Common duct obstruction

Abstract 1. 1. No one symptom of obstruction is diagnostic. Since two conditions may be present, local pathology may show and general affections may be missed. 2. 2. A marked jaundice with clay-colored stools is usually significant of common duct obstruction, most likely due to cancer of the pancreas or bile ducts, chronic pancreatitis, gallstones or catarrhal jaundice. Transient jaundice, in the young, is usually catarrhal. 3. 3. A large liver, with jaundice, most often shows common duct obstruction, lues, cancer, abscess, cirrhosis or poisoning. 4. 4. Any jaundice should be relieved by palliative means as much as possible before surgery is done, inasmuch as the more nearly complete the obstruction is, the more the danger of cholemia. Early thorough treatment spares the liver, pancreas and kidneys. A slow pulse, in jaundice, is usually not present unless chronic pancreatitis occurs. If, with the jaundice, findings point to an essentially complete obstruction, the likely causes are tumors of the ducts or pancreas, stricture, or an accidentally ligated duct. 5. 5. Fever may be present with the attacks due to an infected gall-bladder, but when the hepatic ducts are infected, a continuous fever may result. Charcot's fever means cholangitis as a rule, although jaundice, fever and rigors can follow pylephlebitis and hepatic abscess; malaria and sepsis might give a similar picture. 6. 6. Biliary stones are often found post mortem. Icterus neonatorum has been caused by stones. Females who have been pregnant or had typhoid often have stones form in the gall-bladder and twenty per cent of them have common duct stone also, which usually gives a small gall-bladder with colic and jaundice. There may be no pain or jaundice, however, and the gall-bladder may be enlarged, especially if the cystic duct is blocked. Stones may accompany tumor or stricture. If jaundice follows right upper quadrant pain, it most likely is due to common duct stone. Recurring jaundice in a middle aged woman, with or without colic, is almost pathognomonic of the same; chronic pancreatitis alone may confuse. Should pain occur without jaundice after cholecystectomy, it calls for duodenal drainage and examination of the bile for crystals of cholesterol and calcium bilirubinate. 7. 7. Tumors of the pancreas and biliary ducts usually give a painless jaundice with an enlarged gall-bladder, although pain, Charcot's fever, or a small gall-bladder may be present. Early diagnosis and treatment are imperative, because benign lesions may become malignant, and all malignant growths of the duct metastasize slowly. Carcinoma is more frequent in males, while stones form more frequently in females. Recurrences of jaundice for years is against malignancy, but on the other hand, a middle-aged person with loss of weight, having a history of short duration, together with a deep persistent jaundice without colic, and an enlarged gall-bladder, is almost surely suffering from carcinoma of the pancreas or the bile ducts. 8. 8. Pylephlebitis and cholangitic abscesses cause death, and diabetes is a very serious complication. Vocal cord paralysis may be dependent upon Ewald's node which might be the first sign of abdominal malignancy. 9. 9. Spinal anesthesia spares the liver, while ether, chloroform and avertin may further injure it. A fall in blood pressure is met by the Trendelenburg position combined, if necessary, with adrenalin or ephedrine by hypodermic, 50 c.c. of 50 per cent glucose by vein, a few whiffs of ether combined with artificial respiration, and even massage of the heart and adrenals through the abdominal wound. 10. 10. In the operative work the gall-bladder should always be left in until it is made sure that the duct is all right. The duct should be explored in all suspicious cases, after needling it to be sure the portal vein is not entered; a stone may not be palpable if the duct is thick. It should be opened if there is or has been jaundice, and probed with a uterine sound. Suction, should be used if necessary. Then the duct should be wiped out with gauze, and drainage inserted. Fistula of the duct into the gut calls for operation in most cases. The duodenum should be opened, if necessary, and if a condition is found which prohibits further surgery, the gall-bladder can be anastamosed to the duodenal wound. A stone in the ampulla may require transduodenal removal, if it cannot be removed through the duct above the duodenum. Tumors of the ampulla may be removed transduodenally and the duct reimplanted into the duodenum. 11. 11. Postoperative hemorrhage may be lessened by the use of blood transfusions before operation in conjunction with parathormone hypodermically, calcium chloride by vein, and duodenal drainage. Bile pigment is said to fix the calcium of the blood. Purpuric spots and increased sedimentation rates are indications for blood transfusions before operation. Prostigmin has recently been added to the armamentarium for the care of post-operative distention. Atelectasis after operation is more frequent following biliary surgery than any other type except gastric, and its incidence can be reduced by rebreathing of carbon dioxide and oxygen, deep breathing exercises, and frequent changing of position. Slapping the back sharply will often help loosen a plug of mucus from the bronchus. After release of obstruction, the bile for a few days shows absence of bile salts, increased calcium, and decreased sodium chloride content. If dehydration and loss of weight occur from loss of bile, the latter can be re-fed to the patient in grapejuice or given by rectum. Lipiodal through the drainage tube may be used to reveal the state of patency of the ducts, in cases not progressing normally.