Gallbladder and duodenal bacterial flora after papillotomy in rabbits

Long-term changes in hepatobiliary physiology after Roux-en-Y hepaticojejunostomy

Hepaticojejunostomy (HJ) is a common operation used to by-pass extrahepatic biliary obstructions and to establish biliary-enteric continuity after resections for benign and malignant diseases. Little is known about the effect of this procedure on hepatobiliary physiology. The aim of the present study was to investigate in a swine model the changes in biliary dynamics, bile composition, and hepatic histology induced by Roux-Y HJ. Twenty-four swine (57 (47 to 76) kg) underwent cholecystectomy, with HJ (Group I; n = 12) or without any biliodigestive anastomosis (Group II, n = 12), and were followed up for 6 or 12 mo by repeated weight scaling, blood, serum, and bile analysis, (99m)Technetium (Tc), diethyliminodiacetic acid (HIDA) dynamic biligraphy, and histological analysis. During follow-up, HJ was associated with less weight gain, colonization of the bile duct with aerobic bacteria Escherichia coli dominating (in 75% of the animals), a shortened hilum-intestine transit time but reduced liver clearance in dynamic biligraphy, and fibrous periportal changes in liver histology (in 50% of the animals). We conclude that during 1 y follow-up HJ with no anastomotic stricture formation is associated with improved extrahepatic bile drainage, but with ascending contamination of bile ducts with bacteria, which might be involved with the fibrous periportal changes in the liver resulting in diminished excretion of Tc-HIDA from the hepatocytes into the bile. The clinical significance of these changes, and the reduced weight gain observed is a topic of further investigations.

Long-term symptoms following endoscopic sphincterotomy for common bile duct stones

BACKGROUND

Endoscopic sphincterotomy (ES) has an important role in the management of biliary stones. However, the long-term effects of free duodenobiliary reflux are not established, and it may lead to low-grade morbidity.

METHODS

We used a questionnaire survey to assess the prevalence of symptoms of biliary disorder in patients who had undergone endoscopic retrograde cholangio pancreatography (ERCP) and ES under the care of a single surgeon (R.J.R.G) between November 1993 and May 1998.

RESULTS

ES was carried out on 136 patients during this period. Current addresses were available for 94 patients, and 54 of them (57%) responded. Patients were surveyed a mean of 43 months after ES. Only 42.1% of patients denied having any symptoms. Nausea and pale stools were reported by 28% and 26% of patients, respectively, and nearly one-fifth of patients had symptoms suggestive of cholangitis. In addition, 18.5% of patients experienced one or more symptoms frequently.

CONCLUSION

Severe long-term symptoms are uncommon following ES; however, a significant minority of patients do suffer occasional symptoms that suggest biliary dysfunction.

A bacteriologic and scanning electron microscope study after implantation of foreign bodies in the biliary tract in rats

BACKGROUND

Bacterial adherence to the stent surfaces, concomitant colonization, and possible stent blockage are the main complications after the use of biliary stents. The present study was assigned to investigate bacteriologic and morphologic changes in the biliary tract after the implantation of biliary drain materials.

METHODS

Rubber and silicone pieces with a surface area of 1 cm2 were implanted into the biliary tract in rats after temporary obstruction of the common bile duct by the use of a mini-occluder. The animals were killed at 4, 8 and 14 weeks, respectively, after implantation, and the implants were retrieved, cultured, and examined by scanning electron microscopy (SEM). Bacterial culture and SEM were also performed on tissue samples obtained from the mucosal surface of the biliary tract.

RESULTS

Bacterial colonization and biofilm formation were found on the surfaces of the implanted materials and on the mucosal surface of the biliary tract in animals with implants but not on the biliary tract mucosa in rats without implants.

CONCLUSION

Foreign bodies implanted in the biliary tract facilitate bacterial adherence not only to the surface of the implants but also to the mucosal surface in the biliary tract.

Beta-glucuronidase activity in the bile of gallstone patients both with and without duodenal diverticula

Patients with juxtapapillary duodenal diverticula have an increased occurrence of calcium bilirubinate gallstones. One possible hypothesis to explain this observation is enzymatic deconjugation of bilirubin conjugates in the bile. Beta-glucuronidase of human or bacterial origin may lead to deconjugation of the bilirubin glucuronides in bile. This, in turn, may increase the amounts of unconjugated, water-insoluble bilirubin which can precipitate as calcium bilirubinate, the main component of brown pigment stones. In this study we compared gallstone patients with and without duodenal diverticula treated with endoscopic papillotomy. Increased occurrence of bacteria producing beta-glucuronidase (p less than 0.01) and increased activity of bacterial beta-glucuronidase (pH 7.0) in the bile itself (p less than 0.01) were found in patients with duodenal diverticula. When the activity of the enzyme at pH 4.5, the optimum of the human enzyme, was measured, no such difference was found. The results support the hypothesis of bacterial glucuronidase as an etiologic factor in pigment gallstone disease in patients with duodenal diverticula. The high activity of bacterial enzyme found in the bile in some patients without diverticula suggests bacteria as an etiologic factor, independent of the presence of diverticula.

The 1-g 14C-D-xylose breath test in gallstone patients with and without duodenal diverticula

To assess whether gallstone patients with duodenal diverticula have bacterial overgrowth in the proximal small bowel, the results of the 1-g 14C-D-xylose breath test were compared in 24 patients with duodenal diverticula and in 24 without diverticula. All patients had been treated with endoscopic papillotomy (EPT) for stones in the common bile duct before the study, and cholecystectomy had previously been performed in 20 patients. No significant differences between the groups were found concerning age, sex, and body weight. Cumulative 14CO2 expired in 3 h in percentage of administered dose of 14C-D-xylose was 8.55% (7.58-9.57%) and 7.38% (6.32-8.96%) in patients with and without diverticula, respectively (p = 0.06), indicating a higher bacterial activity in the small bowel in patients with duodenal diverticula than in those without diverticula. The results appeared to be influenced by cholecystectomy.

Cholangiography in rabbits before and after papillotomy

The gallbladder and the function of the sphincter of Oddi were studied after papillotomy (EPT) in New Zealand white rabbits. Intravenous cholangiography (IVC) was performed before and after papillotomy. After papillotomy, IVC showed gallbladder opacification in one of seven test animals, whereas gallbladder filling occurred in all six control animals. The bile ducts were not visualized in any of the test animals, whereas five of six controls showed contrast filling of the bile ducts. Reflux cholangiography was performed after EPT and showed free reflux of contrast from the duodenum to the bile ducts. These findings indicate that papillotomy results in the insufficiency of the sphincter mechanism of the ampulla of Vater, and hence intravenous cholangiography may not be valid for showing the gallbladder and the bile ducts after papillotomy.