Common bile duct pressure changes after fentanyl, morphine, meperidine, butorphanol, and naloxone

Five groups of 10 patients received thiamylal, enflurane, nitrous oxide-oxygen anesthesia for elective cholecystectomy. The common bile duct was intubated via the cystic duct with a 16-g plastic catheter, and the control intraductal pressure was measured. Patients then were given equi-analgesic doses of fentanyl, morphine, meperidine, butorphanol, or placebo intravenously, and the common bile duct pressure was recorded for 20 min. Fentanyl, morphine, and meperidine significantly increased pressure in the common duct (P less than 0.001). Butorphanol produced only insignificant changes. Naloxone given 20 min later significantly (P less than 0.001) decreased pressure in patients given fentanyl, morphine, and meperidine. Naloxone given without narcotics caused an increase in pressure that, although statistically significant (P less than 0.03), was clinically insignificant. In five additional patients anesthetized with thiamylal, nitrous oxide-oxygen and intermittent doses of fentanyl, common bile duct pressures were normal.

Fat absorption in patients with surgically repaired biliary atresia

The degree of fat absorption was studied in 4 patients with unrepaired biliary atresia and 11 with repaired biliary atresia (6 with mild jaundice, 5 with no jaundice). The percent absorption was conspicuously reduced in unrepaired patients (mean 30%, range 21 to 39%), moderately reduced in repaired patients with mild jaundice (mean 78%, range 67 to 89%), and completely normal in repaired patients with no jaundice (mean 93%, range 89 to 97%). The excretion pattern of main fecal fatty acids in unrepaired patients was very different from that of normal controls, low in stearic and high in oleic, but very similar to the pattern of fatty acids contained in ingested milk. In repaired patients with mild or no jaundice the pattern was an intermediate one between those of normal controls and unrepaired patients. The effect of medium-chain triglycerides on fat absorption was favorable in repaired patients with mild jaundice, but not in those with no jaundice. There was an inverse correlation between fat absorption and 15 min indocyanine green retention value.

Jaundice and wound healing: a tissue-culture study

The effects of jaundice on wound healing have been studied by growing fibroblasts, in vitro, in normal culture media, in culture media to which bilirubin has been added, and in culture media containing sera from jaundiced patients. It has been found that the addition of bilirubin to the culture media causes morphological changes in the fibroblasts, and impairs the growth of cells. The addition of jaundiced human sera to the culture also causes similar changes.

Meal stimulated response of serum bile acids levels in normal and altered bile acids enterohepatic circulation

Sequential measurement of postprandial serum levels of bile acids was carried out in ten healthy controls and in four patients with different impairment of bile acids enterohepatic circulation. An enzymathic fluormetric method was used for SBA analysis. The peak of increase above fasting baseline in normal subjects was 11.8 +/- 1.2 microM/1 (mean +/- SD). In a cholecystectomized subject no SBA peak was observed. Two patients with mild and severe liver impairment (i.e. alcoholic steatosis and Summerskill-Walshe disease during an acute attack of jaundice) had postprandial SBA increase of 20 microM/1 and 70 microM/1 respectively. In a patient affected by Crohn's disease, with proved bile acids malabsorption, a negligible postprandial SBA increase was noted (6.65 microM/1). It is concluded that meal stimulated response of SBA levels might be useful index of altered hepatobiliary and intestinal function.

[Morphological and functional evaluation criteria of hepatobiliary functional scintigraphy with 99mTc-diethyl-IDA in hepatocellular jaundice]

In 31 patients with histologically proven hepatocellular jaundice hepatobiliary scintigraphy with Tc-99m labelled IDA derivatives was performed. Results were classified under morphological (demonstration of liver parenchyma, ductus choledochus, bile ducts, gallbladder, kidney) and functional (Tmax, half time of bile excretion, appearance of activity in ductus choledochus, gallbladder, and intestines) criteria. The liver parenchyma could be demonstrated in 90.3% of cases, ductus choledochus in 71%, and the gallbladder in 72.4%. The type of tracer excretion into the intestines showed 9.5% activity accumulation in the gallbladder with late bile excretion into the intestines and 90.5% early activity excretion into the duodenum with late filling of the gallbladder. The intrahepatic bile ducts were demonstrated in 22.6% (left hepatic duct) and 6.5% (right hepatic duct). In 35.5% of cases the kidneys were still visible after 15 min p.i. All cases showed - sometimes delayed - bile excretion into the GI tract. The time of appearance of activity in ductus choledochus (18.4 min) and gallbladder (39.5 min) was delayed. The liver histogram showed likewise delayed values concerning Tmax (14.3 min) and half life of tracer excretion (greater than 30 min) when compared to controls. The differentiation of hepatocellular jaundice from obstructive jaundice is possible by the demonstration of bile excretion into the intestines, normal width of the bile ducts, and filling of the gallbladder.

Hepatic function following portoenterostomy for extrahepatic biliary atresia

Liver structure and function in 10 patients with extrahepatic biliary atresia were studied after portoenteric anastomosis (Kasai operation). Bile flow adequate to reduce the serum bilirubin concentration was established in five patients (improved group), three of whom became anicteric. The serum bilirubin concentration did not decrease in the remaining five patients (unimproved group). Hepatic effluent collected postoperatively from both groups contained small amounts of cholesterol and bilirubin; bile salts, however, were present in the hepatic effluent of only the improved patients. Liver biopsy specimens obtained postoperatively from the five improved patients showed partial (in two) or complete (in three) relief of cholestasis; hepatic fibrosis, however, was unchanged (in one) or worse (in four). The serum concentrations of bile salts were markedly elevated, despite normal excretion of sodium sulfobromophthalein and rose bengal, in two anicteric patients studied 14 and 24 months postoperatively. It is concluded that neither structure nor function of the liver is normalized by portoenterostomy even in clinically well, anicteric patients.

Inhibitory effects of jaundice on regenerating liver

The effects of partial hepatectomy on the energy charge (ATP + 1/2ADP/ATP + ADP + AMP) and mitochondrial oxidative phosphorylation were studied in normal and jaundiced rats. In normal rats and energy charge levels of the remnant liver decreased only slightly with a rise in the phosphorylative activity of the mitochondria at an early stage after hepatectomy, and then rapidly returned to normal. In jaundiced rats subjected to the common bile duct ligation the energy the energy charge levels of the liver decreased to approximately 0.800 from 0.849 of normal value, though their mitochondrial oxidative phosphorylation was within normal limits. In jaundiced rats the energy charge levels of the remnant liver after partial hepatectomy decreased markedly without a return toward normal. The mitochondrial phosphorylative activity increased to only about 50% of hepatectomized normal rats after partial hepatectomy. More than 70% of jaundice rats died within 24 hours after partial hepatectomy. It was suggested that the jaundice inhibits an enhancement of ATP generation to provide sufficient energy for high energy demand rather than the enery-requiring biosynthetic process in an early process of liver regeneration.

Jaundice in pregnancy--1976

An integrative survey is given of three disease processes, in which recent progress of a fundamental nature has been made, primarily affecting the liver, either coincident with or caused by the gravid state. The three conditions considered include (1) recurrent cholestasis of pregnancy (RCP), (2) viral hepatitis coincident with pregnancy, and (3) acute fatty liver of pregnancy (AFLP). In addition to an assessment of our present knowledge with respect to RCP and AFLP, new genetic hypotheses are proposed. In the latter, the proposal of an ornithine transcarbamylase deficiency, similar to that seen in Reye's syndrome, has potential therapeutic implications that are explored. In light of the currently available information on the interaction between maternal viral hepatitis and the variant forms of vertical maternal-fetal transmission, tentative recommendations regarding management of the newborn are suggested.

Post-traumatic hepatic dysfunction as a major etiology in post-traumatic jaundice

Thirty-eight patients who had sustained acute trauma, profound hemorrhagic shock, and massive transfusion were studied prospectively to determine the predominant etiologic factors in the development of post-traumatic jaundice. An analysis of clinical and biochemical factors occurring in association with each bilirubin peak in the postoperative course found the jaundice related to transfusion and surgery in 11 instances, to sepsis and septicemia in 15 instances, and to hepatic dysfunction in 23 instances. Results indicated that admission estimates of SGOT and LDH levels, the height of the bilirubin peak and the postoperative day on which it occurs, and the white cell count and GGT at the time of the peak may be of use in the differential diagnosis. Four case reports were used to emphasize the fluctuating pattern of jaundice and the different etiologic factors that may predominate. Light and electron microscopy from three patients illustrated the structural alterations that accompany the biochemical impairment of liver function and enable a more precise appreciation of this syndrome. Hepatic dysfunction appears to be implicated in a high proportion of patients who develop post-traumatic jaundice, which frequently occurs as part of a spectrum of multiple organ failure.

Effects of jaundiced plasma on vascular sensitivity to noradrenalin

Alterations in renal perfusion have been shown in a variety of liver diseases. We have examined the possibility that the syndrome is due to a renal vascular hypersensitivity to noradrenalin (NA). Isolated perfused kidneys and segments of rabbit femoral artery were used. Potentiation of the pressor effects of injected NA occurred in all (five artery and five kidney) preparations when jaundiced baboon plasma was perfused. These changes were significant (P less than 0.05) in nine out of the ten experiments. Controls to which normal baboon plasma was administered showed no such change. No correlation was found between the degree of NA potentiation and the plasma concentrations of bilirubin (total and conjugated), serum glutamic oxaloacetic transaminase, blood urea nitrogen, serum glutamic pyruvic transaminase, alkaline phosphatase, Na+ ions or K+ ions in the jaundiced plasma. Plasma renin levels were not significantly changed. When arteris were perfused with Krebtentiation of NA was found. Perfusion of sodium taurocholate or sodium deoxycholate (400 mug/ml) yielded no potentiation. Thus, the altered renal perfusion associated with jaundice may be attributed to a potentiated pressor response to NA which may be caused by an increased level of cholesterol carried on the beta-lipoprotein.

Contraction of the canine gallbladder in different degrees of common bile duct obstruction

C-terminal octapeptide of cholecystokinin was administered at six dose levels, 4-128 ng/kg, by 184 intravenous injections to three mongrel dogs under several pressure conditions of the biliary system. Gallbladder contraction was monitored radiographically. A good, dose-dependent contraction response resulted with intraductal pressures of 0 and 10 cm water. At 20 cm water, a markedly reduced and dose-independent response occurred. No contraction response was found with an intraductal pressure of 30 cm water. This animal experimental work suggests that in man, a contraction response of 30% or more may rule out significant common bile duct obstruction.

An evaluation of 75 Se selenomethionine scanning as a test of pancreatic function compared with the secretin-pancreozymin test

The uptake of (75)Se Selenomethionine by the pancreas has been evaluated in 102 patients and compared with the secretin-pancreozymin test of pancreatic function. In groups of patients with chronic pancreatitis and cancer of the pancreas abnormal scans closely parallel the diminished exocrine secretion, especially bicarbonate output, following a submaximal dose of secretin. Thirty per cent of the group with no pancreatic abnormality have abnormal scans, though the secretinpancreozymin test is normal. Though a normal scan excludes the presence of chronic pancreatitis and cancer of the pancreas with a probability greater than 90%, an abnormal scan is found so frequently in normal subjects that it does not provide a reliable index of impaired pancreatic function.