The relationship of lesions of the cystic duct to gall bladder disease
- 22 Downloads
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.
KeywordsGall Bladder Cystic Duct Gall Bladder Disease Complete Obstruction Dense Adhesion
Unable to display preview. Download preview PDF.
- 1.Schmieden, V. and Rhode, C.: Stasis in Gall Bladder.Arch. f. klin. Chir., 118:14, 1921.Google Scholar
- 2.Seelig, M. G.: Bile Duct Anomaly as a Factor in the Pathogenesis of Cholecystitis.S. G. O., 36: 331, 1923.Google Scholar
- 3.Westphal, K.: Muskelfunction, Nervensystem and Pathologie der Gallenwese.Ztschr. f. klin. Med., 96: 22–150, 1923.Google Scholar
- 3a.Westphal, K., Gleichmann, F. and Mann, W.: Gallenwegsfunktion and Gpllensteinleiden. Berlin, 1931. Julius Springer.Google Scholar
- 4.Ivy, A. C.: Physiology of Gall Bladder.Physiol. Rev., 14:1–102, 1934.Google Scholar
- 3b.Ivy, A. C. and Sandblom, P.: Biliary Dyskinesia.Ann. Int. Med., 8:115, 1934.Google Scholar
- 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
- 6.Best, R. R. and Hicken, N. F.: Biliary Dyssynergia; Cholangiography Recognition and its Significance.West. Jour. Surg., 44:467, 1936.Google Scholar
- 7.Mentzer, S. H.: The Valves of Heister.Arch. Surg., 13, 511, 1927.Google Scholar
- 8.Lichtenstein, M. E. and Ivy, A. C.: The Functions of the Valves of Heister.Surgery, 1, 38, 1937.Google Scholar
- 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
- 10.Johnson, C. G. and Brown, C. E.: Studies of Gall Bladder Function.S. G. O., 54:447, 1932.Google Scholar
- 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
- 12.Phemister, D. B., Pembridge, A. G. and Rudisill, H.: Cholecystitis and Cystic Duct Obstruction.J. A. M. A., 97:1843, 1931.Google Scholar
- 13.Womack, Nathan: Personal communication.Google Scholar
- 14.Jenkinson, E. L.: Cholecystography.J. A. M. A., 107, 755, 1936.Google Scholar
- 15.Alexander, H. L. and Bond, R.: Personal communication.Google Scholar