Gallbladder - Eponyms, Triangles, Laws, Signs & Pentad

ANATOMY & NAMED STRUCTURES

Parts of the Gallbladder

The gallbladder has four anatomic areas (Schwartz's Surgery):

Fundus - rounded blind end, contains most smooth muscle
Body - main storage area, elastic tissue
Infundibulum (Hartmann's Pouch) - mucosal outpouching at the junction of neck and cystic duct; a stone impacted here causes Mirizzi syndrome
Neck - lies in the deepest part of the gallbladder fossa, connects to the cystic duct

Cantlie's Line - a vertical plane running from the gallbladder fossa anteriorly to the IVC posteriorly, dividing the liver into right and left lobes.

TRIANGLES

1. Triangle of Calot (Hepatocystic Triangle)

Boundaries: Cystic duct (laterally), common hepatic duct (medially), inferior edge of the liver (superiorly)
Contents: Cystic artery (usually a branch of the right hepatic artery in >90% of cases), cystic lymph node (Lund's node / node of Mascagni)
Significance: Dissection of this triangle is the key step in laparoscopic cholecystectomy to achieve the Critical View of Safety (CVS). CVS requires:
1. The hepatocystic triangle is cleared of fat and fibrous tissue
2. The lower one-third of the gallbladder is separated from the liver to expose the cystic plate
3. Only two structures (cystic duct + cystic artery) should enter the gallbladder

Note: Modern terminology increasingly uses "hepatocystic triangle" over "triangle of Calot," as the latter was originally described with slightly different boundaries.

2. Hepatocystic Triangle

The accepted modern term for what is functionally the same area as Calot's triangle
Bounded by: cystic duct, common hepatic duct, and inferior liver edge

3. Cystohepatic Triangle

Another name for the same anatomical space; used interchangeably with hepatocystic triangle in surgical literature

NAMED POUCHES & STRUCTURES

Name	Description
Hartmann's Pouch	Mucosal outpouching at neck/cystic duct junction; stones can lodge here causing Mirizzi syndrome
Calot's Node (Lund's Node)	Cystic lymph node in the triangle of Calot; sentinel node for gallbladder cancer
Luschka's Ducts (Ducts of Luschka)	Small bile ducts in the gallbladder bed that drain directly into liver parenchyma; can cause bile leak post-cholecystectomy
Rokitansky-Aschoff Sinuses	Mucosal diverticula penetrating the gallbladder muscle wall; seen in adenomyomatosis

LAWS

Courvoisier's Law

"In jaundice due to a calculus in the common bile duct, the gallbladder is usually NOT enlarged (distended) because of previous inflammatory fibrosis, whereas in obstruction due to a malignancy (carcinoma of head of pancreas, cholangiocarcinoma), the gallbladder IS palpably enlarged and non-tender."

A palpable, non-tender, enlarged gallbladder in a jaundiced patient = likely malignant obstruction (carcinoma of pancreatic head or CBD)
Absence of palpable gallbladder in biliary obstruction = likely choledocholithiasis

Exceptions to Courvoisier's Law (S. Das, Clinical Surgery):

Double impaction of stones - one in the cystic duct AND one in the common bile duct
Oriental cholangiohepatitis
Pancreatic calculus obstructing the ampulla of Vater
Mucocele of gallbladder due to a stone in the cystic duct

SIGNS

Sign	Description
Murphy's Sign	Arrest of inspiration on deep palpation of the right hypochondrium (RUQ) as the inflamed gallbladder descends to meet the examiner's fingers; positive in acute cholecystitis
Boas's Sign	Hyperaesthesia (skin hypersensitivity) between the 9th and 11th ribs posteriorly on the right side; suggestive of acute cholecystitis
Courvoisier's Sign	Palpable, non-tender, enlarged gallbladder in a jaundiced patient (malignant obstruction)
Grey-Turner Sign	Flank ecchymosis (pancreatitis, not specific to gallbladder but relevant in gallstone pancreatitis)
Cullen's Sign	Periumbilical ecchymosis (similar context)

SYNDROMES

Mirizzi Syndrome

A stone impacted in the neck of the gallbladder or cystic duct extrinsically compresses the common hepatic duct, causing jaundice and biliary obstruction.

Type	Description
Type I	Compression of CBD by stone in infundibulum or cystic duct (no fistula)
Type II	Cholecystocholedochal fistula (fistula involving < 1/3 of CBD circumference)
Type III	Fistula involving > 1/3 of CBD circumference
Type IV	Complete destruction of CBD wall

Bouveret's Syndrome

Gastric outlet obstruction caused by a large gallstone eroding through a cholecystoduodenal fistula and impacting at the pylorus/duodenum.

Gallstone Ileus

Large gallstone eroding through cholecystoenteric fistula, causing small bowel obstruction (most commonly at the ileocecal valve). Rigler's triad on X-ray: pneumobilia + small bowel obstruction + ectopic gallstone.

TRIADS & PENTADS

Charcot's Triad (Ascending Cholangitis)

Right upper quadrant pain
Fever with chills/rigors
Jaundice

Reynolds' Pentad (Severe/Suppurative Cholangitis)

= Charcot's Triad + 4. Hypotension (shock) 5. Altered mental status (confusion)

From Harrison's (2025): "The presence of shock and confusion (Reynolds' pentad) is associated with a HIGH mortality rate and should prompt urgent intervention to restore biliary drainage."

Quincke's Triad (Hemobilia)

Upper GI bleeding
Obstructive jaundice
Right upper quadrant pain/colic

SUMMARY TABLE

Category	Name	Key Point
Triangle	Triangle of Calot	Cystic duct + CHD + inferior liver edge; contains cystic artery
Triangle	Hepatocystic triangle	Modern term = same as Calot's triangle
Pouch	Hartmann's pouch	Neck-cystic duct junction; stone impaction site
Law	Courvoisier's Law	Palpable GB in jaundice = malignancy, not stones
Sign	Murphy's sign	Acute cholecystitis; inspiratory arrest on palpation
Sign	Boas's sign	Right posterior hyperaesthesia (9th-11th rib) in cholecystitis
Sign	Courvoisier's sign	Non-tender enlarged GB = malignant obstruction
Triad	Charcot's triad	Pain + fever + jaundice = cholangitis
Pentad	Reynolds' pentad	Charcot's triad + shock + confusion = severe cholangitis
Syndrome	Mirizzi syndrome	Stone in GB neck/cystic duct compressing CHD
Syndrome	Bouveret's syndrome	Gallstone causing gastric outlet obstruction
Syndrome	Gallstone ileus	Gallstone causing small bowel obstruction
Sinuses	Rokitansky-Aschoff sinuses	Mucosal diverticula into GB wall; adenomyomatosis
Ducts	Ducts of Luschka	Small bile ducts in GB bed; can bleed/leak post-op
Line	Cantlie's line	GB fossa to IVC; divides liver into R and L lobes

Sources: Schwartz's Principles of Surgery 11th ed., Bailey & Love's Surgery 28th ed., S. Das Manual of Clinical Surgery 13th ed., Harrison's Principles of Internal Medicine 22nd ed. (2025), Sleisenger & Fordtran's GI Disease, Fischer's Mastery of Surgery 8th ed.

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