Cholangitis after endoscopic sphincterotomy in patients with stricture of the biliary duct.

Five patients with stricture of the common hepatic bile duct underwent endoscopic treatment without relief from cholangitis or successful stricture dilation. A Roux-en-Y hepaticojejunostomy was performed upon four patients who are now symptom-free. Endoscopic sphincterotomy leads to bactobilia and increases the risk of cholangitis, particularly in patients with residual obstruction of the bile duct. Although endoscopic treatment may have a role in patients at high risk, there is uncertainty about the long term results and the risk of progressive liver damage. In the majority of patients, the results of operation for benign stricture of the bile duct are such that operative repair is the treatment of choice.

Composition and morphologic and clinical features of common duct stones.

No systematic study of the composition of common duct stones has been carried out to date. In this study, we assessed the chemical composition and morphologic characteristics of common duct stones from 115 patients, and compared them with gallbladder stones in 67 patients who had both. Visually and chemically, common duct stones could be divided into two groups: cholesterol stones and pigment stones. Cholesterol common duct stones contained 83 +/- 1 percent cholesterol, 2.3 +/- 0.4 percent bilirubin, and 5.5 +/- 1 percent insoluble pigment residue. Pigment common duct stones contained 7 +/- 1 percent cholesterol, 24 +/- 2 percent bilirubin, and 38 +/- 3 percent pigment residue. There were two subgroups of pigment stones: one with large amounts of bilirubin and one with large amounts of pigment residue. A high proportion (46 percent) of common duct stones were composed of pigment. Patients with pigment common duct stones were more likely to have cholangitis and pancreatitis than were patients with cholesterol stones. It was not possible to distinguish primary from secondary stones on morphologic grounds. In 65 of 67 patients (97 percent), gallbladder stones and common duct stones were of the same chemical type. Morphologically, cholesterol common duct stones were very similar (3.6+ on a scale of 0 to 4+) to their counterparts. Pigment common duct stones and gallbladder stones were less similar (2.4+). Chemically, cholesterol common duct stones were identical to their gallbladder counterparts. Pigment common duct stones regularly contained a greater fraction of bilirubin and less pigment residue than associated gallbladder stones (p less than 0.05). Earthy common duct stones were associated with earthy gallbladder stones, and were chemically indistinguishable from other pigment stones. These data suggest that all cholesterol common duct stones, and when the gallbladder is present, most pigment common duct stones, are secondary. The latter stones, however, probably grow after entering the duct, adding pigment with a high proportion of bilirubin relative to pigment residue.

Pigment sludge and stone formation in the acutely ligated dog gallbladder.

We studied the effects of stasis of gallbladder bile in a dog model. Three days after cystic duct ligation, all gallbladders contained sludge, and the mucosa was covered by densely adherent mucus with solid particles 1-4 mm in diameter (gravel). Thirty percent of the animals developed stones (greater than 4 mm), which appeared grossly like human pigment stones and microscopically like condensed biliary sludge. Centrifugation of bile yielded colorless pellets (3.8 +/- 3.2 mg/ml) at day 0 and pigmented pellets (33.1 +/- 11.0 mg/ml) at day 3 (p less than 0.05). Pellets contained 73 +/- 8% mucin by weight. Dissolved mucin in supernatant bile increased from 7.46 +/- 1.19 mg/ml (day 0) to 27.36 +/- 3.05 mg/ml (day 3) (p less than 0.001), while bilirubin concentration decreased from 127 +/- 12 mg/dl (day 0) to 71 +/- 16 mg/dl (day 3) (p less than 0.001). Cholesterol concentration increased but did not reach saturation, while the concentration of bile salt and phospholipid did not change. Mucin-bilirubin complexes formed and remained suspended as sludge initially. As bile mucin content increased, sludge particles coalesced, precipitated, and eventually formed gravel and stones. We suspect that stone formation in this setting occurs because of sequestration of biliary lipids by mucin.

Vesicular transport of horseradish peroxidase during chronic bile duct obstruction in the rat.

The vesicular transport system for biliary secretion of plasma-derived proteins was investigated in rats with chronic bile duct obstruction. Horseradish peroxidase, previously demonstrated to be a suitable tracer for vesicular transport, was employed in these studies. Both the time course of horseradish peroxidase secretion into bile and the morphological events in its uptake, transport, and biliary secretion were found to proceed in a manner essentially identical to that of sham-operated control animals. In addition, fragmentation of hepatocytes leading to sloughing into bile of large pieces of cytoplasm bearing horseradish peroxidase-containing endocytic transport vesicles frequently was observed in the cholestatic animals. These data suggest that the vesicular transport system for the secretion into bile of plasma-derived proteins remains intact and functional during chronic bile duct obstruction and that another mechanism, possibly fragmentation and solubilization of hepatocyte membranes followed by regurgitation of proteins released from endocytic vesicles, may be responsible for the elevation of biliary proteins within plasma seen during cholestasis.

Peritoneovenous shunt for refractory ascites: operative complications and long-term results.

We studied the clinical course of 35 patients with refractory ascites who underwent 51 peritoneovenous shunts. Nine of them had hepatorenal syndrome (HRS). Operative complications included shunt malfunction, shunt infection, ascitic leak, fluid overload, and disseminated intravascular coagulation. Two of the patients without HRS died postoperatively. The survival rate in this group was 67% at one year and 43% at two years. Ascites was completely controlled in 83% of the survivors at two months and 50% at two years. Neither survival nor shunt patency were predictable. The shunt reversed HRS in three patients, but failed to do so in the other six. Late complications included shunt malfunction and infection. During the first two years of follow-up, five patients bled from esophageal varices. Liver failure was the sole cause of late death. Peritoneovenous shunt should be reserved for patients with truly refractory ascites, for whom it provides excellent palliation.

Biliary stricture.

Comparison of our results for the past 14 years with those from the period 1940 through 1968 shows that surgical therapy in the repair of biliary stricture has plateaued at a consistent level of more than 90 per cent success. The selection of an operative procedure and its conduct have become standardized based on the principles discussed earlier. The patients that have an unsatisfactory outcome are for the most part predictable. They are mainly those with biliary cirrhosis and its complications, ineradicable intrahepatic stone formation, or rare injuries that are technically incorrectable. Current experience reinforces our previous observation that a history of one or more previous unsuccessful repairs does not preclude success after another attempt. More than 80 per cent of such patients have been rendered symptom-free by stricture repair (Table 3). Since surgical therapy eliminates the need for external tubes and the perpetual morbidity of other forms of palliative therapy, it remains the mainstay of treatment for all but a handful of patients.

The effects of a low level of dietary cadmium on blood pressure, '24Na, '42K, andwater retention in growing rats.

The effects of 5 pg Cd per millilter of drinking water on body weight gain, food intake, systolic blood pressure, '24Na, '42K; and water retention and freference for NaCl solution in male and female rats were studied. After 205 days, Cd had no significant effect on weight gain, food intake, water intake, or feed efficiency. The'24Na retention of the Cd-fed male and female rats was greater at 161 days than in the control animals and was significantly greater (P less than 0.05) in the Cd-treated females than in the control females at 294 days. In vivo retention of '42K was significantly greater in the Cd-treated males than in the control males at 189 days, butthe oppisite was true of the Cd-treated females in comparison with female control animals. There were no significant differences between treatments in '42K retention after 330 days. No significant differences were found between treatments in systolic blood pressure. Water retention was significantly greater in the Cd-treated males and females than in the control animals after 320 days. Preference for 0.20 M NaCl was significantly greater in the Cd-fed males than in the control males at 277 days. Possible mechanisms which might explain the sodium retention in thhe Cd-fed rat are discussed.