Bile Microbiota in Patients with Pigment Common Bile Duct Stones

BACKGROUND

Common bile duct (CBD) stone is one of the most prevalent gastroenterological diseases, but the role played by biliary microbiota in the pathogenesis of CBD stones remains obscure. The aim of this study was to investigate the characteristics of the biliary tract core microbiome and its potential association with the formation of pigment stones.

METHODS

Twenty-eight patients with biliary obstruction of various causes were enrolled. Thirteen had new-onset pigment CBD stone. Of the remaining 15, four had benign biliary stricture, four had gallbladder cancer, three had pancreatic cancer, 3 had distal CBD cancer, and one had hepatocellular carcinoma. Endoscopic retrograde cholangiopancreatography was used to collect bile samples for DNA extraction, 16S ribosomal RNA gene sequencing, and bile microbiota composition analysis.

RESULTS

Proteobacteria (61.7%), Firmicutes (25.1%), Bacteroidetes (5%), Fusobacteria (4.6%), and Actinobacteria (2.6%) were the most dominant phyla in the bile of the 28 study subjects. A comparison between new-onset choledocholithiasis and other causes of biliary obstruction (controls) showed Enterococcus was found to be significantly abundant in the CBD stone group at the genus level (linear discriminant analysis score = 4.38; P = 0.03). However, no other significant compositional difference was observed.

CONCLUSION

This study demonstrates an abundance of microbiota in bile juice and presents a biliary microbiome composition similar to that of duodenum. The study also shows Enterococcus was significantly abundant in the bile juice of patients with a brown pigment stone than in controls, which suggests Enterococcus may play an important role in the development of pigment stones.

[MORPHOLOGICAL CHANGES OF THE LIVER IN OBTURATION JAUNDICE, CAUSED BY CHOLEDOCHOLITHIASIS, DEPENDING ON ITS DURATION]

Abstract The results of surgical treatment of 184 patients for obturation jaundice, caused by choledocholithiasis, were analyzed. Morphological changes of the liver were studied in 20 patients. There were three groups of patients delineated, depending on the obturation jaundice duration: up to 7 days, from 8 to 14 days, more than 15 days, and also a group of patients after the bile outflow restoration. The obturation jaundice occurrence in choledocholithiasis is accompanied by significant morphological changes in the liver, severity of which is enhancing while the obturation jaundice persistence increasing. While persistence of obturation jaundice through 8 days and more the connective tissue volume is enhancing, a relative volume of hepatocytes is reducing and a stromal-parenchymatous index is increasing. The bile outflow restoration secures significant reduction of intensity of alterative and inflammatory changes in hepatic parenchyma, as well as activation of reparative processes in the tissue. In cholangitis, caused by P. aeruginosa and E. coli, according to morphological investigations data, in the liver a diffuse purulent cholangitis on background of chronic changes in accordance to duration of the obturation jaundice persists.

[MICROBIAL LANDSCAPE OF BILE IN PATIENTS WITH AN ACUTE PURULENT CHOLANGITIS]

Bacteriological analysis was conducted in 136 patients with an acute purulent cholangitis (APCH). The APCH causes were: choledocholithiasis--in 40 (29.9%) patients, coexistence of a common biliary duct stricture and choledocholithiasis--in 39 (28.7%), compression of external biliary ducts by the oedematous pancreatic head in secondary pancreatitis--in 15 (11%), pericholedocheal lymphadenitis--in 3 (2.2%).

Diagnostic and post-treatment CT appearance of biopsy proven mixed Cryptococcus and Candida cholangitis

Cryptococcus neoformans and Candida are common opportunistic pathogens of human. There is very limited literature on Cryptococcus neoformans cholangitis or Candida cholangitis in immunocompetent patient while mixed Cryptococcus neoformans and Candida cholangitis has not been reported in the literature ever before. We hereby report the imaging findings of a case of mixed Cryptococcus neoformans and Candida cholangitis in an immunocompetent boy. The CT features included nodules in the cystic duct and common bile duct, dilatation of the intra- and extrahepatic bile ducts with mural thickening, irregular hypodense mass-like lesion extending along the bile ducts from the liver hilum to the periphery which was confirmed by the presence of enlarged and confluent lymph nodes. CT characteristics can contribute to timely diagnosis and treatment of this disease.

[Bile duct infections as a late complication after endoscopic sphincterotomy]

Nowadays endoscopic sphincterotomy (SE) is considered to be a "gold standard" in the treatment of residual choledocholithiasis and biliary pancreatitis. Nevertheless patients after invasive procedures concerning bile ducts with destruction of Oddi's sphincter often have increased succeptibility to chronic infections of bile ducts.

AIM

Assessment of the influence of SE on bacterial colonization, development of main bile duct chronic inflammation and recurrent choledocholithiasis.

MATERIAL AND METHODS

We included to the study 50 patients with main bile duct lithiasis, who underwent endoscopic cholangiopancreatography (ERCP). Among them there were 32 women in age from 45 to 87 (mean 69.7 +/- 12.3) and 18 men in age from 39 to 84 (mean 59.8 +/- 11.56). The studied group was divided into 3 subgroups: In I (control) group were included 10 patients diagnosed with ERCP techniques because of jaundice of unknown origin. Those patients did't have ERCP or operative revision of bile ducts before, but all of them underwent cholecystectomy in the past. Each II and III group consisted of 20 patients, who underwent SE before 12-24 and 25-36 months earlier respectively. Sterile uodenoscope was inserted to the region of major duodenal papilla, and then a sterile brush was used to collect material to cytological smear (brushing) from main bile duct. In all groups 2 ml of bile were taken by a catheter to a syringe. On the basis of radiograms from ERCP findings, the width of main bile duct was assessed. In all patients blood cell count, aspartate and alanine aminotransferases, gammaglutamyltranspeptidase, alkaline phosphatase, amylase, bilirubin, C-reactive protein and procalcitonine levels were measured.

RESULTS

In our study all 40 patients with previously performed endoscopic sphincterotomy (SE) had bacterial colonization in bile ducts, mostly with Gramm negative pathogens. The most virulent pathogens vere cultured from bile duct swabs from patients after two or more revisions of common bile duct, and after a longer time from sphincterotomy. Those patients had multibacterial bile duct infections (Escherichia coli + Pseudomonas aeruginosa; P. aeruginosa + Enterococcus faecalis; E. faecalis + Enterobacter cloacae + Candida albicans; P. aeruginosa + E. cloacae). E. coil and E. faecalis were most frequently cultured (20 and 16 cases respectively). It was observed that with length of time from endoscopic sphincterotomy, the width of main bile duct and also amount of cultured pathogens and their virulency grow. Elevated transaminases activity and serum procalcitonine levels were observed in studied groups. 9 patients after previous sphincterotomy had recurrent lithiasis.

CONCLUSIONS

Sphincterotomy contributes to colonization of main bile duct with pathogenic bacteria. With length of time from endoscopic sphincterotomy, and amount of performed endoscopic sphincterotomies the amount of cultured pathogens, their virulency and drug resistance grow. Chronic infection of bile ducts after endoscopic sphincterotomy causes higher risk of recurrent lithiasis.

Helicobacter species ribosomal DNA in the pancreas, stomach and duodenum of pancreatic cancer patients

AIM: To determine whether gastric and enteric Helicobacter species are associated with pancreatic cancer.

METHODS: Patients with exocrine pancreatic cancer (n = 40), neuroendocrine cancer (n = 14), multiple endocrine neoplasia type 1 (n = 8), and chronic pancreatitis (n = 5) were studied. Other benign pancreatic diseases (n = 10) and specimens of normal pancreas (n = 7) were included as controls. Pancreatic tissue specimens were analyzed by Helicobacter-specific PCR-assay and products were characterized by denaturing gradient electrophoresis and DNA-sequencing. From a subset of the pancreatic cancer patients, gastric and/or duodenal tissue as well as gallbladder and ductus choledochus tissue were analyzed. Gallbladder and choledochus samples were included as controls. Stomach and duodenum samples were investigated to analyze whether a gastric helicobacter might disseminate to the pancreas in pancreatic cancer patients. Pancreatic specimens were analyzed by Bacteroides-specific PCR for detecting the translocation of indigenous gut microbes to the diseased pancreas.

RESULTS: Helicobacter DNA was detected in pancreas (tumor and/or surrounding tissue) of 75% of patients with exocrine cancer, 57% of patients with neuroendocrine cancer, 38% of patients with multiple endocrine neoplasia, and 60% of patients with chronic pancreatitis. All samples from other benign pancreatic diseases and normal pancreas were negative. Thirty-three percent of the patients were helicobacter-positive in gastroduodenal specimens. Surprisingly, H. bilis was identified in 60% of the positive gastroduodenal samples. All gallbladder and ductus choledochus specimens were negative for helicobacter. Bacteroides PCR-assay was negative for all pancreatic samples.

CONCLUSION: Helicobacter DNA commonly detected in pancreatic cancer suggests a possible role of the emerging pathogens in the development of chronic pancreatitis and pancreatic cancer.

Loss of the major duodenal papilla results in brown pigment biliary stone formation in pdx1 null mice

BACKGROUND & AIMS

Pdx1 plays a pivotal role in pancreas organogenesis and specification of some types of cells in the duodenum and antral stomach. However, its expression is not restricted to pancreas, duodenum, and antral stomach but is also found in the common bile duct during embryogenesis. This study aimed to elucidate the role of Pdx1 in the development of the common bile duct, major duodenal papilla, and duodenum.

METHODS

Expression pattern of pdx1 during embryogenesis and the morphology of the common bile duct, major duodenal papilla, and duodenum in pdx1 null mice were analyzed.

RESULTS

The major duodenal papilla, peribiliary glands, and mucin-producing cells in the common bile duct were not formed in pdx1 null mice. Pdx1 null mice had shorter periampullary duodenal villi than wild-type mice at postnatal stages associated with reduced cell proliferation and increased apoptosis of the duodenal epithelial cells. Loss of the major duodenal papilla allowed duodeno-biliary reflux and bile infection, resulting in the formation of brown pigment biliary stones in pdx1 null mice, and antibiotics treatment significantly reduced the incidence of biliary stone formation.

CONCLUSIONS

Pdx1 is required for proper development of the major duodenal papilla, peribiliary glands, and mucin-producing cells in the common bile duct and for maintenance of the periampullary duodenal epithelial cells during perinatal period. Bile infection because of loss of the major duodenal papilla plays a significant role in the formation of brown pigment biliary stones in pdx1 null mice.

Microbiology of choledochal bile in patients with choledocholithiasis admitted to a tertiary hospital

AIM

The present study was designed to investigate the microbiology of choledochal bile of patients with cholangitis and choledocholithiasis.

METHODS

We identified and determined the antimicrobial susceptibility of bacteria isolated in the bile of patients with cholangitis and choledocholithiasis diagnosed by endoscopic retrograde cholangiopancreatography (ERCP).

RESULTS

Nineteen (82.6%) of 23 patients with choledocholithiasis had positive bile cultures. A single agent was detected in 11 patients (57.9%), while a mixed growth, with pathogens ranging from two to three species, were seen in eight patients (42.1%). Patients with clinical manifestations of cholangitis had significantly higher counts of colonies per mL of bile (> 105 cfu/mL). The predominant Gram-negative aerobic bacteria isolated were Escherichia coli (9, 31.0%), Klebsiella pneumoniae (5, 17.2%), Enterobacter cloacae (2, 6.9%), Pantoea agglomerans (1, 3.4%), and Pseudomonas aeruginosa (1, 3.4%). The predominant Gram-positive bacteria were Enterococcus faecalis (5, 17.2%) and Streptococcus sp. (5, 17.2%). Bacteroides fragilis was isolated in one patient with mixed growth. All Gram-positive bacteria isolated in bile were sensitive to ampicillin, and all Gram-negative bacteria isolated were sensitive to gentamicin with a minimum inhibitory concentration (CIM90) ranging from 0.5 to 1.0- micro g/mL. Gram-negative bacteria were also sensitive to imipenem, fluorquinolones, second and third generation cephalosporins. Although all five isolates of E. faecalis were sensitive to ampicillin, two of five (40%) E. faecalis isolates demonstrated high levels of resistance to gentamicin.

CONCLUSION

E. coli, K. pneumoniae, E. faecalis and Streptoccocus sp. were the most common bacteria isolated in the bile of patients with cholangitis and choledocholithiasis, which were sensitive to a simple therapeutic regimen, such as the combination of ampicilin and gentamicin.

Bacterial translocation from the biliary tract to blood and lymph in rats with obstructive jaundice

BACKGROUND

The disruption of the hepatocyte tight junctions observed in biliary obstruction suggests altered permeability of the blood-bile barrier. In this study the role of biliary obstruction and increased biliary pressure on the translocation of bacteria from biliary tract to bloodstream and lymphatic system were evaluated.

MATERIALS AND METHODS

Rats underwent distal bile duct ligation (BDL, n = 33) for two weeks or a sham celiotomy (n = 21). Seventeen of the 33 BDL rats underwent subsequent biliary decompression by a choledochojejunostomy (CJ). Two weeks after the final operation, a laparotomy was performed again and the CBD, the thoracic duct, and the caval vein were canulated. Next, a suspension containing 10(8) Escherichia coli/ml was retrogradely infused in the CBD for 5 min at 5 or 20 cm H2O above the secretory biliary pressure.

RESULTS

A higher biliary infusion pressure resulted in a significant increase of cfu E.coli per milliliter of blood in all the three groups (Sham, BDL, CJ). BDL rats showed significantly more bacterial translocation to the bloodstream than the shams. After biliary decompression, translocation normalized to the control levels. At 5 cm H2O infusion pressure only one lymph culture was positive (CJ group). At 20 cm H2O overpressure, nine lymph cultures were E.coli positive (P = 0.03). These were found mainly in groups with a nonobstructed bile duct (Sham and CJ 40% vs BDL 10%).

CONCLUSION

Translocation of bacteria from biliary tract to bloodstream increased at higher intrabiliary pressures. Longstanding bile duct obstruction was an independent determinant for cholangiovenous reflux. Bacterial translocation to the lymphatic system did not parallel translocation to the bloodstream, although in the nonobstructed biliary tract, increased bacterial translocation to the lymphatic system was pressure related.

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.

Mucus production of choledochal epithelial cells due to bile stagnation in the rat

Mucus secretion is increased by various causative agents of inflammation in the mucosa. Although mucus production of the choledochal epithelial cells (except goblet cells) has never been noted in the rat in normal physiological conditions, it is seen as an inflammatory reaction in animals with choledochoenterostomy, which brings bacteria and active digestive enzymes into the common bile duct through regurgitation of intestinal contents. It is known that stagnant bile alone can cause inflammation in the mucosa of the gallbladder in patients with aseptic acalculous cholecystitis. In this study, aseptic bile stagnation was caused by choledochal dilation made by detaching the common bile duct from the hepatoduodenal ligament in five rats, and histological changes of the choledochal epithelium were observed by light and transmission electron microscopy 17 months after the operative procedure to determine whether stagnant bile could cause mucus production in choledochal epithelial cells. Mucus production was noted in two rats by light microscopy and in all the rats by transmission electron microscopy, and so it was demonstrated that stagnant bile could give rise to this phenomenon in the rat choledochal epithelium.

Experimental foreign-body infection in the biliary tract in rats

BACKGROUND

Biomaterials used for biliary drainage may potentially result in biomaterial-associated infections.

METHODS

Foreign-body infection in the biliary tract was investigated in rats. Rubber drain pieces were implanted in the biliary tract in rats for 1-4 weeks, followed by challenges with 10(2) to 10(4) colony-forming units (cfu) Escherichia coli injected into the common bile duct. The rate of infection was calculated, the bacterial growth in the biliary tract was observed over 72 h after challenges, and the opsonic activity in bile and in sera was assessed.

RESULTS

In the group with drain material, inocula as small as 10(2) cfu produced persisting infection in the common bile duct in 90% of animals, whereas the same number of E. coli infected only 30% of rats in the control and sham implantation groups (p < 0.01, chi-square test). Complement-mediated opsonic activity in bile of animals with implanted drain pieces gradually decreased with time, whereas opsonic activity in sera from the same animals remained unchanged.

CONCLUSIONS

Implants in the biliary tract impair local host defense, resulting in an increased susceptibility to microbial infection.

Sensitivity to new generation of antibiotics in biliary surgery

The treatment of septic complications of cholecystectomy patients requires special attention. In a prospective study of 1009 consecutive cholecystectomy patients (including all acute and elective patients, excluding cases of malignancy), we routinely took cultures from the cystic duct and the gallbladder, and checked the strain for sensitivity. Positive cultures were found in 31.4% of the series, the most frequent bacteria being E. coli (50.3%). The aminoglycosides and the second and third generations of cephaloridins were found more specific for the strains that were cultured. While the new cephaloridins are the first choice for prophylaxis, the combination of aminoglycosides with ampicillin is to be preferred from the medical and cost effective standpoint while the aim is therapeutic.

Bile secretory immunoglobulin A in biliary infection and cholelithiasis

Bile samples from 71 patients with cholelithiasis and a control group of 10 subjects without hepatobiliary diseases were cultured for bacteria and measured for secretory immunoglobulin A (SIgA) using enzyme immunoassay specific for SIgA. The results of bile bacterial culture were all positive in patients with primary bile duct pigment stones, and significantly lower bile SIgA levels were observed than in normal controls (P less than 0.005). It was also shown that the constitutent ratios of SIgA to total bile immunoglobulin and the bile-serum ratio of SIgA were markedly lower in these patients than in normal controls (P less than 0.001, P less than 0.001). In patients with cholecystolithiasis, bile SIgA concentrations of patients with biliary infections were remarkably lower than those of patients without biliary infection (P less than 0.01) and those of normal controls (P less than 0.01). These results suggest a close relationship between biliary tract infection and low concentrations of bile SIgA.

[Correlativity of plasma endotoxin, plasma fibronectin and common bile duct pressure in severe acute cholangitis]

On the basis of common bile duct pressure measurement (CBDP) in 18 patients of severe acute cholangitis, plasma endotoxin (ET) was determined by modified synthetic chromogenic limulus amebocyte lysate assay and plasma fibronectin (FN) was detected with Laurell's rocket immunoelectrophoresis. CBDP was 2.23 +/- 0.49 KPa in patient group. There was striking positive correlation between ET and CBDP. Preoperative ET was 202.73 +/- 88.57 ng/L in patient group which was much higher than 15.47 +/- 7.38 ng/L in the control (P less than 0.001). Preoperative FN was 141.77 +/- 82.37 mg/L in the patient group which was lower than 317.21 +/- 12.57 mg/L in the control (p less than 0.001). Statistical differences could be noticed in postoperative ET and FN between the survivor and the dead. The study suggested that plasma ET levels are greatly influenced by pressure gradient of bile duct, dynamic observations of ET and FN levels are helpful to monitor disease course and predict prognosis.

Bacteriological study of choledochal bile in patients with common bile duct stones, with or without acute suppurative cholangitis

Acute suppurative cholangitis is a serious complication in extrahepatic biliary tract obstruction. Bacteriological studies have shown that in these patients the bile cultures usually present several kinds of bacteria, especially Gram-negative aerobic bacteria such as E. coli and Klebsiella sp. The mortality rate in our patients with common bile duct stones and acute suppurative cholangitis is enhanced 5- to 10-fold. The aim of the present study was to analyse the bacterial properties of choledochal bile in a large number of patients with common bile duct stones, with or without acute suppurative cholangitis, and to determine the sensitivity of the isolated bacteria to several antibiotics used in clinical practice. The greatest sensitivity of the bacteria isolated from the common bile duct was seen for aminoglycosides (gentamicin and amikacin) and for cephalosporins, especially of the third generation (cefotaxime, ceftazidime, ceftriaxone and cefoperazone). Ampicillin showed a low sensitivity rate. The appropriate selection of the antibiotics used in acute suppurative cholangitis depends not only on the concentration of the antibiotic in the bile; a high plasma concentration is even more important to control the septic manifestations. A high excretion to the bile can affect the intestinal flora, leading to diarrhea (e. g. with cefoperazone). Ampicillin has been giving contradictory results in respect of bile and plasma concentrations. Gentamicin attains 30-40% of the plasma concentration in the bile, but persists for as long as 8 hours with excellent sensitivity and clinical efficacy. Amikacin reaches 44% of the plasma concentration with a very high sensitivity (96%).(ABSTRACT TRUNCATED AT 250 WORDS)

Beta-glucuronidase activity related to bacterial growth in common bile duct bile in gallstone patients

Beta-glucuronidase activity in the bile may be of importance in the etiology of pigment gallstones. This enzyme is of hepatic or bacterial origin. We have described a method to measure the activity of bacterial beta-glucuronidase in human bile, using 4-nitrophenyl-beta-D-glucopyranosiduronic acid as substrate. The method was used to measure the beta-glucuronidase activity in the bile from 51 patients with gallstone disease. This activity was related to the presence of beta-glucuronidase-producing bacteria in the bile. Escherichia coli, Bacteroides species, and Clostridium perfringens were the only species found to produce beta-glucuronidase. Patients with beta-glucuronidase-producing bacteria had on an average significantly higher enzyme activity in the bile than patients without such bacteria (p less than 0.01). The limitations of using artificial substrates in this type of studies are discussed.

[Modern diagnostic methods and the antibiotic sensitivity of the gram-negative causative agents of suppurative-inflammatory diseases of the extrahepatic bile ducts]

Microscopic examination of native bile and smears stained with the Gram procedure rapidly provided information on the presence of bactericholia and the necessity of antibacterial therapy prior to closing of the postoperative wound in accordance with the drug spectrum. Determination of the phagocytic and bactericidal activity of the bile leukocytes was a significant adjuvant to routine microscopic examinations, whereas evaluation of the average cytochemical coefficient and phagocytosis intensity was an important factor in prognosis of postoperative pyoinflammatory complications. Gram-negative bacteria were the predominating causative agents of acute cholecystitis and cholangitis (89 per cent). Among them Escherichieae, Klebsielleae and P. aeruginosa were isolated most frequently (32.4, 31.1 and 16.4 per cent, respectively). Amikacin, tobramycin, sisomicin, gentamicin and cefotaxime showed the highest activity against the above pathogens. However, comparative analysis of the antibioticograms revealed differences in antibiotic sensitivity of separate bacterial species.

Common bile duct obstruction due to an intraluminal mass of candidiasis in a previously healthy child

A 3 6/12-year-old previously healthy girl had intermittent attacks of abdominal pain following a blunt abdominal trauma. At admission to the hospital, she had jaundice and hepatomegaly. Results of laboratory tests indicated an obstructive pattern, and ultrasonography revealed an intraluminal mass in the distal common bile duct. At surgery, the mass was confirmed as the cause of obstruction, and it was removed. Microscopic analysis indicated that the amorphous material was fungi infested. Growth cultures from bile and feces yielded Candida albicans. Postoperative treatment with T-tube drainage and antimycotic drugs led to an uneventful recovery. Clinical, biochemical, and ultrasonographic follow-up have shown no evidence of recurrence. A possible cause and effect relationship between the trauma and the development of biliary obstruction is suggested.

Beta-glucuronidase-producing bacteria in bile from the common bile duct in patients treated with endoscopic papillotomy for gallstone disease

This paper reports the occurrence of beta-glucuronidase-producing bacteria in the bile in gallstone patients treated with endoscopic papillotomy (EPT). The study included 36 patients--18 women and 18 men, aged 43-87 years, with a median of 72.5 years. Bile sampling was done with an endoscopic technique. All bacterial strains were tested for beta-glucuronidase activity with a rapid chromogenic tablet test, using 4-nitrophenyl-beta-D-glucuronic acid as substrate. Bacterial growth was found in the bile in 35 patients. Of 103 strains isolated, 30 produced beta-glucuronidase. Twenty-five of the patients had at least one beta-glucuronidase-producing strain in the bile. All 26 strains of Escherichia coli were producing the enzyme. Both strains in the Bacteroides fragilis group and one out of two strains of Clostridium perfringens were producing beta-glucuronidase. The activity of the bacterial beta-glucuronidase was found within the pH range of the bile in these patients. A relationship between the presence of beta-glucuronidase-producing bacteria in the bile and pigment gallstone is suggested.

Bile pancreatitis

Bile pancreatitis was studied both macropathologically and histopathologically in cases with an abnormal pancreatic choledochoductal junction, in which free communication between the pancreatic duct and the common bile duct occurred. The intraductal pressure of the pancreatic duct is normally higher than that of the bile duct, therefore, the pancreatic juice flows into the bile duct. In this study, we found squamous carcinoma cells from an adeno-squamous cell carcinoma of the gall-bladder in the main pancreatic duct. Hence, the possibility of bile reflux into the pancreatic duct was also considered. Outstanding findings, such as degeneration and disappearance of the pancreatic ductal epithelium, intraluminal aggregation of bacilli, and diffuse interlobular fibrosis were found in four of 15 cases with an abnormal junction. Similar ductal alterations and diffuse fibrosis were found neither in the controls nor in the remaining 11 cases. Therefore, it appears that pancreatic disorders due to the reflux of bile occurs in the presence of bacteria.

Effects of sphincteroplasty and endoscopic sphincterotomy on the bacteriologic characteristics of the common bile duct

Forty-five patients with sphincter of Oddi stenosis had specimens of common bile duct cultured during ERCP before either sphincteroplasty or endoscopic sphincterotomy. All had sterile bile before sphincter ablation. Bile was recultured 6 to 36 months later during endoscopy at which time 70 percent of the sphincterotomy and 76 percent of the sphincteroplasty patients had bile colonized principally by enteric organisms. Growth was heavy to moderate in most of the patients and contained few nasopharyngeal organisms. Despite bactobilia, no patient had symptomatic cholangitis, presumably due to excellent drainage of bile. The most likely source of the bactobilia is from direct extension of duodenal organisms into the common bile duct.

Impaired bacterial clearance and trapping in obstructive jaundice

Sepsis is a major cause of mortality in patients with common bile duct obstruction. To define possible contributing factors to this phenomenon, this study evaluates the effect of biliary obstruction on the intravascular clearance and organ trapping of viable Escherichia coli using a rat model. Adult male Sprague-Dawley rats were placed in three groups: Group I controls had sham operation, Group II had division and ligation of common bile duct (CDL), and Group III underwent splenectomy. At 21 days following operation 10(9) radiolabeled E. coli were injected intravenously. At varying intervals after infusion, blood samples were obtained for clearance study. At 10 minutes, bacterial distribution in the liver, spleen, kidneys, and lungs was determined (expressed as the mean percentage of injected viable E. coli). Intravascular clearance was similar in all groups. There was a significant decrease in the trapping of bacteria by the liver of CDL rats 14.5% +/- 4.95 (vs. control = 70.0% +/- 13.3) (p less than 0.005). A significant increase of bacterial trapping by the lung was observed in the CDL animals: 63.1% +/- 7.06 (vs. controls 1.4% +/- 0.82) (p less than 0.005). There was no significant change in bacterial localization in splenectomized rats. These data suggest that biliary obstruction decreases hepatic phagocytosis and increases pulmonary localization of viable E. coli. As the Kupffer cells of the liver are usually effective in removal of blood borne bacteria, this phagocytic dysfunction may contribute to the increased susceptibility to infection noted in instances of biliary obstruction.

Determinants of adverse reaction following postoperative T-tube cholangiogram

The incidence, nature, and mechanisms of adverse reaction following postoperative T-tube cholangiogram have received little attention in the medical literature. This paper presents the experience at one hospital over a 30-month period (1975--1977) covering 139 patients who had 170 cholangiograms. Factors examined included intraoperative and postoperative cultures of bile, the use of antibiotics prior to the performance of the cholangiogram, the technique of cholangiography, the interval between operation and cholangiogram. Eleven (6.5%) cholangiograms were followed by an adverse reaction. Two of these reactions were severe, manifested by signs of septic shock. The administration of antibiotics was not associated with a reduction in adverse reactions. The cholangiographic technique of gravity infusion of dye, which effectively limits the amount of pressure generated during the study, was associated with a significant reduction in adverse reactions. No severe reactions occurred following any study performed by the gravity technique. There was no significant correlation between the age of the patient or the number of days postoperative with adverse reaction. A review of the literature suggests that the mechanism for these severe reactions is cholangiovenous reflux. The avoidance of high intraductal pressures (above 25 cm of water) during the performance of postoperative T-tube cholangiogram should significantly reduce the incidence of adverse reactions.

[Pathogen elimination after surgical interventions on common bile duct (author's transl)]

Of 130 bile samples from the choledochus, 64% were positive for bacteria. Different antibiotics were administered according to the susceptibility tests. Colony counts were monitored daily. Beta-lactam antibiotics lead to a more rapid pathogen clearance than the tetracyclines. Antibiotic therapy is discussed especially in older patients and in patients with recurrent interventions on common bile duct. Bile cultures were positive in most of these patients.

The bacterial flora of the biliary tract and liver in man

A bacteriological study was made of 106 patients undergoing elective surgery for gallbladder disease and as a control group, of patients with a normal biliary tract but requiring laparotomy for gastrointestinal disease. The isolation rate of all species of bacteria from the gallbladder and common bile duct in those patients with calculi in the duct system and in those with nonfunctioning gallbladders was considerably higher than in patients with a normal biliary system. Surprisingly, the number of isolates from patients with a history of cholsecystitis or cholelithiasis was no greater than in the control group of patients.

Using modern techniques of anaerobic retrieval and culture, only a small number of anaerobes were isolated, and despite the prevalence of Bacteroides species as a normal gut inhabitant and as an opportunistic pathogen, this organism was not recovered from any of the sites investigated. Anaerobic species were Isolated from 8 out of the 106 liver biopsy specimens taken at a very early stage after laparotomy, but in such patients only non-specific liver changes were found by histological examinmation. In 8 patients from whom Escherichia colt or other aerobes were isolated from bile samples, at concentrates ranging from 105 to 107/cm3, the same species of organism were consistently isolated from T tube drainage samples for up to 8 or 9 days despite tetracycline therapy.

Improving cholecystectomy

Bacteriologic study of bile in 100 patients undergoing cholecystectomy for various manifestations of choletithiasis yielded 36 per cent positive cultures, with greater frequency in older individuals and those with acute cholecystitis and common duct stone; these results are comparable to those in previous studies and reaffirm the septicity of the bile. Incidence of wound infection, averanging 10 per cent in published series of cholecystectomies, was 0.5 per cent in 200 patients in whom a water-impermeable wound drape was sewn to the peritoneum to prevent contamination by potentially infected bile. This result, in patients with an infectious risk comparable to that in other series, establishes the value of meticulous wound isolation in preventing wound infection.