatic ampulla

descending duodenum

Belongs to the lymphatic system
 Glandlike, but ductless organ

spleen

spleen functions

produce lymphocytes

store/remove dead or dying rbc’s

spleen can be visualized

with/without contrast

general term for radiographic study of the gallbladder

cholegraphy

radiographic study of gallbladder

cholecystography

radiographic study of the biliary ducts

cholangiography

radiography of gallbladder and biliary ducts

cholecystangiography

cholecystocholangiography

contrast agent used for direct injection of biliary may be

any water-soluble iodinated compounds used for IVU

Performed on patients with jaundice when the ductal system has been demonstrated as dilated by CT or sonography, but the cause is unclear

percutaneous transhepatic cholangiography

PTC may also be used to

place a drainage catheter to treat obstructive jaundice

pt is placed __ for PTC with __ surgically prepared and draped

supine

right side (local anesthesia administered)

skinny needle used for PTC

chiba

after ductal system is filled

spot AP projections are made

If dilated ducts are identified

drainage catheter may be placed in the biliary duct

a __ is placed through the needle, the needle removed —>

guide wire

catheter threaded over wire

catheter can be left in place for

prolonged drainage or for stone extraction

__ may be used for stone extraction

wire basket

Performed using a T-shaped or pigtail-shaped catheter left in the common hepatic and common bile ducts for post-op drainage

postoperative cholangiography

postoperative cholangiography also called

delayed cholangiography

t-tube performed to demonstrate

 Caliber and patency of ducts
 Status of sphincter of the heptopancreatic ampulla
 The presence of residual or previously undetected stones

t-tube chol Drainage tube clamped day before exam to

prevent air bubbles that would simulate cholesterol stones

cleansing enema is done __ before t-tube

1 hour

Contrast is water-soluble iodinated, no more than

25-30% so small stones are not obscured

After preliminary abdomen image, patient is adjusted into

RPO position with RUQ of abdomen centered to the grid

Stern stressed the importance of a lateral projection to show

branching of the hepatic ducts.

Used to diagnose biliary and pancreatic pathologic conditions

endoscopic retrograde cholangiopancreatography

ERCP is useful method when

ducts are not dilated and ampulla is not obstructed

ERCP performed by

passing a fiberoptic endoscope through the mouth into the duodenum under fluoroscopy

patient’s throat is __ to make passage of endoscope easier

local anesthetic

• endoscopist locates __ and passes __

• injects contrast into __

ampulla of vater

small cannula

common bile duct

why should radiographs be taken immediately after contrast?

the injected contrast should drain from normal ducts within approx. 5 minutes

dense contrast agents opacify small ducts well but may

obscure small stones

If small stones are suspected, use of a

more dilute contrast is suggested

abnormal passages, usually between two internal organs

fistulae

abnormal channels leading to abscesses

sinuses

to show origin and extent of fistula and sinuses

-fill tract with contrast

-obtain right angle projections