Effects of ethyl alcohol on sphincteric resistance at the choledocho-duodenal junction in man

Proposed management of traumatic blunt gallbladder injuries: A case of a pre-emptive laparoscopic cholecystectomy for suspected gallbladder avulsion after blunt traumatic liver injury

Trauma is the leading cause of death among people aged 1–45 in the United States with the abdomen being the third most commonly injured anatomic region. The incidence of gallbladder trauma in the setting of abdominal injury ranges between 0.5 and 2.1 %. While gallbladder injuries secondary to penetrating abdominal wounds are found intra-operatively owing to the likely progression towards laparotomy, due to the paradigm shift of non-operative management of blunt liver injuries, the diagnosis of blunt gallbladder injuries are commonly delayed upwards of 1 to 6 weeks. ⁴ We present a case of a pre-emptive cholecystectomy less than 36 h after sustaining a grade V liver injury status post blunt abdominal trauma in effort emphasize the importance of critical review of diagnostic images, and support the utilization of diagnostic laparoscopy to definitively diagnose and manage traumatic blunt gallbladder injuries. When operative intervention is not performed, the nonspecific findings suggestive of gallbladder injuries can lead to delayed diagnosis and subsequent increased morbidity and mortality. Due to the lack of previous guidelines we propose a diagnostic algorithm for the approach of traumatic blunt gallbladder injuries.

Acute alcohol-induced pancreatic injury is similar with intravenous and intragastric routes of alcohol administration

OBJECTIVES

Five percent of alcoholics develop an acute pancreatitis (AP). The mechanism leading to pancreatic injury is not yet understood. Microcirculatory disorders seem to play a pivotal role. The objective of this study was to compare alcoholic pancreatic injury in response to intravenous and intragastric routes of alcohol administration.

METHODS

Alcohol was applied in rats intravenously (IV) or gastric via a surgical implanted feeding tube (IG). Serum alcohol concentration was maintained between 1.5‰ and 2.5‰. Four subgroups (n = 6/group) were examined in the IV/IG arm and compared with healthy controls. Pancreatic microcirculation, enzyme levels, and morphological damage were assessed after 3, 6, 12, and 24 hours.

RESULTS

Microcirculatory analysis showed significantly disturbed pancreatic perfusion and increased adherent leukocytes in IV and IG animals. In IV and IG groups, serum amylase was increased without morphological signs of AP compared with healthy controls.

CONCLUSIONS

Alcohol application does not induce AP in rodents, but impairs pancreatic microcirculation irrespectively of the application route. Intravenous application is commonly used and shows no disadvantages compared with the physiological intragastric application form. Therefore, the intravenous route offers a valid model, which mimics the physiological process for further studies of the influence of acute alcohol intoxication on the pancreas.

Potent inhibitory effect of alcoholic beverages upon gastrointestinal passage of food and gallbladder emptying

BACKGROUND AND AIMS

Current knowledge about the effect of alcoholic beverages on postprandial functioning of the digestive system is scarce and inconsistent. This study addresses their influence upon meal movement along the gut and meal-induced gallbladder emptying.

METHODS

Three examination blocks involved each 12 healthy volunteers. Ingestion of a solid 1485 kJ meal was followed by intake of 400 ml beer (4.7%vol), 200 ml red wine (13.7%vol) or 100 ml whisky (43.5%vol) or matching volumes of control fluids. Gastric myoelectrical activity and emptying, orocecal transit and gallbladder emptying was monitored noninvasively.

RESULTS

Alcoholic beverages (beer, red wine, whisky) caused a significant slowdown of the gastric evacuation of the solid meal, the delay being the more potent, the greater was the concentration of ethanol. This inhibitory effect was not caused by interference with the gastric myoelectric activity. Alcoholic beverages produced only by fermentation (beer, red wine), at odds with the effect of their counterpartying aqueous ethanol solutions, did not elongate the orocecal transit of the solid food. Products of distillation-whisky and high proof ethanol solution--elicited a profound delay of the orocecal transit. Alcoholic beverages exerted an inhibitory effect upon the meal-stimulated gallbladder emptying, the magnitude of which increased in the order: beer → red wine → whisky.

CONCLUSION

Alcoholic beverages exert an inhibitory effect upon the gastric emptying of a solid food and the meal-induced gallbladder emptying, whereas the effect upon the orocecal transit depends on the type of a beverage-whisky elicits a delay but beer or red wine are devoid of this effect.

Blunt abdominal trauma resulting in gallbladder injury: a review with emphasis on pediatrics

BACKGROUND

Gallbladder injury in blunt abdominal trauma is a rare and difficult diagnosis. Gallbladder injury is reported to be between 1.9% and 2.1% of all abdominal traumas. It has vague symptoms usually with inconclusive investigation results; hence, it is often diagnosed at laparotomy. The patient typically has vague abdominal pain and occasionally a period of remission depending on the type of gallbladder injury. In pediatrics, blunt abdominal trauma presents additional challenges of difficult historians and compensating physiology. Any delay in diagnosis and definitive management will worsen the prognosis. Making the diagnosis requires astute clinical acumen and radiologic interpretation. The classification system of Losanoff has merit in guiding treatment. While cholecystectomy is the preferred treatment, there are occasions when the gallbladder may be left in situ and these are discussed.

METHODS

Literature searches were performed using Pubmed and Medline with keywords "abdominal trauma," "gallbladder injury," and "gallbladder perforation."

DISCUSSION

The authors highlight the incidence of associated visceral injuries in gallbladder trauma (>90%). Gallbladder perforation is more likely in cases when the gallbladder is distended and thin-walled at the time of injury. Therefore, we recommend that gallbladder perforation is suspected in those patients who have drunk alcohol or eaten recently. Despite the developments in modern computed tomography, identifying gallbladder perforation is difficult because of the subtlety and rarity of the condition. We draw attention to the proposed anatomic classification systems because they are of some use in guiding treatment. In the absence of a diagnosis after blunt abdominal trauma and with intra-abdominal free fluid, the clinician faces the difficult decision of whether surgery is indicated for a potential visceral injury. After discussing the available evidence, the authors advocate a low index of suspicion for performing diagnostic laparoscopy.

Acute pancreatitis with an emphasis on infection

Acute pancreatitis is an inflammatory disease that is mild and self-limiting in about 80% of cases. However, severe necrotizing disease still has a mortality of up to 30%. Differentiated multimodal treatment concepts are needed for these patients, including a multidisciplinary team (intensivists, gastroenterologists, interventional radiologists, and surgeons). The primary therapy is supportive. Patients with infected pancreatic necrosis who are septic undergo interventional or surgical treatment, ideally not before the fourth week after onset of symptoms. This article reviews the pathophysiologic mechanisms of acute pancreatitis and describes clinical pathways for diagnosis and management based on the current literature and guidelines.

Chronic alcohol intake increases the severity of pancreatitis induced by acute alcohol administration, hyperlipidemia and pancreatic duct obstruction in rats

BACKGROUND

The mechanism of alcoholic pancreatitis is still unknown. It is of special interest why only about 5% of all alcoholics develop an episode of pancreatitis. We evaluated the role of long-term alcohol intake in the pathogenesis of alcoholic pancreatitis in rats.

METHODS

To evaluate the effect of long-term alcohol intake, rats were fed either a Lieber-DeCarli control diet (CD) or a Lieber-DeCarli alcohol diet (AD) for 6 weeks. Then, rats were infused over 2 h with either Ringer's solution (CO) or ethanol (E). In additional animals, alcoholic pancreatitis was induced by ethanol combined with hyperlipidemia and temporary pancreatic duct obstruction (EFO). Controls received Ringer's solution combined with hyperlipidemia and temporary pancreatic duct obstruction (RFO). Intravital microscopy (pancreatic perfusion and leukocyte adhesion), alcohol concentrations, amylase, lipase, cholesterine and triglyceride levels in plasma, myeloperoxidase activity and histology were evaluated at different time intervals.

RESULTS

In those animals which received the Lieber-DeCarli control diet, capillary perfusion was reduced in the E group and further reduced in the EFO group as compared to the controls (CO, RFO; p < 0.01). Leukocyte adhesion was significantly increased in rats receiving E (p < 0.01), and was further increased in the combination group EFO (p < 0.01). EFO induced histologically evident acute pancreatitis. The additional administration of a long-term alcohol diet further increased microcirculatory disturbances and pancreatic injury significantly (EFO-AD > EFO-CD).

CONCLUSIONS

This study shows that alcoholic pancreatitis is induced by the combination of ethanol and individual cofactors. Chronic alcohol abuse intensifies these changes. Therefore, long-term alcohol intake seems to be a major factor in the pathogenesis of alcoholic pancreatitis.

A decade of experience with injuries to the gallbladder

BACKGROUND

Considering that injuries to the gallbladder are rare, the purpose of this study was to evaluate injury patterns, operative procedures and outcomes in patients with trauma to the gallbladder. A retrospective review of traumatic injuries to the gallbladder at an urban level 1 trauma center from 1996 to 2008 was performed. Injuries were identified via imaging or during operative exploration.

RESULTS

Injuries to the gallbladder occurred in 45 patients, 40 (89%) of whom suffered penetrating trauma. Associated injuries were present in 44 (98%) patients, including 10 (22%) pancreatic injuries requiring repair and/or drainage. Patients were severely injured (49% hemodynamically unstable at presentation; mean Injury Severity Score = 20; mean length of stay = 22 days; mortality rate = 24%). Cholecystectomy was performed in 42 patients (93%), while the remaining 3 had drainage only as part of a "damage control" operation related to their critical physiologic status. Injuries to the extrahepatic biliary ducts occurred in 3 patients (7%) as well. Although all patients developed trauma related complications, none were a direct result of their biliary tract injuries.

CONCLUSION

Injuries to the gallbladder are rare even in the busiest urban trauma centers. Almost all patients have associated intra-abdominal injuries, and nearly 50% of patients are hemodynamically unstable on admission. Rapid cholecystectomy is the treatment of choice for all mechanisms of injury, except when the first operative procedure is of the damage control type.

Alcohol pretreatment increases hepatic and pulmonary injury in experimental pancreatitis

BACKGROUND

Systemic complications including pancreatitis-associated lung injury (PALI) are critical factors that determine the outcome of severe necrotizing pancreatitis (SNP). The aim of the present study was to evaluate the role of chronic alcohol exposure on the development of PALI.

METHODS

48 rats were fed either a Lieber deCarli control or alcohol diet for 6 weeks. After completion, SNP was induced by intraductal infusion of bile salt followed by intravenous infusion of cerulein over 6 h. Control animals received i.v. Ringer's solution. Intravital microscopy of the liver was performed 6 h after induction of SNP to evaluate hepatic perfusion and leukocyte adhesion. Serum parameters, edema, inflammation, and histological changes were evaluated at 12 h. IL-6 levels were evaluated in portal venous and systemic blood as well as in pancreatic tissue homogenates.

RESULTS

Alcohol pretreatment did not affect pancreatic injury in SNP. PALI was aggravated after alcohol ingestion. These animals showed increased hepatic microcirculatory disturbances, compared to SNP alone. IL-6 showed peak levels in SNP with alcohol pretreatment, although they were also elevated in SNP alone. Systemic levels of IL-6 were higher than in the portal vein.

CONCLUSION

In SNP, alcoholic pretreatment increases pulmonary damage, while pancreatic injury is identical. The liver seems to participate in this effect by increased hepatic cytokine release.

Sphincter of Oddi function in the Australian brush-tailed possum is inhibited by intragastric ethanol

The role of sphincter of Oddi (SO) function in alcoholic acute pancreatitis (AP) is unclear. We aimed to compare the effect of i.v. and intragastric (IG) ethanol on SO function (i.e. trans-sphincteric flow; TSF) and investigate possible neural mechanisms. The involvement of gastric mucosal damage was also investigated by pretreatment with pantoprazole. In anaesthetized Australian possums, blood pressure (BP), TSF and blood ethanol concentrations were measured after i.v. or IG ethanol. Possums were subjected to acute vagotomy, atropine, L-nitro arginine methyl ester (L-NAME) or pantoprazole pretreatment prior to IG ethanol. BP was not significantly altered by ethanol. Ethanol decreased TSF in a dose and route-dependent manner. The lowest dose of IG ethanol reduced TSF but this response was not duplicated by i.v. ethanol producing the same blood ethanol concentrations. Acute vagotomy, atropine or L-NAME pretreatment blocked the ethanol-induced decrease in TSF and simultaneously suppressed the blood ethanol concentration. Pantoprazole pretreatment reduced the TSF response and blood ethanol concentrations implicating mechanisms induced by gastric mucosal damage. We conclude that ethanol (and/or its metabolites) reduces TSF via humoral and neural mechanisms involving vagal pathways, muscarinic receptors and nitric oxide. Reduced TSF could contribute to the onset of AP.

Laparoscopic cholecystectomy for isolated traumatic rupture of the gallbladder following blunt abdominal injury

Gallbladder rupture following blunt abdominal trauma is a rare event usually recognized on evaluation and treatment of other visceral injuries during laparotomy. Isolated gallbladder rupture secondary to blunt abdominal trauma is even more uncommon. Delay in the diagnosis of the injury for several days due to no, or vague, symptoms and an insidious course is common. Early diagnosis is essential, as protracted treatment may result in significant morbidity and mortality. We report the case of a patient who suffered isolated gallbladder rupture due to blunt abdominal trauma from a fall. We propose laparoscopic cholecystectomy as a safe and effective surgical treatment for this solitary injury.

A review: acute and chronic effects of ethanol and alcoholic beverages on the pancreatic exocrine secretion in vivo and in vitro

Whereas oral or intraduodenal ethanol causes a moderate stimulation of pancreatic bicarbonate and enzyme output, intravenous ethanol inhibits basal and hormonally stimulated pancreatic exocrine secretion in humans, dogs, cats, pigs, rabbits, and rats. This inhibition could be mediated by inhibitory cholinergic mechanisms or be the result of a direct cellular effect of ethanol. In vitro investigations have specified several signaling molecules that may be involved in the action of ethanol on stimulus-secretion coupling in the exocrine pancreas, including cyclic adenosine monophosphate, intracellular calcium, and cholecystokinin and somatostatin receptors. In difference to pure ethanol solutions and distilled spirits, beer strongly stimulates pancreatic enzyme output, probably by nonalcoholic fermentation products. During chronic alcoholism, the ethanol-induced inhibition is replaced by an enhanced enzyme output that causes intraductal protein precipitation. In vitro investigations suggest that this increase is reversible after alcohol withdrawal. The occurrence of protein precipitates is considered to be a crucial step in the development of chronic alcoholic pancreatitis in humans. Other ethanol-induced secretory alterations that may contribute to the development of alcoholic pancreatitis are a decreased secretion of trypsin inhibitor, an increased cholinergic tone, and changes in the concentration of lithostathine.

Ethanol inhibits sphincter of Oddi motility

Patients with alcohol-induced liver disease are at increased risk for pigment gallstones, which are known to be particularly associated with biliary stasis. Although the effects of ethanol on the sphincter of Oddi are thought to contribute to alcoholic pancreatitis, the precise effects of ethanol on the biliary component of the sphincter of Oddi are unclear. In the prairie dog the common bile and pancreatic ducts enter the duodenum separately, facilitating pressure measurement in the sphincter choledochus in isolation. We therefore used this model to test the hypothesis that ethanol administration alters sphincter of Oddi motility. Twenty-six male prairie dogs fed a nonlithogenic diet were studied. With the animals under alpha-chloralose anesthesia, a side-hole pressure-monitored perfusion catheter was positioned in the sphincter of Oddi and femoral arterial and venous catheters were placed. Sphincter of Oddi phasic wave frequency (F), amplitude (A), and motility index (MI = F x A) and arterial blood pressure were monitored at 10-minute intervals before (baseline), during 20-minute intravenous infusions of 15 mg/kg (n = 9), 150 mg/kg (n = 10), and 1.5 g/kg (n = 7) ethanol and for 20 minutes after ethanol infusion. The 15 mg/kg dose of ethanol had no effect, the 150 mg/kg dose tended to reduce sphincter of Oddi motility, and significant reductions in sphincter of Oddi amplitude and motility index were seen at the 1.5 g/kg dose. These data demonstrate that ethanol infusion inhibits both sphincter of Oddi amplitude and motility index and that this effect persists for at least 20 minutes following ethanol infusion. Ethanol may contribute to gallstone formation by altering biliary sphincter motility.

Sphincter of Oddi manometry. Paradoxical response to secretin but not to CCK in alcoholic patients with no pancreatic disease

CONCLUSION

In chronic alcohol abusers with no pancreatic disease, secretin was found to induce a paradoxical spasmodic response in the sphincter of Oddi (SO) instead of the relaxation observed in controls. Cerulein, on the contrary, had a normal relaxing effect on the SO.

BACKGROUND

We previously reported SO dyskinesia in cases of chronic pancreatitis. Here we investigated whether chronic alcohol consumption may have contributed to the genesis of this dyskinesia.

METHODS

SO and main pancreatic duct pressures were recorded endoscopically with a dual electronic pressure sensor in 27 chronic alcohol abusers and compared with the values obtained in 15 normal controls. These pressures were recorded both in the basal state and after applying hormonal stimulation by injecting either secretin (1 CU/kg) or cerulein (75 ng/kg).

RESULTS

Cerulein relaxed the SO in both the controls and the chronic alcohol abusers, whereas it transiently enhanced the main pancreatic duct (MPD) pressure. Secretin induced a wave of MPD hyperpressure (+15.4 +/- 3.0 mm Hg) in both groups of subjects, but in the alcoholic group, instead of relaxing SO, it significantly enhanced the amplitude of phasic contractions (+32.6 +/- 8.4 mm Hg). The SO basal pressure was also paradoxically enhanced by secretin in the alcoholic patients (28.8 +/- 8.2 vs 10.1 +/- 2.4 mm Hg).

CT scan evaluation of blunt hepatic trauma

Information provided by CT scan allows for determination of the extent of liver injury and identification of other nonhepatic abdominal injuries. This information, coupled with clinical assessment, can be used to optimize management. Contrast-enhanced CT scan can monitor progression or resolution of hepatic injuries, detect complications, and guide percutaneous treatment of some complications. This article discusses CT scanning technique; classification, sites, and mechanisms of liver injury; CT scan appearance of liver injury; and complications of hepatic trauma.

Clinical update: management of acute pancreatitis

The management of acute pancreatitis commences with confirming the diagnosis and establishing the aetiology. Improved methods of assessing the biliary tree may reduce the number of patients regarded as having idiopathic pancreatitis. Detailed clinical and laboratory protocols, designed to assess severity, have no major advantage over clinical assessment. The contrast-enhanced computed tomography scan is important to assess the degree of pancreatic necrosis and to detect local complications. The treatment of pancreatitis continues to be largely supportive. However, controlled studies support the use of antibiotics in severe acute pancreatitis and indicate a possible role for the use of octreotide and antioxidants. The place of endoscopic and surgical intervention is becoming better defined. Once an attack has passed, further investigation is often required in a bid to prevent further episodes of inflammation.

Non-surgical trauma to the extrahepatic biliary tract

Non-surgical trauma to the extrahepatic biliary tract is uncommon and encountered only rarely by surgeons outside specialist hepatobiliary centres. Such injury often results in significant morbidity and mortality. This review outlines the incidence, classification, mechanisms of injury, presentation, diagnostic techniques and management options. Depending on the type of biliary injury identified, an optimal method of repair is suggested. Recommendations are made for surgeons who encounter this type of injury and do not have the appropriate expertise for definitive management.

Effect of local instillation of alcohol on sphincter of Oddi motor activity: combined ERCP and manometry study

The effect of local instillation of alcohol on sphincter of Oddi motor activity was determined by endoscopic manometry. Sphincter of Oddi pressures and motor function were compared in eight cholecystectomized subjects with normal sphincter of Oddi motor function and in four patients with chronic alcoholic pancreatitis. The effect of local instillation of 3 ml of 40% alcohol was compared with water instillation. In cholecystectomized subjects, alcohol produced a significant increase of basal sphincter of Oddi pressure from 21.0 +/- 2.8 mm Hg to 95.8 +/- 83 mm Hg (p less than 0.01) without significant changes in the amplitude, duration, and frequency of phasic contractions. In patients with alcoholic chronic pancreatitis, alcohol instillation resulted in a significant increase of basal sphincter of Oddi pressure from 32.5 +/- 4.8 mm Hg to 225.1 +/- 105 mm Hg without changes in amplitude, duration, and frequency of phasic contractions. Two patients with chronic alcoholic pancreatitis had a tonic contraction of the sphincter of Oddi with transitory and mild epigastric pain. Local instillation of alcohol increases sphincter of Oddi motor activity which may play a role in the pathogenesis of alcoholic pancreatitis.

Aberrant pancreas is not susceptible to alcoholic pancreatitis

Three cases of chronic alcoholic pancreatitis associated with aberrant pancreas are reported. All three patients underwent laparotomy, and an aberrant pancreas was found in the jejunum of each of the three patients. Microscopic examination of the aberrant pancreas did not show any changes suggestive of chronic pancreatitis, despite severe chronic pancreatitis in the main pancreas.

Alcohol and the small intestine

Several alterations of the small-intestinal morphology and function have been documented after alcohol ingestion. There are morphologic changes macroscopically and microscopically after acute alcohol administration in the proximal part of the small intestine, which are quickly reversible. There are no macroscopic changes and, in most patients, very discrete light microscopic changes in the small intestine after chronic alcohol ingestion. The ultrastructural changes are, however, profound, as seen by both transmission and scanning electron microscopy. The permeability is probably increased, permitting entrance of possible noxious agents, which may explain some of the extraintestinal tissue damage observed in chronic alcoholism. The transit is increased, at least after acute alcohol administration, perhaps contributing to the diarrhea commonly seen after heavy drinking. Several of the enzymes located in the brush border are affected; lactase activity can be depressed and perhaps result in a transient milk intolerance in predisposed individuals. The activity of GGT is increased and may partly account for the GGT elevation in serum after heavy drinking. Other enzymes, such as Na(+)-K(+)-ATPase, can be inhibited and result in a decreased absorption of substances that require active, energy-dependent transport mechanisms. The secretion of water and electrolytes may be increased (an effect on cAMP?). The absorption of several nutrients, vitamins, and other elements is disturbed. The bacterial flora is increased and changed, which may give rise to symptoms and also increase the production of acetaldehyde by bacterial metabolism of ethanol. Acetaldehyde is more toxic than ethanol, and an increased concentration of acetaldehyde can possibly accentuate the damage to the liver and other organs. The bacterial overgrowth can possibly cause endotoxinemia. Although studies on alcohol-related intestinal alterations have been relatively sparse, the acute and chronic effects of alcohol thus seem to be considerable. From available results it is, however, difficult to draw any definite conclusions about the clinical importance of many of the findings. Future research will need to study the relationship between, for example, the chronic morphologic changes, the absorptive dysfunction, and permeability alterations, on the one hand, and the gastrointestinal symptoms, the extraintestinal damage, and various deficiencies, on the other hand.

Morphologic changes in the small intestine after chronic alcohol consumption

The morphology of the small-intestinal mucosa was studied in 11 alcoholic patients admitted to hospital for detoxification. A first biopsy specimen from the small intestine was taken as soon as possible after admission and a second specimen after about 6 weeks of abstinence. The specimens were studied in the light microscope, in the scanning electron microscope, and by immunohistochemistry. Morphometrically, a slight reduction in villus height in relation to crypt depth was observed. One patient had a subtotal villus atrophy. After abstinence the villus height was increased in five of the six patients who accepted a second biopsy. No obvious changes were seen in the frequency and appearance of peptidergic nerves or endocrine cells. Ultrastructurally, pronounced alterations were seen in the surface ultrastructure of the enterocytes. In two specimens bacterial adhesion to the mucosal surface was also found. The ultrastructural changes were unaltered after abstinence. In serum the concentrations of zinc were reduced, and the levels of copper were elevated compared with a group of teetotallers. A recently developed marker of high alcohol consumption, carbohydrate-deficient transferrin, was as good an indicator as the other conventional biochemical markers.

Alcohol-induced pancreatic injury (Part 2). Evolution of pathogenetic theories

In Part I of this paper, features of alcoholic pancreatitis that are still poorly understood were reviewed and factors that might favor biliary-pancreatic reflux were summarized. Part II deals with additional pathogenetic schemes that might shed light on this perplexing disorder.

Effect of alcohol on cyclical myoelectric activity of the opossum sphincter of Oddi

Ethyl alcohol may adversely affect pancreatic function by perturbing sphincter of Oddi (SO) or duodenal motor activity. The aim of this study was to identify the effect of ingested alcohol on the SO, duodenal, and gastric myoelectric activity in conscious opossums. In five adult opossums bipolar stranded stainless-steel wire electrodes were implanted on the SO, gastric antrum, and duodenum. After a 2-week recovery period, each animal underwent eight 8-hr recording sessions while fasted and awake. After two fasting cycles of the migrating myoelectric complex, animals were randomly fed either 10 ml of a 30% ethyl alcohol solution or 10 ml of water via an esophageal tube, and recordings continued for 4-6 hr. During the control state, cyclical myoelectric spike activity was recorded from the SO, gastric antrum, and duodenum with a mean +/- SD cycle length of 7.35 +/- 15.0 min, 74.3 +/- 10.1 min, and 94.8 +/- 8.7 min, respectively. With alcohol, SO and duodenal cycle lengths were unchanged while gastric cycle length decreased. However, alcohol effected a significant increase in peak SO spike burst frequency with no corresponding change in gastric or duodenal spike burst frequency. An equivalent volume of water had no influence on sphincter of Oddi myoelectric activity. It is concluded that ingested alcohol induces increased myoelectric activity from the opossum SO, independent of changes in activity of the duodenum or stomach. Since the SO plays a major role in metering bile and pancreatic flow into the duodenum, this may be a factor in alcohol-induced pancreatitis.

Trace element levels in human alcoholic brain

Copper, magnesium, zinc and manganese levels in the temporal cortex of human alcoholic and control brains were measured by atomic absorption spectrophotometry using both the flame and graphite furnace. All of the 21 alcoholics were male with a mean age of 54.1 years; the 19 male controls had a mean age of 60.2 years. The only statistically significant change in ion levels was an increase in manganese concentration (expressed both as microgram/g wet weight and ng/mg protein) in the alcoholic group when compared to the control group. Five of the alcoholics had malignancies, while 16 of the controls had systemic malignancies. Covariance analysis showed there was no effect of age on the level of manganese in the temporal cortex.

Pathogenesis of alcoholic pancreatitis

The pathogenesis of alcoholic pancreatitis continues to be a puzzle. Of the many theories as to how alcohol might cause pancreatic damage, none satisfactorily explains why only a minority of alcoholics develop clinical pancreatitis. Hypertriglyceridemia and inherited factors could be important antecedents in some individuals, and high fat and protein diets may favour the development of the disease. Disturbances of the sphincter of Oddi have been postulated, but there are experimental and theoretical objections to the view that alcoholic pancreatitis generally results from sphincter dysfunction (obstruction-hypersecretion, biliary-pancreatic reflux and duodeno-pancreatic reflux). Biochemical studies of the effect of alcohol on pancreatic tissue have so far been relatively unrewarding. The most widely held view is that alcohol causes the deposition of protein in peripheral ducts leading to obstruction, inflammation and degeneration. However, it remains to be shown that these deposits are the cause rather than a result of pancreatic inflammation. Research might be facilitated by the development of a suitable animal model of the disease.

Effects of ethanol on the sphincter of Oddi: an endoscopic manometric study

The effects of ethanol, given either intragastrically or intravenously, on the sphincter of Oddi was evaluated by endoscopic manometry. In 12 subjects intragastric ethanol (150 ml of 32%) was given over 10 minutes. In five control subjects saline solution (150 ml of 0.9%) was given intragastrically instead of ethanol. In five other subjects ethanol was infused intravenously (6 ml/kg of 10%) for 36 minutes. Ethanol given intragastrically produced a significant inhibitory effect on sphincter of Oddi pressure. Peak pressure fell from a control value of 75.7 +/- 26.35 mmHg to 39 +/- 15.39 mmHg (p less than 0.001) at 35 minutes. Basal pressure fell from a control value of 30.17 +/- 19.47 mmHg to 11.83 +/- 6.35 mmHg (p less than 0.01) at 35 minutes. Wave height fell from a control value of 41.33 +/- 15.4 mmHg to 27.16 +/- 11.25 mmHg (p less than 0.02) at 35 minutes. No effects on sphincter of Oddi wave frequency were observed. No significant modifications of sphincter motor activity were observed after intragastric saline infusion. Ethanol given intravenously also produced an appreciable inhibitory effect on sphincter of Oddi pressure, without affecting its wave frequency.

Gallbladder injuries resulting from blunt abdominal trauma: an experience and review

Over a seven-year period from 1973 through 1979, 31 patients with blunt gallbladder trauma were treated at the Maryland Institute for Emergency Medical Services Systems. Twenty patients had contusions, ten patients had avulsions and one patient had a perforation of the gallbladder. None of the gallbladder injuries were suspected preoperatively. Twenty-eight of the 31 patients had a diagnostic peritoneal lavage performed on admission, all were positive for blood; bile was not grossly evident. Among the 30 patients, there were 75 associated intraabdominal injuries; there were 25 liver injuries. Five patients died, none as a result of their gallbladder injury. Cholecystectomy is suggested as the definitive procedure of choice for severe contusions and for perforating and avulsive injuries to the gallbladder. Cholecystostomy is indicated in a few patients and should be regarded as a temporary procedure. A review of the English literature shows a total of 101 patients (including the 31 of this study) with gallbladder injuries secondary to blunt trauma. The most commonly reported injury was perforation. The 20 contusions described in the present study are the first such injuries reported.

Isolated perforation of the gall bladder following blunt abdominal trauma

Isolated perforation of the gall bladder as a consequence of blunt abdominal injury is rare. A single case is described which illustrates several features which may characterize this lesion.

The diagnosis and treatment of functional disorders of the biliary tract

An approach to the diagnosis and treatment of patients with presumed functional disorders of the biliary tract (biliary dyskinesia) is described. The current diagnostic criteria are pain compatible with biliary pain in the absence of gallstones and other organic gastrointestinal disease, or other disorders which might produce abdominal pain, together with reproduction of the patient's symptoms by cholecystokinin, or morphine, or both. Other diagnostic methods are described together with their limitations. The results of operation in 38 of 45 patients seen in this Unit during the past six years are presented. The results were poor in 20% of patients, but two-thirds of the group have had good results in the short term.

Jaundice as a sign of delayed gall-bladder perforation following blunt abdominal trauma

A case of delayed rupture of the gall-bladder following blund abdominal trauma is presented. A discussion of the aetiology, clinical and biochemical manifestations, and prognosis of this condition follows.

Acute pancreatitis

FOR MANY DECADES TWO TYPES OF ACUTE PANCREATITIS HAVE BEEN RECOGNIZED: the edematous or interstitial and the hemorrhagic or necrotic. In most cases acute pancreatitis is associated with alcoholism or biliary tract disease. Elevated serum or urinary alpha-amylase is the most important finding in diagnosis. The presence of methemalbumin in serum and in peritoneal or pleural fluid supports the diagnosis of the hemorrhagic form of the disease in patients with a history and enzyme studies suggestive of pancreatitis. There is no characteristic clinical picture in acute pancreatitis, and its complications are legion. Pancreatic pseudocyst is probably the most common and pancreatic abscess is the most serious complication. The pathogenetic principle is autodigestion, but the precise sequence of biochemical events is unclear, especially the mode of trypsinogen activation and the role of lysosomal hydrolases. A host of metabolic derangements have been identified in acute pancreatitis, involving lipid, glucose, calcium and magnesium metabolism and changes of the blood clotting mechanism, to name but a few. Medical treatment includes intestinal decompression, analgesics, correction of hypovolemia and other supportive and protective measures. Surgical exploration is advisable in selected cases, when the diagnosis is in doubt, and is considered imperative in the presence of certain complications, especially pancreatic abscess.