Intraoperative common duct pressure and flow measurements

Operative cholangiography is still the most accurate and available method for assessing the presence or absence of stones in the common duct. However, 30 to 40 percent of stones will still be overlooked with cholangiography. To reduce the incidence of overlooked common duct stones we recommended that pressure and flow measurements be obtained before cholangiography. When pressures are high or high normal and flows low, the duct should be explored even in the presence of a normal cholangiogram. Under these circumstances, the incidence of false-positive pressure flow studies is less than 5 percent even in inexperienced hands.

Pressure-regulating effects of prostaglandin E2, F2 alpha and cholecystokinin on canine choledochal and pancreatic ducts in vivo

Changes in pressure in the choledochal and pancreatic ducts of dogs brought about by PGE2 and PGF2 alpha were studied in vivo. The stimulatory action of the c8-terminal cholecystokinin was inhibited by the prostaglandin synthesis inhibitor naproxen. PGF2 alpha increased the pressure, but PGE2 caused a decrease.

Ribosomal protein modifications in liver injury: effect of carbon tetrachloride and extrahepatic cholestasis on protein phosphorylation

The phosphorylation of ribosomal proteins in rat liver injured fro various times by carbon tetrachloride and extrahepatic cholestasis was studied. The incorporation of [32P]phosphate into the protein moiety of the small ribosomal subunit was increased over 2-fold 1 to 4 h after injection of the hepatotoxin, whereas the specific activity of the 60 S subunit was low and changed only insignificantly. Two-dimensional electrophoretic analysis of ribosomal proteins complemented by autoradiography revealed that CCl4 stimulated the phosphorylation of only a single protein (S6) in the 40 S subunit. The phosphorylation of S6 led to a measurable anodic shift and elongation of the protein on the 2-dimensional electropherograms. In response to bile duct ligation a similar increase in phosphorylation of protein S6 was noticed.

Intraluminal pressure recording from the human sphincter of Oddi

In this study we recorded intraluminal pressure from the human sphincter of Oddi during ERCP examination and determined the effect of enteric hormones on sphincter of Oddi motor function. Studies were obtained in 26 patients who had no demonstrable evidence of pancreaticobiliary disease. After cannulation of the common bile duct (CBD) or pancreatic duct (PD), pressure measurements were made across the sphincter of Oddi (SO) during 1-2 mm incremental withdrawals of the catheter pausing 1 min or longer at each station. The findings showed an SO segment, 4-6 mm in length, that had basal, steady-state pressure about 4 mm Hg higher than CBD or PD pressure. Pronounced phasic contractions were superimposed on the basal SO pressure. These phasic contractions measured 101 +/- 50 SE mm Hg in amplitude and 4.3 +/- 1.5 sec in duration. They had a frequency of 4.1 +/- 0.9/min. Corresponding phasic contractions were not observed in the CBD, PD, or duodenum. Intravenous pulse doses of cholecystokinin octapeptide and glucagon depressed SO motor activity, whereas pentagastrin increased SO pressure. Secretin caused a mixed response of excitation followed by inhibition. We conclude that the human sphincter of Oddi demonstrates unique phasic contractions that are altered by enteric hormones given intravenously. These phasic SO contractions may have an important role in regulating biliary and pancreatic duct employing.

Electrical and mechanical properties of smooth muscle cells of the guinea pig biliary system

The membrane potentials of the smooth muscle cells of the sphincter of Oddi, gall bladder or common bile duct of the guinea pig was --56, --40 or --54 mV, respectively. The length constant of the tissue of the sphincter of Oddi was 1.7 mm and this value was larger than that measured in hypertonic solution. The smooth muscle cells of the gall bladder and common bile duct were always spontaneously active, while this was not the case with cells from the sphincter of Oddi, nevertheless, electrical stimulation consistently produced spike generation. Acetylcholine depolarized the membrane and increased the spike frequency in muscle cells of the sphincter of Oddi, gall bladder and common bile duct. However, noradrenaline produced alpha-adrenergic inhibitory action in the sphincter of Oddi and common bile duct, and alpha-adrenergic excitatory action in the gall bladder. Isoprenaline, a beta-adrenergic agent, induced an inhibitory action in the above three regions. Prostaglandin E1 (PGE1) suppressed the membrane activity in the sphincter of Oddi, and this response was similar to that observed in the circular muscle of the intestine. In the gall bladder, PGE1 accelerated the membrane activity. Gastrin and secretin did not affect the smooth muscle activity of the gall bladder but these agents slightly suppressed electrical and mechanical activities in the sphincter of Oddi. On the other hand, cholecystokinin markedly accelerated the electrical and mechanical activities in the gall bladder but these actions were weak in the sphincter of Oddi. Muscle properties of the smooth muscle cells of the biliary system are discussed in relation to the mechanism of bile expulsion through the sphincter of Oddi.

Effect of biliary excretion on ketamine anaesthesia in the rat

Ligation of the common bile duct in rats resulted in a significant prolongation of ketamine sleeping time and a significant increase of plasma concentration of ketamine and its N-demethylated metabolite, when compared with sham-operated control animals. The treated animals also showed significant increases of plasma bilirubin and glutamate pyruvate transaminase. Cannulation of the common bile duct in rats allowed collection of samples of bile which showed high concentrations of ketamine and its N-demethylated metabolite very shortly after i.p. injection of ketamine, the amount of ketamine alone accounting for 10% of the injected dose after 2 h; including the metabolite up to 25% of the injected dose could be accounted for. In view of this we would suggest that ligation of the bile duct in rats produced a prolongation of ketamine anaesthesia by increasing plasma concentrations through interference with a major excretory route for the drug and its main metabolite.

Studies of the choledocho-duodenal sphincter in patients with and without juxta-papillary duodenal diverticula

The function of the choledocho-duodenal sphincter was studied in 16 patients, 8 with juxta-papillary duodenal diverticula. All patients had calculi in the gallbladder. The common bile duct was normal. At cholecystectomy two catheters were introduced into the common bile duct through the stump of the cystic duct and fixed in place. The examinations were performed when the patients had recovered from the operation. One catheter was connected to a pressure transducer, the other was used for saline infusions. Pressure in the common duct was recorded before infusion and at constant infusion rates of 3,6, and 12 ml/min. The muscular tone, the contractile activity, and the total rhythmic variations of the sphincter during infusions were all significantly less in patients with diverticula than in the controls without diverticula. The findings indicate that there is a dysfunction of the choledochoduodenal sphincter in patients with juxta-papillary duodenal diverticula. This may in part be responsible for the high incidence of biliary calculi in patients with duodenal diverticula.

[Effects of choledochal perfusion with biliary acid solutions on activity of the sphincter of Oddi (author's transl)]

The changes of sphincter of Oddi's resistance, induced by choledochal perfusion of conjugated (taurocolic) and non-conjugated (colic) biliary acid solutions, in anesthetized dogs, were studied. The perfusions were made at a constant flow and intracholedochal pressures were registered. The mean number of contractions per minute, the mean maximal pressures and the mean minimal pressures in each study periods were analysed. The choledochal perfusion with the biliary acids solutions induced a slight but significative increase in sphincteric resistance. After 15 minutes, the perfusion with colic acid solution induced maximal pressures significantly more elevated than the ones observed with taurocolic acid solution. The non-conjugated solution induced a pressure tracing significantly distinct from the tracing observed with the conjugated acid solution. No changes in resistance were observed with a 2% NaCl solution. This implies that the observed changes in resistance were not related to osmotic stimulation of the sphincter of Oddi.

The muscle content and contractile capability of the common bile duct

The supraduodenal portion of the human and canine common bile duct has been shown by indirect immunofluorescent staining with anti-actin sera to contain scattered bundles of smooth muscle arranged predominantly in a longitudinal direction with respect to the axis of the bile duct. Isolated strips of canine common bile duct in vitro can contact in response to stimulation with cholecystokinin. The force of contraction in a longitudinal direction is about three times that in a transverse direction but only 3% of that produced by isolated gallbladder strips. There appears to be a roughly proportional relationship between the amount of muscle demonstrated and the force of contraction in response to cholecystokinin.

A hydraulic behavior of the mucosal structure of the intramural common bile duct. An experimental study

In the intramural portion of the common bile duct in the dog, the lumen is occluded by the mucosal folds which are pointed to the direction of the ductal orifice. Luminal occlusion by the folds becomes more marked from the halfway of the portion as judged from the duodenal muscle layers. A pressure study using the pressure ramp apparatus suggested that the mucosal structure plays some role in generating the passage resistance to bile floow and in the prevention of regurgitation of duodenal content.

Effect of cholecystoduodenostomy and choledochostomy in pancreatic carcinogenesis

The pancreatic carcinogen N-nitrosobis(2-oxopropyl)-amine was administered to Syrian golden hamsters after cholecystoduodenostomy and choledochostomy to investigate a possible bile reflux mechanism as a factor in pancreatic carcinogenesis. The induced lesions were similar in morphology, multiplicity, and distribution to those of animals in other studies without surgery. Hence the findings contraindicate the importance of biliary reflux in pancreatic tumor induction. Other possible mechanisms are discussed.

Increased production of triglyceride-rich lipoproteins after partial biliary diversion in the rhesus monkey

An interrelationship between bile acid and triglyceride metabolism is suggested by observations in patients with endogenous hypertriglyceridemia and in subjects treated with bile acid-binding resins or chenodeoxycholic acid. We investigated this possible interrelationship in the rhesus monkey. The effect of 14 days of partial bile diversion on plasma concentration and secretion rates of triglyceride-rich lipoproteins was studied by means of a stream-splitting device that permitted controlled interruption of the enterohepatic circulation. Diversion of 25% of the enterohepatic circulation resulted in increased bile acid synthesis and decreased bile acid secretion and pool size, and was associated with a 75% increase in fasting serum triglyceride concentration and a twofold increase in the rate of secretion of triglyceride-rich lipoproteins into plasma. Intraduodenal replacemtn of cholic acid during the period of bile diversion completely prevented the increase in lipoprotein secretion and partially prevented the increase in fasting plasma triglycerides, suggesting that these changes resulted from loss of bile acid rather than other components of bile. These studies show that partial removal of bile acids from the enterohepatic circulation augments the secretion of triglyceride-rich lipoprotein into plasma in the rhesus monkey. Elucidation of the mechanism of this effect may provide important new information concerning the control of hepatic lipoprotein secretion.

Determinants of fasting and postprandial serum bile acid levels in healthy man

The relationship between serum levels of conjugates of cholic acid measured by radioimmunoassay, bile acid absorption, and hepatic clearance was studied in order to define the determinants of fasting and postprandial serum bile acids in healthy man. Acute or chronic interruption of the enterohepatic circulation caused a significant decrease in basal serum levels of cholyl conjugates, while liquid or solid meals caused a marked and reproducible increase in serum cholyl conjugates. A temporal correlation was demonstrated postprandially or after intravenous cholecystokinin between intestinal transit of bile acids and simultaneous changes in levels of serum cholyl conjugates. Finally, the plasma disappearance of intravenously injected cholylglycine was shown to be unaffected by serum levels of endogenous cholyl conjugates. These data are consistent with the interpretation that, in the presence of normal hepatic function, the major determinant of serum bile acids is their rate of intestinal absorption.

[The effect of dopamine on the renal function in dogs with chronic ligation of the common bile duct (author's transl)]

The influence of dopamine on glomerular filtration rate (GFR), renal plasma flow (ERPF) and urinary sodium excretion was investigated in dogs before and after a chronic bile duct ligation for a period of 16 days. 1. Dopamine (4 microgram/kg/min.) leads to an increase of GFR, ERPF and urinary sodium excretion. 2. There was no change of GFR and ERPF after bile duct ligation. Urinary sodium excretion was decreased. The decrease was, however, not significant (0.05 less than p less than 0.1). 3. After bile duct ligation dopamine induced increase of GFR and ERPF was of the same order as observed in the preoperative period. Compared with the preoperative values for sodium excretion the dopamine effect was lower (p less than 0.05). The present investigation shows that dopamine is worth trying in cases of obstructive jaundice accompanied by acute renal failure.

[The effect of caerulein on intraluminal pressures of the common bile duct and duodenum in man (author's transl)]

Caerulein is a dekapeptide related to gastrin and cholecystokinin with profound effects on gastrointestinal motility. In the present study we examined the effect of intravenously administered caerulein (0.1 microgram/kg body weight) on the intraluminal pressure of common bile duct and duodenum in 12 patients. The pressure recordings were obtained by endoscopic perfusion manometry. The tip of the perfused catheter was positioned under radiological control and the measurements were carried out under standardized conditions. Following the injection of caerulein there was a rise in pressure in the common bile duct and the mid portion of the duodenum. The pressure increase in the common duct appears to be predominantly due to contraction of the gallbladder as it is considerably less pronounced in patients with cholecystectomy. The problems inherent to endoscopic pressure recordings under pharmacological stimulation are discussed.

Physiologically based pharmacokinetic model for digoxin distribution and elimination in the rat

A plasma flow rate-limited pharmacokinetic model was developed to describe the distribution of digoxin to the heart, liver, kidneys, skeletal muscle, and GI tract in the rat. The model also provides for renal, hepatic (metabolic and biliary), and GI clearance as well as for biliary and GI secretion and GI reabsorption of digoxin. Predicted concentrations of digoxin in the heart, liver, skeletal muscle, and plasma were consistent with experimental observations in conscious rats after an intravenous dose. The model was extended to describe digoxin concentrations in the plasma of bile duct-ligated rats and ureter-ligated rats, simply by modifying appropriate clearance parameters. Excellent agreement was obtained between predicted and observed urinary excretion rates of digoxin for 12 hr after in intravenous dose to normal and bile duct-ligated rats.

[A new method for the fixation of the "T"-drainage in long-term experiments]

A new method of long-term fixing the T-drainage in the abdominal wall in animal experience is discribed. Measurements of the pressure in the ductus choledochus were carried out by using a caroli-manometer in an long-term experiment.

Bile proteins in the serum of jaundiced rats

The major bile proteins can be detected by two-dimensional electrophoresis in the serum of cholestatic rats, three days after ligation of the common bile duct. The novel electrophoresis system used agarose gel electrophoresis in the first dimension followed by equilibrium electrophoresis in a polyacrylamide gel gradient.

Intraoperative measurement of the bile flow resistance in the terminal portion of the common bile duct and its clinical significance in biliary surgery

A practical method, safe and relatively simple to perform, which we have developed for the intra-operative measurement of the resistance to bile flow in the terminal portion of the common bile duct is described. This method performed routinely in conjuction with the operative cholangiography in the operating room, proved to be a powerful diagnostic acid for detecting abnormalities in the terminal portion of the common bile duct. In gallstone disease, the results by this method were compared with the operative results. It was found that minimal organic changes or functional disturbances in the terminal portion of the common bile duct, even those without jaundice, can be detected, and unnecessary choledochotomy or sphincteroplasty avoided. This method has a further advantage in that it gives universality to the resistance R and the residual pressure P as quantitative discriptive indices for the qualitative state of bile flow in the terminal portion of the common bile duct, and, if adopted as a standard and routine method, should make the comparison of works by different investigators easier and more significant.