The structure of the bile ducts. Gallbladder: structural features and transport systems. Anatomy of the extrahepatic bile ducts

MINISTRY OF HEALTH OF THE REPUBLIC OF BELARUS

BELARUSIAN STATE MEDICAL UNIVERSITY

DEPARTMENT OF OPERATIVE SURGERY AND TOPOGRAPHIC ANATOMY

V. F. VARTANYAN, P. V. MARKAUTSAN

OPERATIONS ON THE GALL BLADDER AND BILIDE DUCTS

Educational and methodological manual

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

Approved by the Scientific and Methodological Council of the University as an educational and methodological 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: educational method. allowance / V. F. Vartanyan, P. V. Markautsan. – Minsk: BSMU, 2007 – 16 p.

ISBN 978-985-462-763-2.

Issues of anatomy are considered, as well as general principles of surgical treatment of diseases of the gallbladder and extrahepatic bile ducts used in clinical practice.

Intended for senior students of all faculties.

Anatomy of the gallbladder

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

Skeletotopia. The bottom of the gallbladder is most often projected in the angle formed by the outer edge of the right rectus abdominis muscle and the costal arch, at the level of the anterior end of the 9th costal cartilage (at the place where the cartilage of the 10th rib merges with it). The gallbladder can also be projected at the place where the costal arch is crossed by a line connecting the apex of the right axilla to the navel.

Syntopy. 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 part of the duodenum). The bottom of the gallbladder usually extends from under the anterior inferior edge of the liver by 2–3 cm and is adjacent to the anterior abdominal wall.

The gallbladder (vesica fellea) is pear-shaped (Fig. 1), located on the visceral surface of the liver in the corresponding fossa (fossa vesicae felleae), separating the anterior section of the right lobe of the liver from the quadrate. The gallbladder is covered by peritoneum, usually on three sides (mesoperitoneal). Much less often there is an intrahepatic (extraperitoneal) and intraperitoneal (maybe mesentery) location. Anatomically, the gallbladder is divided into a bottom (fundus vesicae felleae), a wide part - the body (corpus vesicae felleae) and a narrow part - 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 peculiar protrusion of the wall in the form of a pocket (Hartmann's pouch), located below the rest of the cavity of the bladder.

Rice. 1. Diagram 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 represented by a large number of spiral folds, is lined with single-layer prismatic marginal epithelium and has good resorption capacity. It is quite sensitive to various extreme phenomena 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 serosa (Rokitansky-Aschoff sinuses). These sinuses play an important role in the pathogenesis of the development of biliary peritonitis without perforation of the gallbladder: when the gallbladder is overstretched, bile leaks through the mucous and serous membranes directly into the abdominal cavity.

Luschke's passages may be located on the upper surface of the gallbladder (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 flow of bile into the free abdominal cavity, which, as a rule, necessitates drainage of this cavity and the bed of the gallbladder.

Rice. 2. Structure of the gastrointestinal tract:

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

The blood supply to the gallbladder (Fig. 3) is carried out by the cystic artery (a. cystica), which departs from the right branch of the hepatic artery and, approaching the neck of the bladder, divides into two branches going to the upper and lower surfaces. To find it, we can distinguish the so-called Calot's triangle, the walls of which are the cystic and common hepatic ducts, and the base is the cystic artery.

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

duodenum. During the inflammatory process in the gallbladder, these nodes can increase in size and compress the common bile duct.

Rice. 3. Blood supply to the gallbladder:

1 - Calot triangle; 2 - cystic artery; 3 - cystic duct; 4 - common hepatic duct; 5 - common bile duct

Innervation of the gallbladder, ducts, and sphincters comes from the celiac, inferior phrenic plexuses, as well as from the anterior trunk of the vagus nerve. Therefore, diseases of the stomach and duodenum, as well as irritation of the vagus nerve during a sliding hiatal hernia, often 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 with 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 flow of bile, which complicates its retrograde path of movement (similar to a valve).

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

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

Right and left hepatic ducts, leaving the same lobes of the liver, form the common hepatic duct. The width of the hepatic duct ranges from 0.4 to 1 cm and averages about 0.5 cm. The length of the bile duct is about 2.5-3.5 cm. The common hepatic duct, connecting with the cystic duct, forms the common bile duct. The length of the common bile duct is 6-8 cm, width 0.5-1 cm.

The common bile duct has four sections: supraduodenal, located above the duodenum, retroduodenal, passing behind the upper horizontal branch of the duodenum, retropancreatic (behind the head of the pancreas) and intramural, located in the wall of the vertical branch of the duodenum (Fig. 153). The distal portion of the common bile duct forms the major duodenal papilla (papilla of Vater), located in the submucosal layer of the duodenum. The large duodenal papilla has an autonomous muscular system consisting of longitudinal, circular and oblique fibers - the sphincter of Oddi, independent of the muscles of the duodenum. The pancreatic duct approaches the large duodenal papilla, forming, together with the terminal section of the common bile duct, the ampulla of the duodenal papilla. Various options for the relationship between the bile and pancreatic ducts should always be taken into account when performing surgery on the major duodenal papilla.

Rice. 153. Structure of the biliary tract (diagram).

1 - left hepatic duct; 2 - right hepatic duct; 3 - common hepatic duct; 4 - gallbladder; 5 - cystic duct; b _ common bile duct; 7 - duodenum; 8 - accessory duct of the pancreas (duct of Santorini); 9 - major duodenal papilla; 10 - pancreatic duct (duct of Wirsung).

The gallbladder is located on the lower surface of the liver in a small depression. Most of its surface is covered by peritoneum, with the exception of the area adjacent to the liver. The capacity of the gallbladder is about 50-70 ml. The shape and size of the gallbladder can undergo changes due to inflammatory and cicatricial changes. The bottom, body and neck of the gallbladder, which passes into the cystic duct, are distinguished. Often a bay-shaped protrusion forms at the neck of the gallbladder - Hartmann's pouch. The cystic duct often flows into the right semicircle of the common bile duct at an acute angle. Other options for the confluence of the cystic duct: into the right hepatic duct, into the left semicircle of the common hepatic duct, high and low confluence of the duct, when the cystic duct accompanies the common hepatic duct for a long distance. The wall of the gallbladder consists of three membranes: mucous, muscular and fibrous. The mucous membrane of the bladder forms numerous folds. In the area of ​​the bladder neck and the initial part of the cystic duct, they are called Heister valves, which in the more distal parts of the cystic duct, together with bundles of smooth muscle fibers, form the Lütkens sphincter. The mucous membrane forms multiple protrusions located between the muscle bundles - the Rokitansky-Aschoff sinuses. In the fibrous membrane, often in the area of ​​the bladder bed, there are aberrant hepatic tubules that do not communicate with the lumen of the gallbladder. Crypts and aberrant tubules can be a site of microflora retention, which causes inflammation of the entire thickness of the gallbladder wall.

Blood supply to the gallbladder carried out through the cystic artery, coming to it from the neck of the gallbladder with one or two trunks from the proper hepatic artery or its right branch. There are other options for the origin of the cystic artery.

Lymphatic drainage occurs in the lymph nodes of the portal of the liver and the lymphatic system of the liver itself.

Innervation of the gallbladder carried out from the hepatic plexus, formed by branches of the celiac plexus, the left vagus nerve and the right phrenic nerve.

Bile, produced in the liver and entering the extrahepatic bile ducts, consists of water (97%), bile salts (1-2%), pigments, cholesterol and fatty acids (about 1%). The average flow rate of bile secretion by the liver is 40 ml/min. During the interdigestive period, the sphincter of Oddi is in a state of contraction. When a certain level of pressure in the common bile duct is reached, the Lütkens sphincter opens and bile from the hepatic ducts enters the gallbladder. The concentration of bile occurs in the gallbladder due to the absorption of water and electrolytes. In this case, the concentration of the main components of bile (bile acids, pigments, cholesterol, calcium) increases 5-10 times from their initial content in hepatic bile. Food, acidic gastric juice, fats, entering the duodenal mucosa, cause the release of intestinal hormones into the blood - cholecystokinin, secretin, which cause contraction of the gallbladder and simultaneous relaxation of the sphincter of Oddi. When food leaves the duodenum and the contents of the duodenum become alkaline again, the release of hormones into the blood stops and the sphincter of Oddi contracts, preventing further flow of bile into the intestine. About 1 liter of bile enters the intestines per day.

Surgical diseases. Kuzin M.I., Shkrob O.S. et al., 1986

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Liver secretions necessary for digestion move through the gallbladder to the intestinal cavity along the bile ducts. Various diseases provoke changes in the functioning of the bile ducts. Interruptions in the functioning of these pathways affect the performance of the entire organism. The bile ducts differ in their structural and physiological features.

Interruptions in the functioning of the bile ducts affect the performance of the entire body

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. The development of pathological processes in it threatens with serious complications and affects the normal functioning of a person.

The functions of the gallbladder in the human body are:

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

Bile production is carried out by liver cells and does not stop day or night. Why does a person need a gallbladder and why can’t we do without this connecting link when transporting liver fluid?

The secretion of bile occurs constantly, but the processing of food mass with bile is required only during the process of digestion, which is limited in duration. Therefore, the role of the gallbladder in the human body is to accumulate and store liver secretions until the right time. The production of bile in the body is an uninterrupted process and it is produced many times more than the volume of the pear-shaped organ can accommodate. Therefore, bile is split inside the cavity, water and some substances necessary for other physiological processes are removed. Thus, it becomes more concentrated and its volume is significantly reduced.

The amount that the bladder will release does not depend on how much it is produced by the largest gland - the liver, which is responsible for the production of bile. What matters in this case is the amount of food consumed and its nutritional composition. The passage of food into the esophagus serves as a signal to begin work. To digest fatty and heavy foods, a larger amount of secretion 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 liver secretions until the right time.

• the common hepatic duct transfers the secretion to the biliary organ, 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 duodendral papilla relaxes;
• Bile travels along the common bile duct to the intestines.

In cases where the bladder is removed, the biliary system does not cease to function. All the work falls on the bile ducts. The gallbladder is innervated or connected to the central nervous system through the hepatic plexus.

Gallbladder dysfunction affects your health and can cause weakness, nausea, vomiting, itching and other unpleasant symptoms. In Chinese medicine, it is customary to consider the gallbladder not as a separate organ, but as a component of one system with the liver, which is responsible for the timely release of bile.

The gallbladder meridian is considered Yangsky, i.e. paired and runs throughout the body from head to toes. The liver meridian, which belongs to the Yin organs, and the bile meridian are closely related. It is important to understand how it spreads in the human body so that treatment of organ pathologies using 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 the ring toe;
• internal, starting at the shoulders and going through the diaphragm, stomach and liver, ending with a branch in the bladder.

Stimulating points on the meridian of the biliary organ helps not only improve digestion and improve its functioning. Impact on the points of the head relieves:

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

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

The structure of the gallbladder and biliary tract

The gallbladder meridian affects many organs, which suggests that the normal functioning of the biliary system is extremely important for the functioning of the entire body. The anatomy of the gallbladder and biliary tract is a complex system of channels that ensure the movement of bile within the human body. Its anatomy helps to understand how the gallbladder works.

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 intrauterine 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:

• a 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 capable of holding 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 incoming bile is very quickly absorbed and processed. The folded surface contains many mucous glands, the intensive work of which concentrates the incoming fluid and reduces its volume.

The ducts perform a transport function and ensure the movement of bile from the liver through the bladder to the duodenum. Ducts run to the right and left of the liver and form the common hepatic duct.

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

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

The structure of the bile ducts outside the liver consists of several channels:

1. Cystic duct connecting the liver with the bladder.
2. The common bile duct (CBD or common bile duct), starting at the place where the hepatic and cystic ducts connect and going to the duodenum.

The anatomy of the bile ducts distinguishes the sections of the common bile duct. First, bile from the bladder passes through the supraduodendral section, passes into the retroduodendral section, then through the pancreatic section it enters the duodendral section. Only along this path can bile pass from the organ cavity to the duodenum.

How does the gallbladder work?

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

How does the gallbladder work, and what factors influence its activity? During periods when digestion of food is not required, the bladder is in a relaxed state. The job of the gallbladder at this time is to accumulate secretions. Eating food triggers many reflexes. The pear-shaped organ is also included in the process, which makes it mobile due to the contractions that begin. At this point, it already contains processed bile.

The required amount of bile is released into the common bile duct. Through this channel, liquid enters the intestine and promotes digestion. Its function is to break down fats through the acids it contains. In addition, processing 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.

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

The principle of operation of the gallbladder is described by the following points:

1. Collection of bile, which is produced by the liver.
2. Thickening and storage of secretions.
3. The direction of fluid 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 nutrition. The gallbladder meridian, on the contrary, is activated only in the late evening from eleven to one in the morning.

Diagnosis of bile ducts

Failure in the functioning of the biliary system most often occurs due to the formation of some kind of obstacle in the canals. The reason for this may be:

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

Diseases are identified through a medical examination of the patient and palpation of the area of ​​the right hypochondrium, which makes it possible to establish deviations 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 of them have formed in the ducts.

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

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

Causes of bile duct diseases

Disturbances 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 and narrowing of the bile ducts, thickening of the walls of the common bile duct, and the appearance of various formations in the canals indicate 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 the disease in this case may be:

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

Strictures that form in the bile ducts provoke cholestasis, pain in the right hypochondrium, jaundice, intoxication, and fever. The narrowing of the bile ducts leads to the fact that the walls of the canals begin to thicken, and the area above begins 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.

Dilation of the intrahepatic bile ducts occurs due to:

Changes in the bile ducts accompany the symptoms:

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

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

1. Housing and communal services The formation of stones is possible not only in the bladder, but also in the ducts. In many cases, the patient does not experience any discomfort for a long time. Therefore, stones may remain undetected for several years and continue to grow. If 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 you to do this.
2. Dyskinesia. This disease is characterized by a decrease in the motor function of the bile ducts. Disruption of bile flow occurs due to changes in pressure in different areas of the 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 independently. Symptoms of cholangitis include: fever, increased sweating, pain in the right side, nausea and vomiting, and jaundice develops.
4. Acute cholecystitis. The inflammation is infectious in nature and occurs with pain and fever. At the same time, the size of the gallbladder increases, and deterioration of the condition occurs after consuming fatty, heavy meals and alcoholic beverages.
5. Cancerous tumors of the canals. The disease most often affects the intrahepatic bile ducts or pathways at the porta hepatis. With cholangiocarcinoma, yellowing of the skin, itching in the liver area, fever, nausea and other symptoms appear.

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

Anomalies of the bile

An anomaly in the development of the gallbladder ducts is diagnosed in almost 20% of people. Much less common is the complete absence of channels intended for the removal of bile. Congenital defects entail disruption of the biliary system and digestive processes. Most congenital defects do not pose a serious threat and can be treated; severe forms of pathologies are extremely rare.

Duct anomalies include the following pathologies:

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

Anomalies of the bubble itself, according to their characteristics, are conventionally divided into groups depending on:

• localization of the bile;
• changes in organ structure;
• deviations in shape;
• quantities.

An organ can be formed, but have a different location from the normal one and be located:

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

The pathology is accompanied by disturbances in bladder contractions. The organ is more susceptible to inflammatory processes and the formation of stones.

A “wandering” bubble can occupy various positions:

• inside the abdominal region, but almost not in contact with the liver and covered by abdominal tissues;
• completely separated from the liver and communicating with it through a long mesentery;
• with a complete lack of 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, due to underdevelopment of the organ, there is only a small process that is not capable of functioning and full-fledged ducts.
3. Bladder hypoplasia. The diagnosis indicates that the organ is present and capable of functioning, but some of its tissues or areas are not fully formed in the child in the prenatal period.

Functional excesses go away on their own, but true ones require medical intervention

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

An abnormal, non-pear-shaped shape 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 there has been a bend that has disrupted the longitudinal axis. The gallbladder collapses towards the duodenum, and adhesions form at the point of contact. Functional excesses go away on their own, but 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, causing the appearance of stones and accompanied by severe pain.

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

The biliary bile weakens the organ and leads to dropsy, stones and tissue inflammation. The gallbladder may be:

• multi-chamber, in which the bottom of the organ is partially or completely separated from its body;
• bilobed, when two separate lobules are attached to one bladder neck;
• ductular, two bladders with their ducts function simultaneously;
• triplicative, three organs united by a serous membrane.

How are bile ducts treated?

When treating blocked ducts, two methods are used:

• conservative;
• operational.

The main thing in this case is surgical intervention, and conservative agents are used as auxiliaries.

Sometimes, a calculus or mucous clot can leave the duct on its own, but this does not mean complete relief from the problem. The disease will return without treatment, so it is necessary to combat the cause of such stagnation.

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

• starvation;
• installation of a nasogastric tube;
• antibacterial drugs in the form of antibiotics with a wide spectrum of action;
• droppers with electrolytes, protein drugs, fresh frozen plasma and others, mainly for detoxifying the body;
• antispasmodic drugs;
• vitamin products.

To speed up the flow of bile, non-invasive methods are used:

• extraction of stones using a probe followed by drainage of the canals;
• percutaneous puncture of the bladder;
• cholecystostomy;
• choledochostomy;
• percutaneous hepatic drainage.

Normalization of the patient's condition allows the use of surgical treatment methods: laparotomy, when the abdominal cavity is completely opened, or laparoscopy performed using an endoscope.

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

Congenital malformations, as a rule, do not require treatment, but if the gallbladder is deformed or prolapsed due to some injury, what should you do? Displacement of an organ while maintaining its functionality will not worsen health, but if pain and other symptoms appear, it is necessary:

• maintain bed rest;
• drink enough liquid (preferably without gas);
• adhere to the 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 physical therapy and massage to relieve the condition.

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

Video

What to do if a stone appears in the gall bladder.

Source: pechen.org

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The bile ducts are a complex transport route for liver secretions. They go from the reservoir (gallbladder) into the intestinal cavity.

The bile ducts are an important transport route for liver secretions, ensuring its outflow from the gallbladder and liver to the duodenum. They have their own special structure and physiology. Diseases can affect not only the gallbladder itself, but also the bile ducts. There are many disorders that impair their functioning, but modern monitoring methods make it possible to diagnose diseases and treat them.

The bile duct is a collection of tubular tubules through which bile is evacuated into the duodenum from the gallbladder. Regulation of the work of muscle fibers in the walls of the ducts occurs under the influence of impulses from the nerve plexus located in the liver area (right hypochondrium). The physiology of excitation of the bile ducts is simple: when the receptors of the duodenum are irritated by food masses, nerve cells send signals to the nerve fibers. From them, a contraction impulse is sent to the muscle cells, and the muscles of the bile ducts relax.

The movement of secretions in the bile ducts occurs under the influence of pressure exerted by the lobes of the liver - this is facilitated by the function of the sphincters, called motor, GB and tonic tension of the vascular walls. The large hepatic artery feeds the tissues of the bile ducts, and the outflow of oxygen-poor blood occurs into the portal vein system.

Anatomy of the bile ducts

The anatomy of the biliary tract is quite confusing, because these tubular formations are small in size, but gradually they merge, forming large canals. Depending on how the bile capillaries are located, they are divided into extrahepatic (hepatic, common bile and cystic duct) and intrahepatic.

The beginning of the cystic duct is located at the base of the gallbladder, which, like a reservoir, stores excess secretions, then merges with the hepatic duct, forming a common channel. The cystic duct emerging from the gallbladder is divided into four sections: supraduodenal, retropancreatic, retroduodenal and intramural canals. Coming out at the base of the papilla of Vater of the duodenum, a section of a large bile vessel forms an orifice, where the channels of the liver and pancreas are transformed into the hepatic-pancreatic ampulla, from which a mixed secretion is released.

The hepatic duct is formed by the fusion of two side branches that transport bile from each part of the liver. The cystic and hepatic tubules will flow into one large vessel - the common bile duct (choledochus).

Major duodenal papilla

Speaking about the structure of the biliary tract, one cannot help but recall the small structure into which they flow. The major duodenal papilla (DC) or papilla of Vater is a hemispherical flattened elevation located on the edge of the fold of the mucous layer in the lower part of the DP, 10–14 cm above it there is a large gastric sphincter - the pylorus.

The dimensions of the Vater nipple range from 2 mm to 1.8–1.9 cm in height and 2–3 cm in width. This structure is formed when the biliary and pancreatic excretory ducts merge (in 20% of cases they may not connect and the ducts leaving the pancreas open a little higher).

An important element of the major duodenal papilla is, which regulates the flow of mixed secretions from bile and pancreatic juice into the intestinal cavity, and it also prevents intestinal contents from entering the biliary tract or pancreatic canals.

Pathologies of the bile ducts

There are many disorders of the functioning of the biliary tract; they can occur separately or the disease will affect the gallbladder and its ducts. The main violations include the following:

• blockage of bile ducts (cholelithiasis);
• dyskinesia;
• cholangitis;
• cholecystitis;
• neoplasms (cholangiocarcinoma).

The hepatocyte secretes bile, which consists of water, dissolved bile acids, and some metabolic waste products. If this secretion is removed from the reservoir in a timely manner, everything functions normally. If there is stagnation or too rapid secretion, bile acids begin to interact with minerals, bilirubin, creating deposits - stones. This problem is typical for the bladder and bile ducts. Large stones clog the lumen of the bile vessels, damaging them, which causes inflammation and severe pain.

Dyskinesia is a dysfunction of the motor fibers of the bile ducts, in which there is an abrupt change in the pressure of secretions on the walls of blood vessels and the gallbladder. This condition can be an independent disease (of neurotic or anatomical origin) or accompanies other disorders, such as inflammation. Dyskinesia is characterized by the appearance of pain in the right hypochondrium several hours after eating, nausea, and sometimes vomiting.

– inflammation of the walls of the biliary tract, may be a separate disorder or a symptom of other disorders, for example, cholecystitis. The inflammatory process in the patient manifests itself as fever, chills, profuse secretion of sweat, pain in the right hypochondrium, lack of appetite, and nausea.

- an inflammatory process involving the bladder and bile duct. The pathology is of infectious origin. The disease occurs in an acute form, and if the patient does not receive timely and high-quality therapy, it becomes chronic. Sometimes, with permanent cholecystitis, it is necessary to remove the gallbladder and part of its ducts, because the pathology prevents the patient from living a normal life.

Neoplasms in the gallbladder and bile ducts (most often they occur in the common bile duct area) are a dangerous problem, especially when it comes to malignant tumors. Drug treatment is rarely carried out; the main therapy is surgery.

Methods for studying the bile ducts

Methods for diagnostic examination of the biliary tract help to detect functional disorders, as well as track the appearance of neoplasms on the walls of blood vessels. The main diagnostic methods include the following:

• duodenal intubation;
• intraoperative choledo- or cholangioscopy.

An ultrasound examination can detect deposits in the gallbladder and ducts, and also indicates neoplasms in their walls.

– a method for diagnosing the composition of bile, in which the patient is parenterally administered an irritant that stimulates contraction of the gallbladder. The method allows you to detect deviations in the composition of liver secretions, as well as the presence of infectious agents in it.

The structure of the ducts depends on the location of the liver lobes; the general plan resembles the branched crown of a tree, since many small ones flow into large vessels.

The bile ducts are the transport route for liver secretions from its reservoir (gallbladder) into the intestinal cavity.

There are a lot of diseases that disrupt the functioning of the biliary tract, but modern research methods make it possible to detect the problem and cure it.

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Brief anatomy of the biliary tract

Exiting into the interlobular connective tissue, they pass into the interlobular tubules. Further, the interlobular ducts, merging, form interlobular ducts of the first and second order, lined with prismatic epithelium,

Alveolar-tubular mucous glands, connective tissue membrane, and elastic fibers appear in the walls of the ducts. The interlobular ducts form large intrahepatic ducts, which form the right and left hepatic ducts. The latter, merging, form the common hepatic duct, which has the Mirizzi sphincter. After the connection of the common hepatic duct and the cystic duct, the common bile duct (choledochus) begins, which is a direct continuation of the common hepatic duct. The width of the ducts varies: common bile ducts from 2 to 10 mm, hepatic ducts from 0.4 to 1.6 mm, cystic ducts from 1.5 to 3.2 mm. It should be noted that the diameter of the bile ducts when determined by different methods may vary.

Thus, the diameter of the common bile duct, measured intraoperatively, ranges from 5-15 mm, with ERCP up to 10 mm, with ultrasound - 2-7 mm.

In the common bile duct, the length of which is 5-7 cm, there are supraduodenal, retroduodenal, retropancreatic, intrapancreatic and intramural sections. The common bile duct passes between the leaves of the lesser omentum anterior to the portal vein and to the right of the hepatic artery, and, as noted earlier, in most cases merges with the pancreatic duct in the thickness of the posterior wall of the duodenum, opening into its lumen on the longitudinal fold of the mucous membrane with the major papilla of the duodenum. Options for connecting the common bile duct and the gastrointestinal tract in the area of ​​the nipple of Vater are shown in Fig. 1-6.

Rice. 1-6. Options for the fusion of the intrapancreatic portion of the common bile duct and the main pancreatic duct

The capacity of the gallbladder is about 50-100 ml, but with hypotension or atony of the common bile duct, blockage with a stone, or compression by a tumor, the gallbladder can significantly increase in size. The gallbladder has a fundus, a body and a neck, which gradually narrows and becomes the cystic duct. At the junction of the neck of the gallbladder and the cystic duct, smooth muscle fibers form the sphincter of Mirizzi.

The saccular expansion of the neck of the gallbladder, which often serves as the site of stone formation, is called Hartmann's pouch. In the initial part of the cystic duct, its mucous membrane forms 3-5 transverse folds (valves or valves of Heister). The widest part of the gallbladder is its bottom, facing anteriorly: it is this that can be palpated when examining the abdomen.

The wall of the gallbladder consists of a network of muscle and elastic fibers with poorly defined layers. The muscle fibers of the neck and bottom of the gallbladder are especially well developed. The mucous membrane forms numerous delicate folds. There are no glands in it, but there are depressions that penetrate into the muscle layer. There is no submucosa or intrinsic muscle fibers in the mucous membrane.

Brief anatomy of the duodenum

The duodenum is partially fixed to the surrounding organs, does not have a mesentery and is not completely covered by the peritoneum, mainly in the front, actually located retroperitoneally. The posterior surface of the duodenum is firmly connected through fiber to the posterior abdominal wall.

The size and shape of the duodenum are very variable; many variants of the anatomy of this organ have been described. The normal shape of the duodenum depends on gender, age, constitutional characteristics, physical development, body weight, condition of the abdominal muscles, and degree of stomach filling. This is due to the existence of many classifications of its form. Most often (in 60% of cases), the duodenum has a horseshoe shape, bending around the head of the pancreas (Fig. 1-7). However, there are also other forms of duodenum: ring-shaped, folded, angular and mixed forms, in the form of steeply curved loops located vertically or frontally, etc.

Rice. 1-7. Duodenum, normal anatomy

Maev I.V., Kucheryavyi Yu.A.