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The American Journal of Digestive Diseases

, Volume 5, Issue 9, pp 576–586 | Cite as

The relationship of lesions of the cystic duct to gall bladder disease

  • W. H. COle
  • L. J. Rossiter
Article

Summary

While examining the gall bladders from routine cholecystectomies during the past year or two several instances of partial obstruction of the cystic duct were encountered. A classification of the various types of lesions which are apt to produce partial obstruction has been discussed. Important lesions in this group are adhesions, kinks, an acute inflammatory process, anomalous folds of Heister, stone in the cystic duct and compression by extrinsic factors. Complete obstruction such as illustrated by hydrops and empyema is not discussed because the mechanisms of production and pathology are so clearly understood. It is obviously very difficult to prove that a given lesion of the cystic duct is producing an incomplete obstruction, but an analysis of the cases studied has led us to believe that on many occasions the lesion in the cystic duct represents perhaps the only significant lesion of the gall bladder and that on other occasions it may be the instigating factor of disease in the gall bladder. It is difficult to demonstrate the obstruction experimentally, not only because a criteria of the degree of obstruction based on the rapidity of flow of bile of a given viscosity through the cystic duct would be difficult to establish, but also because of the fact that accurate reading could only be obtained after cholecystectomy. Removal of the gall bladder would of necessity destroy the attachment of the cystic duct thereby altering the factors producing the obstruction, because fixation and adhesions are bound to be important factors in a great majority of the obstructions even though the primary lesion may be a congenital anomaly involving the folds of Heister.

It should be emphasized that in a great majority of instances, an anatomical lesion may be present without exerting any obstructive influence until an acute inflammatory process is implanted upon it. There is very good evidence that acute inflammation of the cystic duct occurs commonly. The fact that adhesions about the cystic duct are so commonly encountered in gall bladder disease is in itself fairly good proof. The presence of severe clinical manifestations typical of gall bladder disease, with a demonstrable lesion of the duct in the absence of significant pathologic changes in the gall bladder wall, as was the case in most of the patients studied in this series, is also suggestive proof that the lesion in the cystic duct may be an important factor in the production of the manifestations. This is particularly true if cholecystectomy relieves the

patient’s symptoms. A consideration of some of the patients in this series suggests very decisively that at least in some instances the failure of the gall bladder to empty (as determined by cholecystographic study) following the fat meal is indicative of serious choleeystic disease. It is conceivable that the failure of emptying might be due to (1) obstructive lesions of the cystic duct; (2) inefficient muscular response on the part of the gall bladder (e.g. atony) or (3) spasm of the sphincter of Oddi. In this study, however, attention was directed only to mechanisms involved in the first group.

Keywords

Gall Bladder Cystic Duct Gall Bladder Disease Complete Obstruction Dense Adhesion 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Schmieden, V. and Rhode, C.: Stasis in Gall Bladder.Arch. f. klin. Chir., 118:14, 1921.Google Scholar
  2. 2.
    Seelig, M. G.: Bile Duct Anomaly as a Factor in the Pathogenesis of Cholecystitis.S. G. O., 36: 331, 1923.Google Scholar
  3. 3.
    Westphal, K.: Muskelfunction, Nervensystem and Pathologie der Gallenwese.Ztschr. f. klin. Med., 96: 22–150, 1923.Google Scholar
  4. 3a.
    Westphal, K., Gleichmann, F. and Mann, W.: Gallenwegsfunktion and Gpllensteinleiden. Berlin, 1931. Julius Springer.Google Scholar
  5. 4.
    Ivy, A. C.: Physiology of Gall Bladder.Physiol. Rev., 14:1–102, 1934.Google Scholar
  6. 3b.
    Ivy, A. C. and Sandblom, P.: Biliary Dyskinesia.Ann. Int. Med., 8:115, 1934.Google Scholar
  7. 5.
    McGowan, J. M., Butsch, W. L. and Walters, W.: Pressure in the Common Bilé Duct of Man.J. A. M. A., 106:2227, 1936.Google Scholar
  8. 3c.
    McGowan, J. M., Butch, W. L. and Walters, W.: The Use of Glyceryl Trinitrate for the Control of Pain Following Cholecystectomy.Ann. Surg., 104:1013, 1936.PubMedCrossRefGoogle Scholar
  9. 6.
    Best, R. R. and Hicken, N. F.: Biliary Dyssynergia; Cholangiography Recognition and its Significance.West. Jour. Surg., 44:467, 1936.Google Scholar
  10. 7.
    Mentzer, S. H.: The Valves of Heister.Arch. Surg., 13, 511, 1927.Google Scholar
  11. 8.
    Lichtenstein, M. E. and Ivy, A. C.: The Functions of the Valves of Heister.Surgery, 1, 38, 1937.Google Scholar
  12. 9.
    Lohner, L.: Beitrage zum Reservoirproblem. II. Mitteilung die Gallenblase als monodoches Reservoir.Pflügers Arch. f. d. ges. Physiol., 206:434, 1924; Gallen- und Gallenwegstudien. I. Mitteilungen zur Fulhmgsund Entleerungsmechanik der Gallenblase und über die Funktion der Valvulae Heisteri.Pflügers Arch. f. d. ges. Physiol., 211:356, 1926.CrossRefGoogle Scholar
  13. 10.
    Johnson, C. G. and Brown, C. E.: Studies of Gall Bladder Function.S. G. O., 54:447, 1932.Google Scholar
  14. 11.
    Lyon, B. B. Vincent and Swalm, W. A.: Obstruction of the Cystic Duct of a Catarrhal Variety.J. A. M. A., 90, 833, 1928.Google Scholar
  15. 12.
    Phemister, D. B., Pembridge, A. G. and Rudisill, H.: Cholecystitis and Cystic Duct Obstruction.J. A. M. A., 97:1843, 1931.Google Scholar
  16. 13.
    Womack, Nathan: Personal communication.Google Scholar
  17. 14.
    Jenkinson, E. L.: Cholecystography.J. A. M. A., 107, 755, 1936.Google Scholar
  18. 15.
    Alexander, H. L. and Bond, R.: Personal communication.Google Scholar

Copyright information

© Springer-Verlag 1938

Authors and Affiliations

  • W. H. COle
    • 1
  • L. J. Rossiter
    • 1
  1. 1.Chicago, Illinois

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