Gallbladder and ducts anatomy. The structure of the gallbladder and biliary tract

The right and left hepatic ducts emerge from the liver, merging at the hilum into the common hepatic duct. As a result of its fusion with the cystic duct, the common bile duct is formed.

The common bile duct passes between the layers of the lesser omentum anterior to the portal vein and to the right of the hepatic artery. Located posterior to the first section of the duodenum in a groove on the posterior surface of the head of the pancreas, it enters the second section of the duodenum. The duct crosses the posteromedial wall of the intestine obliquely and usually joins the main pancreatic duct to form the hepatopancreatic ampulla (ampulla of Vater). The ampoule forms a protrusion of the mucous membrane directed into the intestinal lumen - the major duodenal papilla (papilla of Vater). In approximately 12-15% of those examined, the common bile duct and the pancreatic duct open into the lumen of the duodenum separately.

The dimensions of the common bile duct, when determined by different methods, are not the same. The diameter of the duct measured during operations ranges from 0.5 to 1.5 cm. With endoscopic cholangiography, the diameter of the duct is usually less than 11 mm, and a diameter of more than 18 mm is considered pathological. With ultrasound examination (ultrasound), it is normally even smaller and amounts to 2-7 mm; with a larger diameter, the common bile duct is considered dilated.

The part of the common bile duct passing in the wall of the duodenum is surrounded by a shaft of longitudinal and circular muscle fibers, which is called the sphincter of Oddi.

The gallbladder is a pear-shaped sac 9 cm long, capable of holding about 50 ml of fluid. It is always located above the transverse colon, adjacent to the duodenal bulb, projected onto the shadow of the right kidney, but located significantly in front of it.

Any decrease in the concentration function of the gallbladder is accompanied by a decrease in its elasticity. Its widest section is the bottom, which is located in front; it is this that can be palpated when examining the abdomen. The body of the gallbladder passes into a narrow neck, which continues into the cystic duct. The spiral folds of the mucous membrane of the cystic duct and the neck of the gallbladder are called the valve of Heister. The saccular expansion of the neck of the gallbladder, in which gallstones often form, is called Hartmann's pouch.

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, called Luschka's crypts. The mucous membrane does not have a submucosal layer or its own muscle fibers.

Rokitansky-Aschoff sinuses are branched invaginations of the mucous membrane that penetrate the entire thickness of the muscular layer of the gallbladder. They play an important role in the development of acute cholecystitis and gangrene of the bladder wall.

Blood supply. The gallbladder is supplied with blood from the cystic artery. This is a large, tortuous branch of the hepatic artery, which can have a different anatomical location. Smaller blood vessels enter from the liver through the fossa of the gallbladder. Blood from the gallbladder flows through the cystic vein into the portal vein system.

The blood supply to the supraduodenal part of the bile duct is carried out mainly by the two accompanying arteries. The blood in them comes from the gastroduodenal (bottom) and right hepatic (top) arteries, although their connection with other arteries is possible. Strictures of the bile ducts after vascular damage can be explained by the peculiarities of the blood supply to the bile ducts.

Lymphatic system. There are numerous lymphatic vessels in the mucous membrane of the gallbladder and under the peritoneum. They pass through the node at the neck of the gallbladder to the nodes located along the common bile duct, where they connect with the lymphatic vessels that drain lymph from the head of the pancreas.

Innervation. The gallbladder and bile ducts are richly innervated by parasympathetic and sympathetic fibers.

Development of the liver and bile ducts

The liver is formed in the form of a hollow protrusion of the endoderm of the anterior (duodenal) intestine in the 3rd week of intrauterine development. The protrusion is divided into two parts - hepatic and biliary. The hepatic part consists of bipotent progenitor cells, which then differentiate into hepatocytes and ductal cells, forming the early primitive bile ducts - the ductal plates. As cells differentiate, the type of cytokeratin changes. When the c-jun gene, which is part of the API gene activation complex, was experimentally deleted, liver development stopped. Normally, fast-growing cells of the hepatic part of the protrusion of the endoderm perforate the adjacent mesodermal tissue (transverse septum) and meet with capillary plexuses growing in its direction, emanating from the vitelline and umbilical veins. From these plexuses, sinusoids are subsequently formed. The biliary part of the endoderm protrusion, connecting with the proliferating cells of the hepatic part and with the foregut, forms the gallbladder and extrahepatic bile ducts. Bile begins to be released around the 12th week. From the mesodermal transverse septum, hematopoietic cells, Kupffer cells and connective tissue cells are formed. In the fetus, the liver performs mainly the function of hematopoiesis, which fades in the last 2 months of intrauterine life, and by the time of birth only a small number of hematopoietic cells remain in the liver.

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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:

Serous outer layer.
Epithelial layer.
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:

Cystic duct connecting the liver with the bladder.
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 bile movement 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:

Collection of bile, which is produced by the liver.
Thickening and storage of secretions.
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.

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

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.
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.
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.
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.
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:

Complete absence of the organ and extrahepatic bile ducts.
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.
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

Anatomy

What is the danger of blocked ducts?

Diagnosis of diseases

Features of treatment

Therapeutic diet

ethnoscience

Dear readers, the bile ducts (bile tract) perform one important function - they conduct bile to the intestines, which plays a key role in digestion. If for some reason it periodically does not reach the duodenum, there is a direct threat to the pancreas. After all, bile in our body eliminates the properties of pepsin that are dangerous for this organ. It also emulsifies fats. Cholesterol and bilirubin are excreted through bile because they cannot be fully filtered by the kidneys.

If the gallbladder ducts are blocked, the entire digestive tract suffers. Acute blockage causes colic, which can result in peritonitis and urgent surgery; partial obstruction impairs the functionality of the liver, pancreas and other important organs.

Let's talk about what is special about the bile ducts of the liver and gallbladder, why they begin to conduct bile poorly and what needs to be done to avoid the adverse consequences of such blockage.

The anatomy of the bile ducts is quite complex. But it is important to understand it in order to understand how the biliary tract functions. Bile ducts are intrahepatic and extrahepatic. On the inside, they have several epithelial layers, the glands of which secrete mucus. The bile duct has a biliary microbiota - a separate layer that forms a community of microbes that prevent the spread of infection in the organs of the biliary system.

The intrahepatic bile ducts have a tree-like structure. The capillaries pass into the segmental bile ducts, which, in turn, flow into the lobar ducts, which form the common hepatic duct outside the liver. It enters the cystic duct, which drains bile from the gallbladder and forms the common bile duct (choledochus).

Before entering the duodenum, the common bile duct passes into the pancreatic excretory duct, where they unite into the hepatopancreatic ampulla, which is separated from the duodenum by the sphincter of Oddi.

Diseases that cause obstruction of the bile ducts

Diseases of the liver and gallbladder in one way or another affect the condition of the entire biliary system and cause blockage of the bile ducts or their pathological expansion as a result of a chronic inflammatory process and stagnation of bile. Obstruction is provoked by diseases such as cholelithiasis, cholecystitis, kinks in the gallbladder, the presence of structures and scars. In this condition, the patient needs urgent medical attention.

Blockage of the bile ducts is caused by the following diseases:

bile duct cysts;
cholangitis, cholecystitis;
benign and malignant tumors of the pancreas and organs of the hepatobiliary system;
scars and strictures of the ducts;
cholelithiasis;
pancreatitis;
hepatitis and cirrhosis of the liver;
helminthic infestations;
enlarged lymph nodes of the hepatic hilum;
surgical interventions on the biliary tract.

Most diseases of the biliary system cause chronic inflammation of the biliary tract. It leads to thickening of the mucosal walls and narrowing of the lumen of the ductal system. If, against the background of such changes, a stone enters the gallbladder duct, the stone partially or completely blocks the lumen.

Bile stagnates in the bile ducts, causing them to expand and aggravating the symptoms of the inflammatory process. This can lead to empyema or hydrocele of the gallbladder. For a long time, a person tolerates minor symptoms of blockage, but eventually irreversible changes in the bile duct mucosa will begin to occur.

Why is it dangerous?

If the bile ducts are clogged, you need to contact a specialist as soon as possible. Otherwise, there will be an almost complete loss of the liver from participating in detoxification and digestive processes. If the patency of the extrahepatic or intrahepatic bile ducts is not restored in time, liver failure may occur, which is accompanied by damage to the central nervous system, intoxication and turns into a severe coma.

Blockage of the bile ducts can occur immediately after an attack of biliary colic https://site/zhelchnaya-kolika against the background of movement of stones. Sometimes obstruction occurs without any preliminary symptoms. The chronic inflammatory process, which inevitably occurs with dyskinesia of the bile ducts, cholelithiasis, cholecystitis, leads to pathological changes in the structure and functionality of the entire biliary system.

In this case, the bile ducts are dilated and may contain small stones. Bile stops flowing into the duodenum at the right time and in the required volume.

Emulsification of fats slows down, metabolism is disrupted, the enzymatic activity of the pancreas decreases, food begins to rot and ferment. Stagnation of bile in the intrahepatic ducts causes the death of hepatocytes - liver cells. Bile acids and direct active bilirubin begin to enter the bloodstream, which provokes damage to internal organs. The absorption of fat-soluble vitamins against the background of insufficient flow of bile into the intestines worsens, and this leads to hypovitaminosis and dysfunction of the blood coagulation system.

If a large stone gets stuck in the bile duct, it immediately closes its lumen. Acute symptoms occur that signal the severe consequences of biliary obstruction.

How does blocked duct manifest itself?

Many of you probably think that if the bile ducts are clogged, the symptoms will immediately be so acute that you will not be able to tolerate them. In fact, the clinical manifestations of blockage may increase gradually. Many of us have experienced discomfort in the area of the right hypochondrium, which sometimes even lasts for several days. But we do not rush to specialists with these symptoms. And such aching pain may indicate that the bile ducts are inflamed or even clogged with stones.

As ductal patency worsens, additional symptoms appear:

acute girdling pain in the right hypochondrium and abdomen;
yellowing of the skin, the appearance of obstructive jaundice;
discoloration of feces due to a lack of bile acids in the intestines;
itching of the skin;
darkening of urine due to active excretion of direct bilirubin through the kidney filter;
severe physical weakness, increased fatigue.

Pay attention to symptoms of obstruction of the bile ducts and diseases of the biliary system. If you undergo diagnostics at the initial stage and change your diet, you can avoid dangerous complications and maintain the functionality of the liver and pancreas.

Diseases of the biliary system are treated by gastroenterologists or hepatologists. You should contact these specialists if you have complaints of pain in the right hypochondrium and other characteristic symptoms. The main method for diagnosing diseases of the bile ducts is ultrasound. It is recommended to look at the pancreas, liver, gall bladder and ducts.

If a specialist detects strictures, tumors, dilatation of the common bile duct and ductal system, the following studies will be additionally prescribed:

MRI of the bile ducts and the entire biliary system;
biopsy of suspicious areas and tumors;
feces for coprogram (low bile acid content is detected);
blood biochemistry (increased direct bilirubin, alkaline phosphatase, lipase, amylase and transaminases).

Blood and urine tests are prescribed in any case. In addition to the characteristic changes in the biochemical study, when the ducts are obstructed, the prothrombin time is prolonged, leukocytosis with a shift to the left is observed, and the number of platelets and red blood cells decreases.

Features of treatment

Treatment tactics for bile duct pathologies depend on concomitant diseases and the degree of blockage of the lumen of the duct system. In the acute period, antibiotics are prescribed and detoxification is carried out. In this condition, serious surgical interventions are contraindicated. Experts try to limit themselves to minimally invasive treatment methods.

These include the following:

choledocholithotomy - an operation for partial excision of the common bile duct in order to free it from stones;
stenting of the bile ducts (installation of a metal stent that restores duct patency);
drainage of the bile ducts by installing a catheter into the bile ducts under endoscopic control.

After restoration of patency of the ductal system, specialists can plan more serious surgical interventions. Sometimes blockage is caused by benign and malignant neoplasms, which have to be removed, often together with the gallbladder (with calculous cholecystitis).

Total resection is performed using microsurgical instruments under endoscopic control. Doctors remove the gallbladder through small punctures, so the operation is not accompanied by heavy blood loss and a long rehabilitation period.

During cholecystectomy, the surgeon must assess the patency of the ductal system. If stones or strictures remain in the bile ducts after the bladder is removed, severe pain and emergencies may occur in the postoperative period.

Removing a bladder clogged with stones in a certain way saves other organs from destruction. And ducts too.

You should not refuse surgery if it is necessary and threatens the entire biliary system. The entire digestive tract and immune system suffer from stagnation of bile, inflammation, and the proliferation of infectious pathogens.

Often, against the background of ductal diseases, a person begins to lose weight sharply and feel unwell. He is forced to limit his activity and give up his favorite job, because constant pain attacks and health problems do not allow him to live a full life. And the operation in this case prevents the dangerous consequences of chronic inflammation and bile stagnation, including malignant tumors.

Therapeutic diet

For any diseases of the bile ducts, diet No. 5 is prescribed. This involves eliminating fatty, fried foods, alcohol, carbonated drinks, and dishes that cause gas formation. The main goal of such nutrition is to reduce the increased load on the biliary system and prevent the sharp flow of bile.

In the absence of severe pain, you can eat as usual, but only if you have not abused prohibited foods before. Try to completely avoid trans fats, fried foods, spicy foods, smoked foods, and processed foods. But at the same time, nutrition should be complete and varied. It is important to eat often, but in small portions.

ethnoscience

It is necessary to resort to treatment with folk remedies when the bile ducts are clogged with extreme caution. Many herbal recipes have a strong choleretic effect. By using such methods, you risk your own health. Since it is impossible to clean the bile ducts with herbal mixtures without the risk of developing colic, you should not experiment with herbs at home.

First, make sure there are no large stones that could cause blockage of the duct system. If you use choleretic herbs, give preference to those that have a mild effect: chamomile, rose hips, flax seeds, immortelle. Please consult your doctor first and perform an ultrasound. You should not joke with choleretic compounds if there is a high risk of blockage of the bile ducts.

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This video describes a method of gentle cleansing of the gallbladder and ducts that can be used at home.

Chapter 1. Anatomy and physiology

The liver tissue consists of many lobules, separated from each other by layers of connective tissue, in which bile ducts, branches of the portal vein, hepatic artery and nerves intertwining the lobules with a dense mesh pass. Hepatocytes in the lobules are located so that one pole of them faces the blood vessels, and the other faces the bile canaliculi,

Secreted bile is secreted from hepatocytes into bile canaliculi - gaps with a diameter of 1-2 microns between adjacent hepatocytes. Along the canaliculi, bile moves in the direction from the centrolobular cells to the interlobular portal triads and enters the bile ducts. The latter, merging, form larger ducts, and these, in turn, bile ducts, lined with sinusoidal epithelial cells (A. L. Tones et al., 1980).

Intrahepatic bile ducts run parallel to the branches of the portal vein and hepatic artery. Connecting with each other, they form larger intrahepatic ducts and ultimately form extraorgan hepatic ducts for the right and left lobes of the liver.

In the right lobe, for the outflow of bile from the anterior and posterior segments, there are 2 main ducts - anterior and posterior, which are formed from the fusion of the ducts of the upper and lower zones - subsegments. The anterior and posterior ducts are directed to the gates of the liver, with the posterior duct located slightly higher and longer. Merging, they form the right hepatic duct. In 28% of cases, fusion does not occur, and the inferior segmental duct is considered to be a right accessory hepatic duct. However, this is incorrect, since bile flows through it from a certain area of the liver.

In the bed of the gallbladder you can often find a thin duct that drains bile from the V segment of the right lobe and has a direct connection with the right hepatic duct; Damage to it should be avoided during cholecystectomy. A direct connection between this duct and the gallbladder has not been established.

From the left lobe of the liver, as well as from the right, the outflow of bile is carried out through 2 segmental ducts - lateral and medial.

The lateral segmental duct drains bile from the left anatomical lobe and is formed by the fusion of the ducts of the upper and lower zones. The fusion site is located along the line of the left sagittal groove (50% of cases) or slightly to the right of it (42% of cases) -K. Schwartz (1964).

The medial duct is formed from several (usually 2) ducts of the upper and lower zones and joins the lateral one at the porta hepatis, forming the left hepatic duct.

In the caudate lobe, the ducts are divided into 2 systems. From the right section, bile flows into the right hepatic duct, from the left - into the left. Intrahepatic communication between the left and right hepatic ducts in the region of the caudate lobe has not been established.

Hepatic ducts. Typically, the fusion of the left and right ducts occurs outside the liver parenchyma, 0.75-1.5 cm from its surface (95% of cases) and much less often (5% of cases) - in the hepatic parenchyma (I. M. Talman, 1965). The left hepatic duct is narrower and longer than the right one, and is always located outside the parenchyma in front above the left portal vein. Its length ranges from 2 to 5 cm, diameter - from 2 to 5 mm. More often it is located in the transverse groove posterior to the posterior edge of the quadrate lobe. At the posterior corner of the quadrate lobe there is a dangerous place where the anterior surface of the left hepatic duct is crossed by the branches of the hepatic artery going to the IV segment (A. N. Maksimenkov, 1972). The left hepatic duct receives bile from segments I, II, III and IV of the liver. It should be noted that the bile ducts of the first segment in some cases can flow into both the left and right hepatic ducts, although significant anastomoses between both ducts were not detected even at the height of biliary hypertension with obstructive jaundice (A. I. Krakovsky, 1966).

The right hepatic duct, located at the portal of the liver, is often enveloped in its parenchyma. Its length is less than the left one (0.4-1 cm), and its diameter is slightly larger. The right hepatic duct is most often located behind and above the right portal vein. It is usually located above the hepatic artery, and sometimes below it. Essential for surgery of the biliary tract is the fact that at the level of the neck of the gallbladder at a distance of 1-2 cm posterior to it or the initial part of the cystic duct, the right hepatic duct passes very superficially in the liver parenchyma (A. I. Krakovsky, 1966), which can easily be damaged during cholecystectomy or when suturing the gallbladder bed.

The study of the intrahepatic architectonics of the bile ducts and the projection of these ducts onto the surface of the liver (A. F. Khanzhinov, 1958; G. E. Ostroverkhoe et al., 1966; A. I. Krakovsky, 1966) served as the basis for the creation of accurate visualization schemes for the most accessible intrahepatic ducts and biliodigestive anastomoses.

The wall of the intrahepatic bile ducts consists of loose fibrous connective tissue, internally covered with single-layer cuboidal epithelium.

The common hepatic duct originates from the confluence (fork) of the lobar hepatic ducts at the porta hepatis and ends at the confluence with the cystic duct. Depending on the location of the confluence of the latter, the length of the common hepatic duct ranges from 1 to 10 cm (usually 3-7 cm), and the diameter ranges from 0.3 to 0.7 cm. The common hepatic duct is formed at the porta hepatis, being, as it were, a continuation of the left hepatic duct, and is located in front of the bifurcation of the portal vein. Most often it is formed as a result of the fusion of 2 hepatic ducts - right and left (67% of cases, according to G. A. Mikhailov, 1976) and less often 3, 4, 5 ducts. This branching of the common hepatic duct is of particular interest when performing interventions on the bifurcation of the ducts at the porta hepatis.

The common hepatic duct is located at the right edge of the hepatoduodenal ligament, in front of the right edge of the portal vein. In the event that the fusion of the hepatic ducts occurs at the edge of the duodenum, both ducts run parallel, and the cystic duct can flow into one of them at different levels.

Common bile duct. The common bile duct runs from the junction of the cystic duct to the duodenum. Its length varies depending on the level of confluence of the cystic duct (on average - 5-8 cm). The diameter of the duct is 5-9 mm. Before entering the pancreatic tissue, the common bile duct expands slightly, then gradually narrows as it passes through the pancreatic tissue, especially at the point of entry into the duodenum. Under pathological conditions, the common bile duct can expand to 2-3 cm or more.

The common bile duct is usually divided into 4 parts: 1) supraduodenal—from the point of confluence of the cystic duct to the upper edge of the duodenum (0.3-3.2 cm); 2) retroduodenal (about 1.8 cm). It is located behind the upper horizontal part of the duodenum before the duct enters the pancreas. To the left of the common bile duct is the portal vein, below it is the inferior vena cava, separated by a thin layer of connective tissue; 3) pancreatic (about 3 cm). Located between the head of the pancreas and the duodenum. More often (in 90% of cases), the common bile duct passes through the pancreas, and sometimes it is located on its dorsal surface. The common bile duct, passing through the pancreas, has the shape of a groove

and is not completely surrounded by the parenchyma of the gland (I.M. Talmai, 1963). Hess (1961), on the contrary, notes that in 90% of people this part of the common bile duct is located within the pancreatic parenchyma; 4) intramural. The introduction of the common bile duct into the duodenum occurs along the left medial edge of its vertical section at the border with the posterior wall 8-14 cm from the pylorus when measured along the intestine (M. D. Anikhanova, 1960; I. M. Talman, 1963; A. N. Maksimenko, 1972; A. I. Edemsky, 1987), that is, in the middle part of the vertical section. In some cases, the confluence may be located 2 cm from the pylorus or even in the stomach, as well as in the area of the duodenal-small intestinal flexure. According to Baynes (1960), who studied 210 preparations, the place of confluence of the common bile duct into the duodenum was in the upper horizontal part in 8 patients, in the upper half of the vertical part - in 34, in the lower half of the vertical part - in 112, at the transition to the lower horizontal part - 36, in the lower horizontal part - in 6, to the left of the midline near the duodenal-small intestinal flexure - in 4 patients. All this, of course, must be kept in mind when performing surgical interventions on the major duodenal papilla and the distal part of the common bile duct.

The higher the confluence of the common bile duct, the straighter the angle of perforation of the intestinal wall and the greater the predisposition to duodenal-papillary reflux.

The intramural part of the common bile duct has a length of 10-15 mm. It obliquely pierces the wall of the duodenum, forming the major duodenal papilla on the mucous membrane side.

The wall of the common hepatic and common bile ducts consists of a plate of connective tissue rich in elastic fibers. The latter are located in two layers - along the long axis of the duct and circularly covering it. Smooth muscle cells are located among the fibers, but there is no continuous layer of muscle. Only in certain areas (at the junction of the cystic duct into the gallbladder, at the confluence of the common bile duct and the pancreatic duct, and also at their entry into the duodenum) clusters of smooth muscle cells form sphincters.

The inner surface of the ducts is lined with single-layer high prismatic epithelium, which in some places forms crypts. The mucous membrane also contains goblet cells.

Major duodenal papilla. At the point where the intestinal wall passes, the common bile duct narrows somewhat and then expands in the submucosal layer, forming an ampullary extension 9 mm long, and sometimes 5.5 mm long. The ampoule ends in the intestinal lumen with a papilla the size of a millet grain. The papilla is located on a longitudinal fold formed by the mucous membrane itself. In the major papilla of the duodenum there is a muscular apparatus consisting of circular and longitudinal fibers - the sphincter of the hepatic-pancreatic ampulla. Longitudinal fibers are divided into ascending and descending, with the ascending fibers being a continuation of the muscle fibers of the duodenum, and the descending fibers running along the duodenal side of the common bile duct and ending at the same level as the circular fibers.

The results of a study of the anatomical and histological characteristics of the major duodenal papilla in children conducted by A. I. Edemsky (1987) showed that in the first years of life its submucosal and intramuscular sections are poorly developed. Studying the topography of the confluence of the bile and pancreatic ducts, the author found that in children they always merge, resulting in the formation of a common channel 2-3.5 mm long. The presence of a common channel from the moment of birth promotes the mixing of bile and pancreatic juice, which ensures normal digestion. The mucous membrane of the common canal is represented by many high triangular folds, which are the prototype of valves that fill the lumen of the canal and their ends are directed towards the mouth, which in itself prevents the occurrence of reflux. Studying the function of the sphincter of the major papilla of the duodenum using retrograde cine or telecholangiopancreatograms, M. D. Semin (1977) established that the own sphincter of the distal common bile duct (sphincter of the hepatic-pancreatic ampulla) has 3 more internal sphincters, the work of which is closely is associated both with the release of bile into the duodenum and with the prevention of duodenobiliary reflux. As studies conducted in our clinic have shown, at rest these three sphincters are not differentiated and are tightly closed; radiographs show a blunt or cone-shaped break in the contrast agent in the common bile duct at a distance of slightly more than 1 cm from the wall of the duodenum (this is the length of the sphincter zones ). Differentiation of sphincter zones begins during the passage of bile or in a state of atony.

We found ampulla-shaped extensions, like the true ampulla of the major duodenal papilla at the confluence of the bile duct and the pancreatic duct, in only 15 of 1387 retrograde endoscopic pancreatocholangiograms. Most often, both ducts, when connecting, form a common channel of uniform width, and ampullary expansion is a consequence of pathological conditions (cicatricial stenosis of the orifice of the papilla, strangulated or fixed stone in the papilla).

The common canal in the sphincter zone, which opens at the top of the major papilla of the duodenum with a hole with a diameter of about 3 mm, in its direction is like a continuation of the main pancreatic duct, and the common bile duct in most cases flows into it at an acute angle. This explains the easier catheterization of the pancreatic duct when performing retrograde pancreatic cholangiography and the danger of damage to the latter during surgery, when the ampulla of the duodenal papilla is slightly expressed.

The proper sphincter of the main pancreatic duct is less pronounced and does not have complex differentiation (M. D. Semin, 1977). It is significantly shorter than the sphincter zone of the terminal part of the common bile duct.

The excretory duct of the pancreas, perforating the wall of the duodenum, merges with the terminal section of the common bile duct at different levels and at different angles. All options for connecting the common bile duct with the excretory duct of the pancreas are usually divided into 3 groups.

1. The common bile duct connects with the pancreatic duct to the apex of the major duodenal papilla. In this case, both ducts flow into the ampulla, or the ampulla forms the common bile duct, and the pancreatic duct flows into it (86%).

2. There is no connection of the ducts, but they flow into the ampulla through a common opening (6%).

Both ducts flow independently and even at a distance of 1-2 cm from each other (8%).

Schumacher (1928) proposed his own scheme for variations in the connection of the common bile duct with the excretory duct of the pancreas (Fig. 38).

Due to frequent interventions on the major duodenal papilla, this scheme has a certain practical interest. The total length of the major duodenal papilla in adults is (17.2±1.5) mm (A.I. Edemsky, 1987). The blood supply to the major duodenal papilla occurs through small branches of the gastroduodenal, pancreaticoduodenal and superior mesenteric arteries.

The gallbladder is located in the right longitudinal groove of the lower surface of the liver, in the groove of the gallbladder; 2/3 of this thin-walled organ is covered by peritoneum, and 1/3 is adjacent to the liver.

And the wall of the gallbladder is divided into the following layers: serous, subserous, fibromuscular and mucous membrane. The pear-shaped gallbladder has 3 sections: the bottom, the body and the neck. Usually there is a bend at the junction of the gallbladder body and the neck. Here, near the neck, the wall of the gallbladder forms 1, less often - 2 pockets, which are often the location of stones and blockage of the cystic duct. Due to the activity of muscle fibers located on the neck and cystic duct, due to the bend between them, there is a pressure difference in the gallbladder and bile ducts.

There are also various deviations in the topographic-anatomical position of the gallbladder. There is a double, or accessory, gallbladder; mobile gallbladder; gallbladder dystopia; intrahepatic location of the gallbladder; absence of gallbladder.

The cystic duct is a tube, slightly narrowed in the anteroposterior direction, 3 to 10 mm long, originating from the surface of the neck of the gallbladder, facing the hilum of the liver. Here the cystic duct, bending, goes to the gate of the liver, and then at an angle goes down to the hepatic duct and flows into it. The lumen of the proximal segment of the cystic duct resembles an irregularly shaped corkscrew due to the spiral structure of its mucous membrane. Both in the place of confluence, and in shape, length and location, there are quite a few different variants of the cystic duct, which are described in detail in the chapter devoted to the surgical treatment of congenital malformations of the gallbladder and bile ducts.

The blood supply to the gallbladder is carried out mainly through the cystic artery, which most often arises from the right branch of the proper hepatic artery (64-91% of cases). The cystic artery can also arise from the superior mesenteric, proper hepatic, left and common hepatic, gastroduodenal, and gastroepiploic arteries. Sometimes it is a steam room (Fig. 39).

The vessel runs along the left surface of the gallbladder from the neck to the bottom. At the neck it gives off an anterior branch, which also goes to the bottom of the gallbladder. The length of the cystic artery trunk is 1-2 cm.

The cystic artery does not always follow its usual path. In 4-9% of cases it is located below and behind the cystic duct. Of particular danger are those options when the hepatic artery, located along the cystic duct, can be mistaken for the cystic artery and crossed during cholecystectomy. If a vessel with a diameter of 3 mm or more is detected near the cystic duct, Moosman (1975) recommends ligating it after isolation from the surrounding tissues only at the very wall of the gallbladder.

The physiology of the biliary tract has not yet been sufficiently studied, however, it has been established that the flow of bile secreted by hepatocytes from the liver is regulated by nerve endings located in the walls of the extrahepatic bile ducts.

The main function of the extrahepatic biliary tract, including the gallbladder, is the accumulation of bile and its periodic excretion into the duodenum at the moment necessary for a complete act of digestion. In the absence of a gallbladder, this role is taken over by the common bile duct, which dilates up to 1 cm and empties more frequently than the gallbladder. In addition, bile constantly flows through it into the duodenum, regardless of the phase of digestion. The outflow of bile through the hepatobile duct into the duodenum also occurs with a functioning gallbladder, but it is very insignificant.

In the intervals between meals, the gallbladder, due to an increase in the tone of the sphincter muscles of the hepatopancreatic ampulla and a decrease in pressure in its cavity, is filled with bile, where it is concentrated due to the reabsorption of electrolytes, water, chlorides and bicarbonate into the bloodstream. Thus, a small-volume (30-70 mm) gall bladder, concentrating liver bile 5-10 times or more, ensures normal digestion, releasing high-concentration bile into the intestine.

centered colloidal solution of bile salts, pigment and cholesterol. The flow of bile from the bile ducts and gallbladder into the duodenum is caused by food, especially one rich in fat. The amount of bile secreted is directly proportional to the amount of food taken. In the gallbladder, regardless of the effects of the above reasons, after the release of bile into the duodenum, a small amount of it still remains (residual bile).

In pathological conditions, all physiological functions of the digestive organs are disrupted. Thus, when the cystic duct is obstructed, bile pigments can completely disappear from the cystic bile. At the same time, the amount of bicarbonates and cholesterol, water and chlorides increases, and serous fluid and mucus are exuded into the cavity of the bladder, which leads to an increase in the volume of the bladder, and its contents become transparent and watery. A similar process occurs in the common bile duct when it is obstructed in the terminal section. Thus, “white” bile appears due to a violation of the physiological function of the biliary tract.

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Part II. Biliary tract surgeryChapter 2. Anomalies of the biliary tract

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