Where in the world is your gallbladder and what does it do?
Because if you can remove this structure, say like what often happens with gallstones
or complications from gallstones, how truly important or vital can the gallbladder really
be to the function of the human body?
So in today's video, we'll talk about the location and its function and of course dabble
in this idea of how stones form, how painful they are in some treatment options, and of
course, do what we always do - take a look at a real gallbladder on one of our cadavers
to help us with this story.
So, let's do this.
[Intro]
so, one of the things we're going to talk about in today's video is that sometimes gallstones can be asymptomatic,
or in other words the person wouldn't even know that they had them, kind of like they're undetectable.
And we'll definitely talk about how that can occur but first, if you want to be undetectable,
kind of like an undetectable gallstone or maybe you don't want anybody to know or even
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So, back to the gallbladder.
Where is the gallbladder located?
Well, it's located in the right upper quadrant of the abdomen just underneath the liver or
inferior to the liver.
So let's take a look at the liver first and then we'll go on to the gallbladder.
So, this is an abdominal dissection, you can see the small intestine coiled up here and
the liver, massive organ, second largest organ in the human body and just a reference, here's
the diaphragm muscle which helps us breathe but the gallbladder should be tucked up underneath
the liver here.
And I mentioned should be on this particular cadaver because it's been removed from this
body.
Now, don't worry we do have a body with a gallbladder that we're going to show you.
But I wanted to start kind of with the zoomed out perspective because the body with the
gallbladder is actually cut in half in the sagittal plane and we're really going to zoom
into that, so it's nice to kind of see it from a zoomed out perspective first, but let's
take a look at that next body.
So here is the sagittal cut to section, that I was talking about.
You're getting a really zoomed in view to the right upper quadrant here.
If I push this down, this is the bottom ridge or margin of the lower portion of the rib
cage and you can see the liver here which has been cut in half so just to kind of give
you this idea on me - cut like so and even cut along the border of the rib cage just
so you can see into that right upper quadrant.
Now again, I mentioned here's a portion of the liver.
This is just the very end of the stomach that we've kind of pulled down but it would continue
on to the small intestine but what are we really curious about here is this cool little
organ called the gallbladder.
Now, gall is just essentially refers to bile and bladder - when we talk about bladders,
these are essentially storage organs.
When we talk about the urinary bladder, that's just storing urine but the gallbladder stores
something called bile.
Now, bile helps us digest and break down fats.
However, the gallbladder doesn't actually produce the bile, that's the job of the liver.
So the liver will actually produce the bile and if I pull that stomach out of the way
so we can get a better look here, you can see this duct right here - let me pull that
up here, this is called the hepatic duct.
Hepatic just means liver and you can see it's coming down from the under portion of the
liver and this is where the bile would be secreted and actually would make it down and
join with this other duct.
Now, this other duct as you can see is coming from the gallbladder here and they refer to
this as the cystic duct.
So, cystic duct and hepatic duct.
Now, when these two join together about right here, they change the name again because anatomists
love changing names and naming things, then it's called the common bile duct.
So, just to review that, cystic duct, common hepatic duct joined together to form the common
bile duct.
Now, that bile is going to be taken down and if you can see and look closely, we've got
a portion of the pancreas here, kind of this rough rigid organ or it's got ridges on it,
I should say, and that common bile duct is going to - let me pull it up again if I can
grab it and you can see it right there, is going to pass through the pancreas.
And the pancreas is even going to throw its pancreatic duct into the common bile duct
so it can have some secretions as well.
But the whole point of this is getting bile down into the small intestine to break down
fats because that's essentially what bile does.
So let me give you a little bit of a scenario here - let's say i'm really enjoying this
really cheesy saturated fat pizza, I swallow it down through my esophagus, comes down the
bottom portion of the esophagus here and then into the stomach.
Now, the stomach has got some of its acid which is going to help denature some of the
protein in that pizza and also some gastric lye paste which will help start the process
of breaking down some fats and then it's going to mix the food like a little muscular blender.
Now, as that food or I should say chyme at this point, is going to be mixed - it's going
to be pushed forward and eventually make it down into the small intestine right here.
Now, the beginning portion of the small intestine is referred to as the duodenum or sometimes
pronounced "duodenum" whenever you like potato, potato.
But regardless, once it's in here and you can't see it on this particular dissection
but that bile duct, that common bile duct is going to enter into the small intestine
so it can start helping to break down fats even more.
And granted the pancreas is going to secrete some enzymes to break down other things, that's
a whole other video.
But that gives us this idea or that scenario where we can get the bile into there and that's
essentially the kind of the whole point of the gallbladder which is to store this excess
bile because the liver is going to be constantly producing bile but, when we eat a fatty meal
especially, there are some neuronal impulses or I should say nervous system gets involved
to let the gallbladder in the liver know as well as some hormones - there's a hormone
called cholecystokinin or cholecystokinin that's secreted by some of the cells in the
duodenum or duodenum that'll signal back to the gallbladder to start squeezing.
So if you come back here, that gallbladder is actually going to - if I can get in there
with you guys seeing, is going to contract and squeeze to push that bile out of itself
into that cystic duct and eventually into the common bile duct.
Now, between meals, we need to talk about that.
Between meals, there is a sphincter at the very end of the common bile duct and when
we're not eating, we don't need to be secreting all this bile into the small intestine so
that sphincter kind of closes off and that causes this retrograde or kind of the reflux
of the bile going back upward.
And instead of that bile going back upwards directly into the liver, it just goes back
into the gallbladder through that cystic duct, comes back in here and then is stored in the
gallbladder for later.
So, the fattier the meals, the more we need that gallbladder to get involved and squeeze
and contract.
But we do need to talk about - when there are some problems with the gallbladder, such
as gallstones.
So, gallstones are essentially stony formations that will form in the gallbladder.
They kind of look like stony little pebbles and they essentially will hang out and can
build up in the gallbladder and I kind of just mentioned to loosely hang out and in
some cases, they really do just hang out because they figure about six percent of men and nine
percent of women will have gall stones throughout some point in their lifetime but the majority
of patients are asymptomatic when they have gallstones and that's kind of an interesting
thing to think about because when you hear about people with gallbladder removals, they
are almost always blaming it on the stone and we'll get more into that in just a second.
But when we talk about the formation or I should say the presence of gallstones in the
gallbladder, there's a technical term for it.
It's called "cholecystolithiasis".
Chole just refers to gall, cyst means bladder and lith means stone, so cholecystolithiasis
naturally.
Now, how do these things form?
Well, we don't always know exactly but there are some theories and at least some things
we do kind of know as far as the constituents of bile or what we would think of as the ingredients
of bile.
Bile is essentially water - bile salts, bilirubin which we'll talk about a little bit later
and fatty substances, specifically cholesterol.
So water, bile salts, bilirubin and cholesterol.
Now, when we're talking about why they would form, they believe it's an imbalance between
those ingredients and the most common type of gallstone is a cholesterol formed stone.
So, there's this ratio or this increased ratio of cholesterol compared to the other constituents
or ingredients and they're thinking that's creating this hard formation of a cholesterol
stone.
Now, like I said most people don't know they have them, they're usually found on ultrasound,
just kind of an incidental ultrasound when somebody is like getting an ultrasound for
something else but what happens when there is a problem or when there are symptoms?
Some people will describe that this is quite the painful experience.
Now, the first one we're going to talk about is simply just essentially biliary colic.
Now, if you've talked about colic before or a colicky baby, colicky pain is kind of referred
to as pain that comes and goes.
So, let's give you the scenario here.
So let's say i've got some stones in here, now if they're just hanging out and there's
just few stones in there and they're able to move around, you're not going to have much
of a problem, those are likely going to be the asymptomatic patients.
But if you come to the point where maybe some of the stones - let me pull that up, get close
- get close to the cystic duct and maybe get to the point where the bile cannot leave and
get out into the cystic duct, that can cause some pain in the right upper quadrant and
they refer to that as biliary colic.
Now, often it happens or occurs about a half an hour after somebody eats a really fatty
meal - and why would that be?
Because we know that the gallbladder is going to squeeze and contract to get the bile out
to help digest those fatty foods.
Now, some people can range from an hour to a few hours when they have biliary colic but
oftentimes, it just resides and there is a I guess, you could say a range of frequency
of how often somebody will experience biliary colic compared to another person.
Now, you don't just immediately do a knee-jerk reaction and rip the gallbladder out with
patients who have biliary colic but if it does become more frequent and a problem, somebody
may discuss with their doctor or general surgeon about an elective procedure to remove that
gallbladder.
But it does put a person more at risk for what we'd call complicated gallbladder pathologies
or complications of gallstones.
And that first one is referred to as cholecystitis.
Now, cholecystitis, since we've broken down some other terms before, choli again refers
to gall, cyst means bladder, itis means inflammation.
So, we're getting an inflammation of the gallbladder and that typically occurs when a stone gets
squeezed out of the gallbladder, and let me just move that piece out of the way here,
and gets lodged in that cystic duct and because we're getting this obstruction, the gallbladder
will often get inflamed.
Now, the pain with cholecystitis tends to be a little bit worse than say, just a biliary
colic.
Now, when we're talking about that, people will often have some other symptoms.
Oftentimes they can get a little bit of a low-grade fever with this as well as if you
do blood work, they'll get something called leukocytosis because the white blood cells
are going to elevate.
Now, one of the things I do in the clinic when I'm trying to evaluate for a possible
cholecystitis or a gallbladder pathology is I'll actually palpate right up in the upper
abdomen and get my hands just right here at the lower ridge of the ribs here.
And what I do is I tell the patient to breathe in.
And what happens is when they breathe in the diaphragm pushes downward and it will actually
pull - push the gallbladder - let me get the stomach out of the way there, will push the
gallbladder down and if it's inflamed and it pushes down against my fingertips right
there, they'll actually just hold their breath because it hurts so bad when the gallbladder
pushes down on my fingertips.
We call that murphy's sign and makes us a little bit more suspicious for a cholecystitis
and then we throw the ultrasound on there to help confirm that.
Now, what will we do in that case?
Well, with cholecystitis often patients will be admitted into the hospital and observed
and frequently they'll get put on prophylactic antibiotics.
Now, that's an interesting discussion because they don't technically have an infection at
this point - are they at a greater risk for infection?
Yes they are and so, most of the protocols will essentially say "Well, we're going to
kind of protect them with preventative antibiotics just in case something goes wrong" and then
they'll discuss how soon do we need to do a cholecystectomy, which is essentially the
fancy pants name for removing the gallbladder.
They may do it more emergently depending on other signs and symptoms or they may do it
later on.
Again, that'll be a discussion in a case-by-case basis with each patient.
But, what happens if the gallstone moves even further downstream?
So, if this gall stone moves further downstream again, that would mean it's moved down from
right here from the cystic duct into the common bile duct...
If I can get that stomach out of the way, you can see it a little bit better.
But in this case everyone, now we're not just blocking the gallbladder, we're also blocking
bile from the liver to get down to that small intestine.
Now, there's a specific name for that it's called "Choledocholithiasis", that is a mouthful.
Chole again referring to gallbladder, docholithiasis, this is referring to blocking this common
bile duct and now we're getting kind of this potential reflex of even bile and bilirubin
moving up into the liver.
Now, often times when this happens, when it gets stuck in that common bile duct, there's
a risk to progressing even further to another condition called cholangitis and that's when
we truly get an infection in the biliary tree.
And the biliary tree are just all these ducts we've mentioned throughout this discussion
here and in that case, we're really concerned about infection seeding and moving throughout
the body.
Even sepsis is a potential risk but this infection, we're definitely moving on to antibiotics
or at least definitely utilizing those antibiotics because with cholecystitis we're kind of just
preventing, in this case, we actually have to kill some stuff and we're likely going
to be doing some surgical procedures to get the stone out of the way as well as probably
removing that gallbladder, again, with this discussion of the surgeons but oftentimes
they are going to take this thing out.
Now, I want to talk about some of the symptoms and some of the differences because it's really
cool to think about this from an anatomical perspective.
Remember with cholecystitis, you could have like a low-grade fever, a lot of people will
also get like nausea and vomiting but we're only blocking that cystic duct.
When we get choledocholithiasis or cholangitis blocking the whole common bile duct, we tend
to get a higher grade - higher grade fever, again, that positive murphy sign when I was
talking about pushing on the upper abdomen there but also you see jaundice.
Now, why in the world would you get jaundice?
Well, remember the whole ingredients are the constituents of bile.
One of those ingredients was bilirubin.
Bilirubin is a waste product from hemoglobin from broken down red blood cells.
Now, red blood cells are always constantly breaking down and you're replacing them but
typically what happens is the liver takes up - remember our wonderful liver here, takes
up all of that bilirubin and then essentially secretes it into the bile and it creates a
certain color as we know, because if we have a bilirubin issue that's going to be where
we get the jaundice but it'll secrete it down and gets it into the small intestine and yes,
the bile helps break down food but also that excess bilirubin can now be mixed into the
food and eventually get to the colon, mix in with the poop and that's why your feces
or poop has the specific color that it has.
But again, if we're blocked right here, that bilirubin is no longer being able to be excreted
from the liver and therefore getting backed up in the bloodstream and that's creating
a color or that yellowing of the skin.
They call those three things, and we're talking about high grade fever, positive murphy's
sign and jaundice, charcot's triad or some people will say they are like charcoal's triad
and that's this topic people will talk about in the ER or in the hospital setting when
we're worried about cholangitis and potentially needing to get this gallbladder out in more
of an emergent type of a situation.
So yeah, that was kind of a lot of information, but hopefully going through the anatomy step
by step gave you a better understanding of the different gallbladder conditions.
And of course, we are the Institute of Human Anatomy, so we are going to promote all kinds
of different anatomical awesomeness and most of the time, anatomy is pretty awesome and
joyous and every once in a while a little bit painful like in gallbladder conditions.
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