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A Case of Catarrhal Cholangitis and Chronic Pericholangitis, on Which Suppurative Inflammation Supervened in the Portal Spaces

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A Case of Catarrhal Cholangitis and Chronic Pericholangitis, on Which Suppurative Inflammation Supervened in the Portal Spaces A CASE OF CATARRHAL CHOLANGITIS AND CHRONIC PERICHOLANGITIS, ON WHICH SUPPURATIVE INFLAMMATION SUPERVENED IN THE PORTAL SPACES. Ey H. D. ROLLESTON,M.D., F.R.C.P., Senior Assistant Physician and Lecturer on Pntlaology, St. George’s Hospital ; aid T. STRANGEWAYS PIGG,Demonstrator of Pathology in tlze University qf Cambridge. (PLATESXXV. AND XXVI.) ABSTRACTOF CLIXICAL HISTORY.-Aman, at. 44, was admitted into St. George’s Hospital on 24th March 1896, under one of US (R.), with a history that he had passed a quart of blood by the bowel. He was deaf, very blanched, and with a low tension pulse, the arterial walls being distinctly thickened. The heart was hypertrophied ; there was albuminuria, old optic neuritis, and a trace of edema of the legs. He evidently had renal disease, and it was thought that the melaena was due to hamorrhage taking place into the submucous layer of the intestine, leading to the condition of albuminuric ulceration, first described by Dr. W. H. Dickinson (I). With rest in bed he improved temporarily, but subsequently severe abdomiiial pain, diarrhea, and hamorrhage from the bowels came on. Death was preceded by a rash, which was thought to be uraemic. At no time was he jaundiced, and no history,of a past attack of jaundice was obtained. AT THE nuToPsY.-The skin was generally anaemic, and showed the remains of a rash which in places was petechial. There was no cedema of the feet. Slight uratic deposit was present on the cartilages of the first metatarso- phalangeal joints. Head.-On removing the skull-cap the Pacchionian bodies were present in excess. The vessels at the base of the brain were healthy. The brain weighed 44 oz., and was remarkably anaemic, the lateral ventr&les were sonie- what dilated, but there was nothing else abnormal. The margins of the optic discs were indistinct, but there were no hemorrhages in the retina. Thorax.-The pleura were healthy, as were the lungs, except for some edema. The larynx, thjroid body, and pericardizeiiz were healthy. The heart weighed 14 oz., and showed simple hypertrophy of the left ventricle ; the valves were healthy, and the myocardium, though palc, did not show any “ tabby-cat ’’ striation, indicating fatty degeneration. The aorta was healthy. Abdonzea.-There was no ascites. The esophagus was healthy, but the mucous membrane of the stomach was rugose and pigmented, as if from past gastritis of some standing, though free from ulceration. The duodenum and commencement of the jejununi were also pigmented. 223 H. D. ROLLESTON AND I: STRANGEKAYS PIGG. The vermiform appendix was curled up to the right of and behind the ascend- ing colon, and for the greater part of its extent was impervious. The mucous membrane of the small intestine and colon was normal, and no ulceration or source for the hemorrhage either there or in the rectum was forthcoming. Peyer’s patches were normal. The ileum, just before it entered the caecum, was adherent to the signioid flexure. To the right of the second part of the duodenum, and extending up into the lesser omentum, there was a whitish soft mass of enlarged glands, which, though close to the common bile duct, did not obstruct the passage of bile through it. The adjacent aortic, and to a lesser extent the mesenteric, glands, were similarly enlarged. The portal fissure contained large glands, and a white growth was seen tracking along the portal vein into the substance of the liver. After following the portal canal for some distance, the white growth generally faded away, but in part of the right lobe became continuous, with suppnra- tion resembling pylephlebitis. To the naked eye the hepatic artery and bile duct could be seen in the growth, and a ragged space apparently representing the situation of the portal vein. Near the bifurcation of the portal vein into the two main branches there had evidently been some thrombosis, for attached to its wall was a parietal clot ; there was no complete thrombosis of the portal vein, and it was quite pervious. The liver, though but little increased in size, weighed 80 oz. There were old adhesions between the upper surface of the right lobe and the diaphragm, and surrounded by these fibrous adhesions was a firm, oval body, rather smaller than a Barcelona nut. Microscopically it was seen to be composed of a fibrous capsule enclosing structureless material, and was thought to be the remains of a necrosed lymphatic gland which had become pednnculated and finally loose in the peritoneal cavity (”. The oval body had formed for itself a smooth depression on the surface of the liver. On the upper surface of the left lobe there was an old cicatrix. On section the larger portal spaces showed the packing of white growth, already referrcd to. This gradually disappeared, and the liver tissue in most prts then showed no abnormality except cloudy swelling. In psrt of the right lobe there were multiple small abscesses, resembling what is seen in pylephlebitis. This affected area was close to the place where the loose body was embedded. There does not, however, appear to be any association between the two. The gall bladder was large and full of bile, which by pressure could be made to issue from the biliary papilla in the dnudenurn. There were no calculi. The spleeib weighed 12 oz., and was healthy on section. 8uprarenals.-The right was quite free from the enlarged glands. The left was normal; close to it there was a large accessory gland. On section, both appeared healthy, though ansmic. Kidne?js.-The right weighed 54 oz. and the left 5 oz. The capsules were slightly adherent, and on being removed exposed a finely granular surface with a few scattered cysts. On section the organs resembled a contracting white kidney. Microscopically the tubules were dilated, and contained fatty debris. There were alternating areas of recent fibrosis and of dilated tubules in the cortex, the glomeruli in many places were undergoing fibrotic atrophy, but there was no proliferation from the inside of Bowman’s capsule. The vessels showed some, but by no means excessive, arterio-sclerosis. MICROSCOPICALEXAMINATION.-A careful microscopical examination of the liver was made by means of both frozen and paraffin sections. Of the latter a large number were cut and stained in various ways. Sections of one of the larger portal spaces, which contained the abnormal CHOLANGITIS AND CHRONIC .PERICHOLAArGITIS. 223 formation, spoken of as “new growth,” show that the portal space is much enlarged, and that its increase in size is due to a packing of fibrous and inflammatory tissue. In this are embedded the hepatic artery, the bile ducts, and nerves. The portal vein is not seen, but what appears to have been its site is taken by an abscess cavity (Plate XXV. Fig. 1, a and F). The outlines of the space are fairly well preserved, and in places sharply limited by what is evidently the remains of Glisson’s capsule (Fig. 1, c). Outside this limiting membrane there is some little infiltration of the peripheral parts of the hepatic lobules ; in places the liver cells are flattened and atrophied from pressure, and between the liver cells and other parts there is a prominence and increase of Kupffer’s cells. The liver cells contain some yellow pigment, probably biliary in origin. There is a complete absence of any microscopic biliary calculi or inspissated bile- stained masses. The added tissue of the portal space is composed of well-formed fibrous tissue, between the strands of which small round cells and developing connective tissue cells are packed (Plate XXV. Fig. 2). This evidently in- flammatory process is much more recent around the central cavity, the wall of which is composed of inflammatory cells (Plate XXV. Fig. 3). This space, from the absence of the portal vein elsewhere, probably represents its site, but the walls of the vein have completely disappeared. There is no throm- bosis or remains of blood clot in the cavity, but in some sections liver cells can be seen, though these are probably of post-mortem origin, and due to handling of the liver. In several of the sections remains of the larger bile ducts can be seen lying at the edge of the cavity, and in one there is a duct cut transversely and lined with large columnar cells ; it would seem probable that these represent the remains of a bile duct which has only been partially destroyed by the sup- purative process, but they may possibly be of similar origin to the liver cells before mentioned, namely, artefacts. The hepatic artery has lying between the blood corpuscles in its lumen some spindle cells, probably derived about the time of death from the intima. That the cells have not long been detached is shown by the fact that their nuclei stain well, and by the absence of signs of degeneration in the cells or of their nuclei. In this vessel also some liver cells are seen. These, again, are probably accidental phenomena of post-mortem origin, and not of any significance. The bile ducts are extremely prominent objects in the section. They are markedly increased in number, and vary greatly in size, from very small canals, with hardly any lumen, to enormous ducts with cyst-like cavities. The mucous membrane of many of the larger ducts is thrown into folds, and presents a papillomatous arrangement (Plate XXV. Figs. 4, 5) resembling the appear- ances seen in the liver of a rabbit affected with psorospermosis. Their lumen is distended, and the ducts are tortuous (Plate XXV. Figs. 4A and 4B).
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