Cystic duct

Bile is secreted by the liver, stored in the gallbladder, and used in the small intestine. It is transported toward the small intestine by the hepatic duct (from the liver) and the cystic duct (from the gallbladder), which join to form the common bile duct. Pancreatic juice is transported toward the small intestine by the pancreatic duct. The common bile duct and the pancreatic duct join to form the hepatopancreatic ampulla, which empties into the duodenum. The entrance to the duodenum is surrounded by the Sphincter of Oddi. This sphincter is closed between meals in order to prevent bile and pancreatic juice from entering the small intestine it relaxes in response to the intestinal hormone cholecystokinin, thus allowing biliary and pancreatic secretions to flow into the duodenum. 

In an earlier study 5 it was found that in 33 per cent of the cases the pancreatic and bile ducts have separate openings. This and other similar variations probably occur in different percentages among populations with different racial origins. Some evidence on this point has been found in connection with the variations in the junctions of the hepatic and cystic ducts. 

N1 Metastasis in the cystic ducts, pericholedochal lymph nodes,... 

Regional node(s) cannot be assessed No regional lymph node metastasis Metastasis in the cystic ducts, pericholedochal lymph nodes, and/or hilar lymph nodes (i.e., in the hepatoduodenal ligament) Metastasis in the peripancreatic (head only), periduodenal, periportal, celiac, superior mesenteric, and/or posterior pancreaticoduodenal lymph nodes... 

Gallbladder (cholecyst vesica bUiaris vesica fellea). The pear-shaped reservoir for the bile in the post inferior surface of he liver, between the right and quadrate lobe the cystic duct projects to join the common bile duct. 

Outside the liver the common hepatic duct is joined by the cystic duct of the gallbladder and becomes the common bile duct (CBD). The extrahepatic and intrahepatic ducts are supplied with blood by a fine network of tiny arterial branches that originate from the hepatic and gastroduodenal arteries. As it has no other blood supply, the biliary tree is particularly susceptible to ischaemic injury, such as hepatic artery thrombosis or injury to the biliary plexus during laparoscopic surgery. This can result in extrahepatic and complex hilar and perihilar ischaemic strictures of the biliary tree. 

If the c is absorbed by the liver but not secreted into the bile ducts, there is probably a complete obstruction of the ducts exiting the liver. When the c fails to appear in the gallbladder but is detected in the intestine, there is probably an obstruction of the cystic duct leading to and from the gallbladder. Finally, if the c appears outside the liver, bile ducts, gallbladder or intestine, there is probably a bile leak from the bile ducts or gallbladder. 

Extrahepatic obstructive jaundice is caused by stenos-ing processes. The region of Vater s papilla is particularly affected, for example by inflammations, stones, duodenal diverticula, carcinoma, parasites, cicatricial stenosis or adenomatosis. In this respect, special mention should also be made of carcinoma, cicatricial strictures and gallstones (s. figs. 8.14, 8.15 32.1, 32.15), compression of the common bile duct due to a cystic duct stone (= Mirizzi syndrome), haemobilia, and various parasites - such as Ascaris lumbricoides (s. fig. 25.8 ). All of these disorders can be found in the area of the extrahepatic bile ducts. (9, t9)... 

Intrahepatic localizations must be distinguished from extrahepatic CCC. They are subdivided into three areas of the large bile duct (1.) the upper third from the hver hilum to the opening of the cystic duct (frequency about 49%) (2.) the medial third of the common bile duct (frequency about 25%) (i.) the lower third reaching to the opening into the duodenum (frequency about 19%). Diffuse involvement of the whole extrahepatic area was found in 7% of cases. Tumours situated in the upper third are designated proximal, central or hilar CCC and are also known as Klatskin tumours. (204) Distal localizations of the extrahepatic CCC must be clearly differentiated from carcinomas of Vater s ampulla and of the pancreas head. 

Contraindications The following contraindications should be observed acute cholecystitis, acute cholangitis, obstruction of the cystic duct and common bile duct as well as frequent biliary colic. 

The primsu7 clinical indication for this study is posacute cholecystitis. In acute cholecystitis, there is obstrux of the cystic duct leading to the gallbladder. The galIblaU i is not visualized becau.se the radiotracer cannot cnlu < Some other clinical conditions that can be diagnosed byh... 

Protopine (0.5 - 5.0 mcg/ml) exhibited smooth muscle relaxant activity on the isolated ileum of guinea pig, rabbit, and albino rat, and a marked relaxation of the intestine in situ (5 mg/kg, i.v.) of the anesthetized dog. It addition, the alkaloid demonstrated hydrocholeretic activity at the same dose in the anesthetized dog (with cystic duct ligated and common bile duct cannulated). Protopine (2000 pg/ml) also exhibited prominent antifungal activity as assessed against the spore germination of a number of plant pathogenic fungi [338]. 

Hydrops of the gallbladder (mucocele) chronic obstruction of the cystic duct leads to the resorption of the normal gallbladder contents and... 

The patient should not eat 2-6 h prior to the hepatohihary scintigraphy, because hepa-tocyte clearance of the radiotracer and parenchymal transit time is affected hy the ingestion of food. The gallbladder cannot be visualized in 65% of cases within the first 60 min of injection of the " Tc-lDA complex, even if the cystic duct is patent (Fink-Bennett 1995). Gallbladder contractility can be provoked with a fatty meal or intravenous cholecystokinin. 

On US the liver will usually have a normal echo signal. However, in severe cases, the hepatocytes will swell and fatty infiltration will occur, and this may appear as a hyperechoic liver with increased echoes in the portal vein radicles. The gallbladder wall may be thickened and an increase in the size of the lymph nodes around the portal vein and around the cystic duct may be visualized. 

Within a week of dietary treatment, Harman et al. (113) have observed the formation of apical cellular vesicles in the gallbladder mucosa, PAS-staining material on the surface of the mucosa and in the crypts, and the occurrence of 1-2 mm surface gel particles staining intensely with PAS, mucicarmine, and alcian blue (see also references 5 and 8). Bile hexosamine levels were also increased (169 40 jug % versus U3 22 jug %). These findings suggest that increased mucin formation and excretion are early results of the lithogenic diet. A similar conclusion has been from studies on mucin secretion in dihydrocholesterol-induced cholelithiasis in rabbits (114-116) (see Section IVB). It is not known whether this increased mucin secretion is common to all forms of cholelithiasis, what the mechanism is, or whether it is the same in both of these experimental models. In rabbits, it apparently depends on a factor excreted in bile, since it can be prevented by cystic duct ligation (116), but the factor or factors responsible have not been identified. 

Phemister et al. (124) produced calcium carbonate stones in dogs and rabbits following cystic duct ligation. Chemical analyses showed the stones to contain calcium carbonate, 70.7% calcium phosphate, 1.8% and organic matter, 17.5%. They observed that the concentration of calcium and carbonate ions in the supernatant fluid exceeded the solubility product tenfold. 

Fig. 2.11a,b. Oblique coronal MRCP MIP projection (a) and volume rendering view (b) based on a 3D turbo spin echo sequence, which was acquired with respiratory triggering to minimize respiratory-related motion artifacts. Note the superiority of the volume rendering view in revealing a low insertion point of the cystic duct (arrow)... 

Fig. 22.1a,b. Aberrant bile duct. Both coronal oblique MIP 3D heavily T2-weighted (a) andmangafodipir-trisodium-enhanced Tl-weighted (b) MR cholangiograms show the aberrant drainage of the right posterior duct into the common hepatic duct in this patient with a history of recurrent choledocholithiasis after cholecystectomy, a residual cystic duct is also appreciable... 

Navigation sequences can be simulated through the common bile duct (CBD), hepatic duct (HD), left (LHD) and right (RHD) hepatic ducts and intrahe-patic branches, pancreatic duct (PD), cystic duct (CD) and gallbladder. All these anatomical details appear as tubular structures, with a smooth internal surface. 

The gallbladder is a pear-shaped organ in the lower right portion of the liver. The base of the organ, the fundus, is covered with peritoneum and emerges below the lower border of the liver in direct contact with the abdominal wall. The body narrows into an undulated stalk forming the cystic duct, which joins the hepatic duct. 

Cholecystokinin relaxes the sphincter of Oddi and contracts the gallbladder, and as a result bile is secreted in the intestine. When the sphincter closes again, the bile flows into the duct and refluxes into the cystic duct and the gallbladder. The pressure of bile in the gallbladder is usually the same as or slightly lower than that in the duct because the gallbladder simultaneously relaxes and withdraws water from the bile as it is contained in the reservoir. 

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