[Abnormal choledocho-pancreatico ductal junction causative of cystic-cylindric dilatation of intra- and extrahepatic bile ducts]

During the last 5 years there were 6 patients found to have abnormal ductal junction of the choledochus into the pancreas. Clinical signs were: repeating upper abdominal pain, intermittent icterus, signs of pancreatitis and/or palpable tumor. Sonography is the initial examination to show up a dilatation of the intra- and extrahepatic bile ducts. But intraoperative cholangiography alone reveals the true condition of the choledocho-pancreatico ductal junction. Only after this procedure the therapeutic step of a choledocho-jejunostomy should be done.

Bile leakage following T-tube removal

Three cases of common bile duct leakage following T-tube removal are presented. It is suggested that biliary tract strictures occur as a result of postoperative as well as intra-operative injuries, and suggestions to minimize their occurrence are given.

Spontaneous rupture of the cystic duct during pregnancy

A patient with an acute abdomen during pregnancy is reported. It was due to perforation of the cystic duct by a cholesterol gallstone. A cholecystectomy and T-tube drainage resulted in recovery and normal delivery twelve weeks after operation. The presence of gallstones, their location at the weakest point of the cystic duct, and the possible hemodynamic changes (as there is a higher pressure in the vena cava) occurring during pregnancy, are discussed as possible causes of this acute abdominal condition.

Histologic changes and intrahepatic biliary abnormalities in extrahepatic biliary tract obstruction

To assess the role of extrahepatic biliary obstruction in the production of damage to the liver and biliary ductal apparatus, 100 patients underwent choledochoduodenostomy for malignant or benign extrahepatic biliary obstruction. Patients were observed by means of barium meal studies for one month to one year postoperatively. Emphasis was placed upon the relationship of the appearance, structure and function of the extrahepatic and intrahepatic biliary tree in these studies with the findings after histologic examination of the liver, gallbladder or commmon bile duct wall; liver function tests, and cultures of the bile. It has been shown that barium meal studies are an indicative criterion for the evaluation of the extent and progress of the hepatobiliary damage and of its further development after relief of the obstruction. It has been proved that chronic extrahepatic biliary obstruction of long standing seen in patients with a long history of symptoms, with a high incidence of primary common bile duct stones and with a high rate of contaminated bile as well as a high percentage of common bile duct dilation is a challenging and serious disease for both the patient and the hepatobiliary apparatus.

Hemolysis-induced gallstones in mice: increased unconjugated bilirubin in hepatic bile predisposes to gallstone formation

We recently reported that nb/nb mice with hereditary hemolytic anemia spontaneously developed calcium bilirubinate gallstones. We undertook this study to determine whether the differences in gallbladder bile composition were due to altered gallbladder function or hepatic bile composition. Hepatic bile was obtained by cholecystostomy after common bile duct ligation. We found that (a) the hepatic bile of nb/nb mice with or without stones had higher concentrations of unconjugated (p less than 0.001) and total bilirubin (p less than 0.001) but lower concentrations of bile acids (p less than 0.05) than that of control mice; (b) the concentrations of total calcium and hydrogen ion were similar in all groups; (c) nb/nb mice with stones compared with nb/nb mice without stones had higher concentrations of unconjugated (p less than 0.05) and total bilirubin (p less than 0.05); (d) the outputs of unconjugated and total bilirubin of nb/nb mice with or without stones were higher than control mice (p less than 0.001) while bile acid, hydrogen ion, and calcium outputs were similar in all groups; (e) nb/nb mice with stones had higher outputs of unconjugated (p less than 0.005) and total bilirubin (p less than 0.05) than nb/nb mice without stones; (f) in nb/nb mice with stones, but not in those without stones or control mice, unconjugated bilirubin output was associated with bile acid output (p less than 0.001); and (g) unconjugated bilirubin and total bilirubin outputs were significantly correlated in all groups (p less than 0.001). Thus, an increased concentration and amount of unconjugated bilirubin in nb/nb hepatic bile is an essential factor in hemolysis-induced gallstone formation and modification of this abnormal nb/nb hepatic bile within the gallbladder promotes stone formation.

Early post-operative endoscopy after biliary tract surgery

Immediate post-operative complications such as obstructive jaundice, biliary fistulae or gastrointestinal hemorrhage, occurring after biliary tract surgery can be diagnosed endoscopically. The causes of bile flow obstruction and leakage from the common bile duct can be identified using ERC. In many cases the diagnosis can be followed by endoscopic treatment, therefore obviating re-laparotomy. Between 1972 and 1979 we carried out early post-operative ERC or esophago-gastro-duodenoscopy in a total of 94 patients after biliary tract surgery. In 75 patients with residual gallstones and 4 cases with overlooked stenoses of the papilla, successful papillotomies were carried out. The procedure was unsuccessful in one case with an extremely narrow papilla. Complete removal of stones was achieved in 72 cases. In two other patients with gastroduodenal stress ulcers, bleeding was stopped by submucosal infiltration.

Percutaneous transhepatic drainage preoperatively for benign biliary strictures

In two patients, the value of percutaneous transhepatic decompression in the management of benign biliary strictures is illustrated. The procedure can help provide relief of jaundice, control of infection and improvement of nutritional status. Results of previous experience indicate that these factors play a major role in determining the over-all success rate in the surgical management of these patients.

Disparate dilatation of the intrahepatic and extrahepatic bile ducts in surgical jaundice

Intrahepatic biliary dilatation on ultrasound has been reported as an early sign of biliary obstruction. This paper reports 12 patients with extrahepatic biliary obstruction in whome the extrahepatic biliary system was increased in caliber despite a normal appearance of the intrahepatic ducts. The bile ducts in all of these patients were evaluated with ultrasound and percutaneous transhepatic cholangiography. Computed tomography was performed in one case. The causes of obstructive jaundice included stricture, choledocholithiasis, and neoplasm. The common bile duct provides a sensitive indicator of biliary obstruction, and its demonstration by noninvasive or invasive means is mandatory even when the intrahepatic ducts appear to be normal.