Effects of structural injure in the bile bacterial contamination after balloon transduodenal sphincteroplasty (papillary dilation) in dogs / Efeitos da lesão estrutural na contaminação bacteriana biliar após a esfincteroplastia transduodenal (dilatação papilar) em cães

PURPOSE: To evaluate, in dogs, the biliary sphincter subjected to dilation by hydrostatic balloon by the point of view of structural alterations of the papilla and the biochemestry and bacterial contamination of the bile. METHODS: Twenty dogs were submitted to laparotomy, duodenotomy, and enlargement of the major duodenal papilla- GA(n=10) - with balloon of 8mm inflated with pressure of 0,5atm, during 2 minutes or to the sham procedure - GB(n=10). Blood samples collected on times t(0day), t(7days) and t(28days) were subjected to dosages of alkaline phosphatase (ALP) and gamma-glutamyltransferase (GGT) for cholestasis evaluation. The collected material from the gall bladder at the same times were registered and numbered to be submitted to culture in BHI, blood agar (rich, non-selective element) and Mac Conkey (selective element for Gram-negative bacillus. On the 28th day three fragments of the papilla were tranversally cut by the choledoc axis 3mm from the duodenal papilla and the cuts, stained with hematoxylin-eosin and Masson's tricome, were evaluated according to their inflammatory reaction. RESULTS: The GGT and ALP averages on the three periods in the groups A and B did not show significant differences, not being characterizes the cholestasis. The bacterian contamination was significantly higher in GA (2,19) than in GB (1,96); the contamination was lower in the initial time compared with 7 and 28 days (t0

OBJETIVO: Avaliar, em cães, a papila duodenal maior submetida à dilatação por balão hidrostático sob o ponto de vista das alterações estruturais da papila e da bioquímica e contaminação bacteriana da bile. MÉTODOS: Vinte cães foram submetidos a laparotomia, duodenotomia, dilatação da papila maior GA (n=10) - com balão de 8mm insuflado com pressão de 0,5atm, durante 2 minutos ou ao procedimento simulado - GB(n=10). Amostras de sangue coletadas nos tempos t(0dia), t(7dias) e t(28dias) foram submetidas às dosagens da fosfatase alcalina (FA) e gama-glutamil-transferase (GGT) para avaliação da colestase. Material colhido da vesícula biliar nos mesmos tempos foi registrado e numerado para ser submetido à cultura em BHI, ágar sangue (meio rico não seletivo), e Mac Conkey (meio seletivo para bacilos Gram-negativos). No 28°. dia três fragmentos da papila forma cortados transversalmente ao eixo do colédoco a 3mm da papila duodenal e os cortes corados em hematoxilina-eosina e tricômio de Masson e avaliados quanto a reação inflamatória. RESULTADOS: As médias da GGT e da FA nos três períodos nos grupos A e B não mostraram diferenças significantes, não sendo caracterizada a colestase. A contaminação bacteriana foi significante maior em GA(2,19) que no GB(1,96); a contaminação foi menor no tempo inicial em relação aos 7 e 28 dias( t0

Effects of structural injure in the bile bacterial contamination after balloon transduodenal sphincteroplasty (papillary dilation) in dogs.

PURPOSE: To evaluate, in dogs, the biliary sphincter subjected to dilation by hydrostatic balloon by the point of view of structural alterations of the papilla and the biochemestry and bacterial contamination of the bile. METHODS: Twenty dogs were submitted to laparotomy, duodenotomy, and enlargement of the major duodenal papilla- GA(n=10) - with balloon of 8mm inflated with pressure of 0,5 atm, during 2 minutes or to the sham procedure - GB(n=10). Blood samples collected on times t(0 day), t(7 days) and t(28 days) were subjected to dosages of alkaline phosphatase (ALP) and gamma-glutamyltransferase (GGT) for cholestasis evaluation. The collected material from the gall bladder at the same times were registered and numbered to be submitted to culture in BHI, blood agar (rich, non-selective element) and Mac Conkey (selective element for Gram-negative bacillus. On the 28th day three fragments of the papilla were tranversally cut by the choledoc axis 3mm from the duodenal papilla and the cuts, stained with hematoxylin-eosin and Masson's tricome, were evaluated according to their inflammatory reaction. RESULTS: The GGT and ALP averages on the three periods in the groups A and B did not show significant differences, not being characterizes the cholestasis. The bacterian contamination was significantly higher in GA (2,19) than in GB (1,96); the contamination was lower in the initial time compared with 7 and 28 days (t0

[Bile duct infections as a late complication after endoscopic sphincterotomy]. / Zakazenia dróg zólciowych jako pózne powiklanie sfinkterotomii endoskopowej.

UNLABELLED: Nowadays endoscopic sphincterotomy (SE) is considered to be a "gold standard" in the treatment of residual choledocholithiasis and biliary pancreatitis. Nevertheless patients after invasive procedures concerning bile ducts with destruction of Oddi's sphincter often have increased succeptibility to chronic infections of bile ducts. AIM: Assessment of the influence of SE on bacterial colonization, development of main bile duct chronic inflammation and recurrent choledocholithiasis. MATERIAL AND METHODS: We included to the study 50 patients with main bile duct lithiasis, who underwent endoscopic cholangiopancreatography (ERCP). Among them there were 32 women in age from 45 to 87 (mean 69.7 +/- 12.3) and 18 men in age from 39 to 84 (mean 59.8 +/- 11.56). The studied group was divided into 3 subgroups: In I (control) group were included 10 patients diagnosed with ERCP techniques because of jaundice of unknown origin. Those patients did't have ERCP or operative revision of bile ducts before, but all of them underwent cholecystectomy in the past. Each II and III group consisted of 20 patients, who underwent SE before 12-24 and 25-36 months earlier respectively. Sterile uodenoscope was inserted to the region of major duodenal papilla, and then a sterile brush was used to collect material to cytological smear (brushing) from main bile duct. In all groups 2 ml of bile were taken by a catheter to a syringe. On the basis of radiograms from ERCP findings, the width of main bile duct was assessed. In all patients blood cell count, aspartate and alanine aminotransferases, gammaglutamyltranspeptidase, alkaline phosphatase, amylase, bilirubin, C-reactive protein and procalcitonine levels were measured. RESULTS: In our study all 40 patients with previously performed endoscopic sphincterotomy (SE) had bacterial colonization in bile ducts, mostly with Gramm negative pathogens. The most virulent pathogens vere cultured from bile duct swabs from patients after two or more revisions of common bile duct, and after a longer time from sphincterotomy. Those patients had multibacterial bile duct infections (Escherichia coli + Pseudomonas aeruginosa; P. aeruginosa + Enterococcus faecalis; E. faecalis + Enterobacter cloacae + Candida albicans; P. aeruginosa + E. cloacae). E. coil and E. faecalis were most frequently cultured (20 and 16 cases respectively). It was observed that with length of time from endoscopic sphincterotomy, the width of main bile duct and also amount of cultured pathogens and their virulency grow. Elevated transaminases activity and serum procalcitonine levels were observed in studied groups. 9 patients after previous sphincterotomy had recurrent lithiasis. CONCLUSIONS: Sphincterotomy contributes to colonization of main bile duct with pathogenic bacteria. With length of time from endoscopic sphincterotomy, and amount of performed endoscopic sphincterotomies the amount of cultured pathogens, their virulency and drug resistance grow. Chronic infection of bile ducts after endoscopic sphincterotomy causes higher risk of recurrent lithiasis.

The influence of sphincterotomy and hepatic plexus vagotomy on ascending infections of the biliary tract: an experimental study in dogs.

BACKGROUND/AIMS: Hypertonic dyskinesia of the sphincter of Oddi is an important factor in the pathogenesis of postcholecystectomy syndrome, and this condition is usually treated by endoscopic sphincterotomy. However, it has been demonstrated that the biliary tract may also be contaminated after sphincterotomy. In various experimental studies, it has been established that the choledochal pressure decreases by a mean of 32% to 28% after hepatic plexus vagotomy. This experimental study was performed to investigate whether hepatic plexus vagotomy and/or sphincterotomy result in contamination of the biliary tract. METHODOLOGY: Thirty street dogs were divided into three equal groups. The three groups underwent simple laparotomy, transduodenal papillotomy, hepatic plexus vagotomy, respectively, and gallbladder bile samples were taken from all of them. Relaparotomy was performed after four weeks, and again, bile samples were taken from the gallbladder. All bile samples were examined microbiologically. RESULTS: Bacteria were not found in the first bile samples taken from the three groups. Bacteria were not found in the bile samples taken during the second surgery in the simple laparotomy and hepatic plexus vagotomy groups. However, both aerobic and anaerobic bacteria were found in the papillotomy group in seven of the ten dogs. CONCLUSION: These results demonstrate that hepatic plexus vagotomy decreased choledochal pressure and did not cause contamination of the biliary tract. It may be a treatment of choice to prevent postcholecystectomy syndrome resulting from sphincter of Oddi dysfunction.

Biliary manometry, bacterial characteristics, bile composition, and histologic changes fifteen to seventeen years after endoscopic sphincterotomy.

AIM: To evaluate the function of the biliary sphincter 15 to 17 years after endoscopic sphincterotomy and to investigate if loss of sphincter function is associated with bacterial colonization, changes in bile composition, or inflammation of the biliary system. METHODS: Eight patients who had undergone endoscopic sphincterotomy for bile duct stones 15 to 17 years previously underwent ERCP with biliary manometry, bile sampling, and biopsy. Manometry was performed using a perfused triple-lumen manometry catheter and a station pull-through technique. Bile samples were cultured and analyzed for biliary lipids, bile salts, bacterial beta-glucuronidase, and phospholipase A2. Biopsy specimens were taken from the proximal common heptic duct for histologic examination. RESULTS: Manometry demonstrated absent basal sphincter pressure and no choledochoduodenal pressure gradient in all patients. Phasic contractions were observed in two patients. Cholangiography showed stones in one patient. Positive cultures were obtained in three patients, including the patient with stones. All bile samples showed a high content of biliary lipids and cholesterol. Some samples contained considerable amounts of hydrophobic bile salts. Five samples contained very high levels of phospholipase A2 activity. Significant bacterial beta-glucuronidase activity was found in one patient, the patient with stones. Biopsy specimens of the proximal common hepatic duct in three patients showed chronic inflammation with fibrosis and reactive epithelial changes. CONCLUSIONS: After endoscopic sphincterotomy for bile duct stones, the function of the biliary sphincter is permanently lost. This is associated with bacterial colonization, presence of cytotoxic components in the bile, and chronic inflammation of the biliary system.

Defense system in the biliary tract against bacterial infection.

Bacteria can invade the biliary tract by ascending from the duodenum and via the hematogenous route from the hepatic portal venous blood. The sphincter of Oddi, situated at the junction of the biliary tract and the upper gastrointestinal tract, forms an effective mechanical barrier to duodenal reflex and ascending bacterial infection. Conversely, Kupffer cells and the tight junctions between hepatocytes help prevent bacteria and toxic metabolites from entering the hepatobiliary system from the portal circulation. The continuous flushing action of bile and the bacteriostatic effects of bile salts keeps the biliary tract sterile under normal conditions. Secretory immunoglobulin A (sIgA), the predominant immunoglobulin in the bile, and mucus excreted by the biliary epithelium probably function as antiadherence factors, preventing microbial colonization. When barrier mechanisms break down, as in surgical or endoscopic sphincterotomy and with insertion of biliary stents, pathogenic bacteria enter the biliary system at high concentrations and take up residence on any foreign bodies. Intrabiliary pressure is a key factor in the development of cholangitis. Chronic biliary obstruction raises the intrabiliary pressure. This adversely influences the defensive mechanisms such as the tight junctions, Kupffer cell functions, bile flow, and sIgA production in the system, resulting in a higher incidence of septicemia and endotoxemia in these patients. Knowledge of biliary defense against infection is still quite primitive. Unclear are the roles of sIgA in the bile, mechanism of bacterial adhesion to the biliary epithelium, Kupffer cell function in biliary obstruction, and the antimicrobial activity of bile salts.

Ascending infection of the biliary tract after surgical sphincterotomy and biliary stenting.

It has been widely accepted that there is an ascending route of bacterial infection of the biliary tract but there is a lack of direct evidence. This hypothesis was tested in an animal experiment using the cat as an animal model. The implantation of biliary stents and surgical sphincterotomy were performed in these animals, with sham controls. Stents bypassing the sphincter of Oddi with the tip in the duodenal micro-organisms and the biliary tract was heavily contaminated. Blockage of these stents resulted in biliary obstruction. Stents implanted within the common bile duct, proximal to the sphincter were largely unaffected by biofilm formation. After surgical sphincterotomy the biliary tract was also contaminated but, in the absence of obstruction, the animals did not develop any symptoms. It was concluded that ascending infection by duodenal biliary reflux, via the sphincter of Oddi, is an important route of infection in the biliary system.