Gall bladder

Introduction to the Gallbladder

According to Love and Bailey’s “A Short Practice of Surgery”, the gallbladder is a pear-shaped muscular sac located on the visceral surface of the liver that serves as a reservoir for bile. It plays a crucial role in the storage, concentration, and release of bile into the duodenum.

Clinical Significance

Most common site of biliary tract disease
Gallstone disease affects 10-15% of adult population
Cholecystectomy is one of the most common abdominal operations
Gallbladder cancer, though rare, has poor prognosis
Increasing incidence with age and obesity

Embryological Development

Week	Development	Clinical Significance
4th week	Hepatic diverticulum from ventral foregut	Origin of liver, gallbladder, and biliary tree
5th week	Gallbladder primordium appears	Development of gallbladder and cystic duct
12th week	Bile secretion begins	Functional development complete

Surgical Anatomy of the Gallbladder

Gross Anatomy

Feature	Description	Clinical Significance
Location	Gallbladder fossa on visceral surface of liver, segments IV and V	Anatomical relationship important for surgery
Dimensions	7-10 cm long, 3 cm wide, capacity 30-50 mL	Distension in disease states
Parts	Fundus, body, infundibulum (Hartmann’s pouch), neck	Hartmann’s pouch common site for stone impaction
Relations	Anterior: Anterior abdominal wall Posterior: Transverse colon, duodenum Superior: Liver Inferior: Transverse colon	Important for understanding spread of inflammation

Blood Supply

Vessel	Origin	Course	Surgical Importance
Cystic Artery	Usually from right hepatic artery (90%)	Through Calot’s triangle to gallbladder neck	Key structure in cholecystectomy, variations common
Cystic Vein	Drains directly to portal vein or right branch	Multiple small veins from gallbladder bed	Bleeding source during dissection
Arterial Variations	Multiple origins possible	From left hepatic, common hepatic, gastroduodenal arteries	Important to identify to avoid injury

Calot’s Triangle

Boundaries:
- Superior: Inferior surface of liver
- Inferior: Cystic duct
- Medial: Common hepatic duct
Contents: Cystic artery, cystic lymph node (of Lund), lymphatics
Surgical importance: Critical area for dissection during cholecystectomy
Critical view of safety: Clear identification of cystic duct and artery before division

Lymphatic Drainage

Pathway	Nodes	Clinical Significance
Primary	Cystic node (Calot’s node) → hepatoduodenal ligament nodes	First echelon nodes for gallbladder cancer
Secondary	Pericholedochal nodes → celiac nodes → para-aortic nodes	Advanced drainage pathway
Additional	Direct drainage to liver, retropancreatic nodes	Explains unusual spread patterns

Nerve Supply

Nerve	Origin	Function
Sympathetic	T7-T9 via celiac plexus	Vasomotor, pain sensation (referred to right scapula)
Parasympathetic	Vagus nerve	Motor to gallbladder, stimulates contraction

Histology

Layer	Composition	Function
Mucosa	Columnar epithelium with microvilli, Rokitansky-Aschoff sinuses	Absorption and concentration of bile
Muscularis	Smooth muscle fibers in circular, longitudinal, oblique directions	Gallbladder contraction
Perimuscular	Connective tissue with vessels, nerves	Support and nutrition
Serosa	Visceral peritoneum (except liver attachment)	Covering and protection

Gallbladder Physiology

Bile Composition

Component	Concentration	Function
Bile Salts	50-60% of solids	Emulsification of fats, cholesterol solubilization
Phospholipids	20-30% of solids	Form mixed micelles with bile salts
Cholesterol	3-5% of solids	Elimination of excess cholesterol
Bilirubin	2-3% of solids	Excretion of heme breakdown products
Electrolytes	Similar to plasma	Maintain osmotic balance

Gallbladder Functions

Function	Mechanism	Capacity
Bile Storage	Reservoir function between meals	30-50 mL
Bile Concentration	Active absorption of water and electrolytes	5-10 fold concentration
Mucin Secretion	Protection of epithelium, lubrication	Variable
Acidification	Hydrogen ion secretion	pH 6.5-7.0 (from hepatic bile pH 7.5-8.2)

Gallbladder Emptying

Stimulus	Mediator	Effect
Food (especially fat)	Cholecystokinin (CCK)	Strong gallbladder contraction, sphincter of Oddi relaxation
Vagal Stimulation	Acetylcholine	Moderate contraction
Other Hormones	Motilin, gastrin	Mild contraction

Enterohepatic Circulation

95% of bile salts reabsorbed in terminal ileum
Portal venous return to liver
Resecretion into bile (6-8 cycles/day)
Liver synthesizes 0.2-0.6 g/day to replace fecal losses

Investigations for Gallbladder Disease

Imaging Modalities

Investigation	Indications	Findings	Sensitivity/Specificity
Ultrasound (USG)	First-line for suspected gallbladder disease	Stones, wall thickening, pericholecystic fluid, sonographic Murphy’s sign	95% for stones, 80% for acute cholecystitis
CT Scan	Complicated cholecystitis, malignancy, unclear diagnosis	Stones (60-75%), inflammation, complications, lymph nodes	Good for complications, poor for uncomplicated stones
MRCP	Biliary anatomy, choledocholithiasis, biliary strictures	Detailed biliary tree anatomy, stones, tumors	95% for bile duct stones, excellent anatomical detail
HIDA Scan	Suspected acute cholecystitis, biliary dyskinesia	Non-visualization of gallbladder in acute cholecystitis	95% sensitivity, 90% specificity for acute cholecystitis
ERCP	Therapeutic for choledocholithiasis, biliary obstruction	Direct visualization, stone extraction, stenting	Gold standard for bile duct intervention

Laboratory Investigations

Test	Normal Range	Significance in Gallbladder Disease
Total Bilirubin	0.2-1.2 mg/dL	Elevated in biliary obstruction
Alkaline Phosphatase (ALP)	40-120 U/L	Elevated in biliary obstruction (early marker)
Gamma-Glutamyl Transferase (GGT)	8-61 U/L	Elevated in biliary disease, more specific than ALP
ALT/AST	7-56 U/L / 10-40 U/L	Mild elevation in biliary obstruction
Amylase/Lipase	30-110 U/L / 7-60 U/L	Elevated in gallstone pancreatitis
White Blood Cell Count	4,000-11,000/μL	Elevated in acute cholecystitis

Sonographic Criteria for Gallbladder Disease

Condition	Major Criteria	Minor Criteria
Acute Cholecystitis	Gallstones, sonographic Murphy sign, wall thickening >3mm	Pericholecystic fluid, gallbladder distension >8cm x 4cm
Chronic Cholecystitis	Gallstones, contracted gallbladder, wall thickening	Sludge, porcelain gallbladder
Gallbladder Polyps	Echogenic foci attached to wall, no acoustic shadowing	Size >10mm, solitary, sessile morphology

Gallstone Disease (Cholelithiasis)

Types of Gallstones

Type	Composition	Incidence	Risk Factors	Radiology
Cholesterol Stones	>70% cholesterol, with calcium salts, mucin	80% in Western countries	Female, forty, fertile, fat, fair (5 F’s), rapid weight loss	Radiolucent (10-20% radio-opaque)
Pigment Stones	Calcium bilirubinate, <20% cholesterol	20% in West, more common in Asia	Hemolytic anemia, cirrhosis, biliary infection, ileal disease	Radiolucent
Mixed Stones	30-70% cholesterol with calcium salts	Most common overall	Combination of cholesterol and pigment stone risk factors	Often radio-opaque

Pathogenesis of Cholesterol Stones

Mechanism	Pathophysiology	Clinical Correlation
Cholesterol Supersaturation	Excess cholesterol secretion relative to bile salts and phospholipids	Obesity, high cholesterol diet, clofibrate therapy
Nucleation Factors	Mucin, calcium salts, proteins promote crystal formation	Gallbladder hypomotility, pregnancy
Gallbladder Hypomotility	Stasis allows crystal growth and stone formation	TPN, fasting, pregnancy, diabetes, octreotide

Clinical Presentation of Gallstones

Presentation	Symptoms	Signs	Management
Asymptomatic	None (incidental finding)	None	Observation (prophylactic cholecystectomy in selected cases)
Biliary Colic	Episodic RUQ pain, postprandial, radiating to back/scapula	RUQ tenderness, no fever, normal labs	Elective cholecystectomy
Complicated Disease	Persistent pain, fever, jaundice, vomiting	Murphy’s sign, fever, jaundice, peritonism	Urgent intervention depending on complication

Natural History of Gallstones

Outcome	Annual Incidence	Cumulative Probability (20 years)
Remain Asymptomatic	70-80%	60-70%
Develop Symptoms	1-4%	20-30%
Develop Complications	0.1-0.3%	1-2%

Cholecystitis and Complications

Types of Cholecystitis

Type	Pathogenesis	Clinical Features	Management
Acute Calculous Cholecystitis	Stone impaction in cystic duct → distension, inflammation, ischemia	RUQ pain, fever, Murphy’s sign, leukocytosis	Antibiotics, cholecystectomy (early vs. delayed)
Acute Acalculous Cholecystitis	Ischemia, stasis, concentration of bile in critically ill patients	Critically ill patient, fever, RUQ pain, often subtle	Urgent cholecystectomy or percutaneous cholecystostomy
Chronic Cholecystitis	Recurrent inflammation from stones, mechanical irritation	Recurrent biliary colic, dyspepsia, fatty food intolerance	Elective cholecystectomy
Emphysematous Cholecystitis	Gas-forming organisms in gallbladder wall (clostridia, E. coli)	Severe toxicity, gas on imaging, higher perforation risk	Emergency cholecystectomy, broad-spectrum antibiotics

Complications of Acute Cholecystitis

Complication	Incidence	Clinical Features	Management
Gangrenous Cholecystitis	2-30% of acute cases	Severe pain, high fever, marked leukocytosis, sepsis	Emergency cholecystectomy
Perforation	3-10% of acute cases	Sudden pain relief then peritonitis, abscess formation	Emergency surgery, drainage, antibiotics
Empyema	5-15% of acute cases	Toxic, high fever, palpable mass, marked leukocytosis	Emergency cholecystectomy, antibiotics
Cholecysto-enteric Fistula	1-2% of chronic cases	Gallstone ileus, chronic diarrhea, pneumobilia	Fistula repair, cholecystectomy, bowel resection if obstructed
Mirizzi Syndrome	0.1-0.7% of cholecystectomies	Jaundice, stone impacted in Hartmann’s pouch compressing CHD	Difficult dissection, may require biliary reconstruction

Tokyo Guidelines for Acute Cholecystitis (2018)

Grade	Criteria	Recommended Treatment
Grade I (Mild)	No organ dysfunction, mild gallbladder inflammation	Early laparoscopic cholecystectomy (<72 hours)
Grade II (Moderate)	WBC >18,000, palpable mass, duration >72h, marked local inflammation	Early cholecystectomy or initial medical treatment then delayed surgery
Grade III (Severe)	Organ dysfunction (cardiovascular, neurological, respiratory, etc.)	Medical treatment and organ support, delayed cholecystectomy or percutaneous drainage

Gallbladder Cancer

Epidemiology and Risk Factors

Factor	Relative Risk	Mechanism
Gallstones	4-5 times	Chronic inflammation, bacterial degradation of bile salts
Porcelain Gallbladder	10-50% develop cancer	Chronic inflammation, calcification of wall
Gallbladder Polyps	Variable (size dependent)	Adenoma-carcinoma sequence, especially >1 cm
Chronic Infection	Salmonella typhi (6-8 times)	Chronic inflammation, bacterial enzymes
Anomalous Pancreaticobiliary Junction	10-20% develop cancer	Pancreatic reflux, chronic irritation

Pathological Types

Type	Frequency	Features	Prognosis
Adenocarcinoma	85-90%	Intestinal or biliary type, often scirrhous	Poor (5-year survival 5-10%)
Squamous Cell Carcinoma	2-3%	Metaplasia of epithelium, aggressive	Very poor
Adenosquamous Carcinoma	1-2%	Mixed glandular and squamous elements	Poor
Other (sarcoma, lymphoma)	Rare	Various patterns	Variable

Staging of Gallbladder Cancer (AJCC 8th Edition)

Stage	T	N	M	5-year Survival
0	Tis	N0	M0	>80%
I	T1	N0	M0	50-60%
II	T2	N0	M0	20-30%
IIIA	T3	N0	M0	10-15%
IIIB	T1-3	N1	M0	5-10%
IVA	T4	N0-1	M0	<5%
IVB	Any T	N2	M0 or M1	<2%

Treatment Approaches

Stage	Surgical Treatment	Adjuvant Therapy
T1a (incidental)	Simple cholecystectomy	None
T1b-T3	Extended cholecystectomy with liver resection (segments IVb/V) and lymphadenectomy	Chemotherapy (gemcitabine/cisplatin), consider radiotherapy
T4 or N2	Palliative procedures (biliary drainage, bypass)	Palliative chemotherapy, best supportive care

Surgical Management of Gallbladder Disease

Cholecystectomy Techniques

Procedure	Indications	Advantages	Disadvantages
Laparoscopic Cholecystectomy	Elective cases, uncomplicated acute cholecystitis	Less pain, faster recovery, better cosmesis	Learning curve, bile duct injury risk
Open Cholecystectomy	Complicated cases, conversion from laparoscopic, surgeon preference	Better visualization, tactile feedback, lower bile duct injury rate	More pain, longer recovery, larger scar
Single Incision Laparoscopic Surgery (SILS)	Selected elective cases	Better cosmesis, potentially less pain	Technically challenging, longer operating time
Robotic Cholecystectomy	Complex cases, teaching situations	3D vision, tremor filtration, ergonomic	Cost, setup time, availability

Critical View of Safety in Laparoscopic Cholecystectomy

Definition: A method to minimize bile duct injury by positive identification of structures
Three Criteria:
- Clearance of fat and fibrous tissue from hepatocystic triangle
- Separation of lower one-third of gallbladder from liver bed
- Two and only two structures entering the gallbladder (cystic duct and artery)
Importance: Reduces major bile duct injury by 50-70%

Intraoperative Cholangiography

Indication	Rationale	Findings
Routine	Anatomical mapping, detect unsuspected stones	Normal anatomy, unsuspected stones (5-10%)
Selective	Abnormal anatomy, elevated LFTs, pancreatitis, wide cystic duct	Anatomical variations, stones, injuries
Therapeutic	Stone extraction, sphincterotomy	Successful clearance or need for additional procedures

Complications of Cholecystectomy

Complication	Incidence	Risk Factors	Management
Bile Duct Injury	0.3-0.5% (laparoscopic), 0.1-0.2% (open)	Acute inflammation, anatomical variations, surgeon experience	Intraoperative repair, hepaticojejunostomy, stenting
Bile Leak	0.5-1%	Accessory ducts, cystic duct stump leak, liver bed leak	ERCP with sphincterotomy/stenting, drainage, reoperation
Bleeding	0.5-1%	Portal hypertension, inflammation, vascular anomalies	Electrocautery, clips, sutures, angiographic embolization
Retained Stones	1-2%	Multiple small stones, wide cystic duct, missed IOC	ERCP with sphincterotomy and stone extraction
Port Site Hernia	0.5-1%	Large port sites, midline placement, obesity	Hernia repair

Post-cholecystectomy Syndrome

Cause	Frequency	Symptoms	Management
Biliary Causes	10-15%	Retained stones, cystic duct stump, sphincter of Oddi dysfunction	ERCP, sphincterotomy, medical therapy
Non-biliary Causes	85-90%	GERD, IBS, pancreatitis, other gastrointestinal disorders	Appropriate medical management
Extra-intestinal Causes	Rare	Cardiac, musculoskeletal, psychological	Specific to cause

References

Love, R. J. M., & Bailey, H. (Latest Edition). A Short Practice of Surgery. London: Edward Arnold.
Chapter on Gallbladder and Biliary Tree in Love & Bailey’s textbook
Tokyo Guidelines 2018 for acute cholecystitis
Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines
American College of Surgeons Guidelines
World Society of Emergency Surgery Guidelines

Key Learning Points from Love & Bailey

“The gallbladder, though a small organ, presents significant surgical challenges. A thorough understanding of biliary anatomy, particularly the variations in cystic artery and duct anatomy, is essential for safe cholecystectomy. The critical view of safety remains the cornerstone of preventing bile duct injuries.”
- Love & Bailey, A Short Practice of Surgery

Important Clinical Pearls

Always obtain a preoperative ultrasound for suspected gallbladder disease
Consider MRCP if complicated anatomy or suspected common bile duct stones
Follow Tokyo Guidelines for management of acute cholecystitis
Always achieve critical view of safety during cholecystectomy
Have a low threshold for conversion to open procedure in difficult cases
Consider gallbladder cancer in porcelain gallbladder or large polyps (>1 cm)
Multidisciplinary approach is essential for gallbladder cancer management

This educational blog is based on the surgical textbook “A Short Practice of Surgery” by Love and Bailey.

For medical professionals and students only. Always consult current guidelines and local protocols.