---_._----~~ lEI'"""'''"""'''"""""""'" ''""'''"""'''"""''''"''"'"""""'''''''""''''''''''''"''''''''''''"'''''T Complications of Cholecystitis By]. EARL ELSE, M. D., F. A. C. S., Portland, Oregon .~ >~ •• ~ t" ~ ;: ;:s § Reprinted from the Medical Sentinel, Portland, Oregon ;: § May, 1929 [!]III1UI ft••llt'IIIIIIIIIII.Ulltllllll.II.IU.11111.11 11 1 111111.111111..11 111 •••11 ..111 lIlllllltlll.III.Um IX B. Local. 1. Hepatitis COMPLICATIONS OF CHOLE:CYSTITIS* 2. Pancreatitis 3. Peritonitis *Read before the Portland (Ore.) City and County Medical Society. a. Local b. General By J. Earl Else, M.D., F.A.C.S., Portland, Oregon 4. Arthritis Clinical Professor and Chairman, Department of General Surgery, University 5. Neuritis 6. Myocarditis and endocarditis of Oregon Medical School. 7. Enteritis. a. Colitis Cholelcystitis is one of our most common di~eases. Ac~te cho- 8. Cholangitis and infection of larger ducts 'tI'S because of its severity, usually receIves attentIOn, but 9. Secondary anemia. 1ecyStI , . d fi' . b . holecystitis is usually neglected for an 111 e mte tune e- Under intrinsic complications the various types of inflam­ chromc c . d' cause of its insidious onset. The symptoms point to gastnc IS- mation are not included, as these are varieties of cholecystitis rather turbances rather than that of the gall bladder, so it often ~oes un­ than complications. Gall stones, perhaps, should not be included, suspected by both the patient and the physician and when dIagnosed as they are such a common accompaniment of chronic cholecystitis, its significance is frequently not realized. It is for the purpose ~f yet they are not always present and they are nearly always, if not ' ttention to the results of neglect in treatment of chromc always, secondary to gall bladder infection. Ulceration may be the ca11111g a .' . 'bl cholecystitis that this paper is being WrItten.. ~t :"111 b: Impossl e result of either tissue destruction to cover all of the complications of cholecystItIs 111 a s111gle paper. through the action of very viru­ This paper is one of a series of five which are being prepared on lent organisms, or pressure necro­ various phases of the subject. sis from gall stones. The ulcer The complications of cholecystitis may be classified as follows: may be so extensive that a good share of the mucosa is involved, or 1. Intrinsic. it may be deep and result in per­ A. Gall Stones. B. Ulceration. foration. In a series of one thou­ C. Perforation. sand gall bladders studied at the D. Stricture. Pathological Institute in the Uni­ E. Gangrene. versity of Vienna, I found one in F. LU5chka glands. which almost the entire mucosa Figure No.1 G. Tumors. 1. Benign. had been replaced by scar tissue covered with thin epithelium. With a. Papillomata. the healing of extensive ulcers a stricture (5) producing a deformity b. Adeno-papillomata. often occurs. This deformity may be slight, or it may be so extensive 2. Malignant. as to nearly or completely obstruct the lumen. The acquired stricture a. Sarcoma. (I) Primary. IS usually found in the proximal half of the gall bladder, in con­ (II) Metastatic. tradistinction to the congenital elbow deformity which always occurs b. Carcinoma. in the distal third. Gangrene results from extensive inflammation (1) Primary. with virulent organisms. (A) Adeno carC1110ma (B) Papillary Carcinoma. The significance of the relationship of chronic cholecystitis to (C) Cylindrical cell carc~noma tumors (7) of the gall bladder is not fully realized. It is quite doubt­ (D) Squamous cell ~arc1110ma ful if the benign tumors or carcinoma develop except in the presence (E) Round cell carc1110ma. of a long standing chronic cholecystitis. The most frequent benign (II) Metastatic carcinoma. tumor is papilloma. When present, they usually exist as small deli­ II. Extrinsic. .f . h t cate, finger-like projections. In the series of cases referred to, I A. General. Various symptoms and mam estatlOns t a may come from focal infection. found one adeno-papilloma (Fig. 1). 9'" ' &E . .. 2 Primary sarcoma occurs, but is rare. There were none m this mous-celled, and round"celled carcinomas occur, but are rare. I found one melano-carcinoma metastasis from a primary melano-carcinoma series. Metastatic sarcoma is also rare. of the choroid of the eye. Carcinoma of the gall bladder is not as rare as is often supposed. The early diagnosis of cardnoma of the gall bladder can be made In the Breslau statistics it was found in 5 per cent; in Basle in 5.19 only by its removal at operation. Late carcinoma may be suspected per cent; and in Gottingen statis­ in patients giving a history of a long standing cholecystitis with a tics it was found in 6 per cent. mass in the liver. Adenoma carcinoma (Fig. 2) is the most frequent form. At first The extrinsic complications may be either or both general, or local. thought this appears difficult to An infected gall bladder may act as a focus of infection from which explain because thete are no nor­ toxins or organisms may be carried to any part of the body. A most mal glands in the gall bladder. A striking example of the gall bladder as a source from which toxins study of a large series of chronical­ may be distributed was seen in a physician about 18 months ago. ly infected gall bladders, however, He had been having various pains over a considerable period of time. His teeth and tonsils, both of which showed infection had been re­ shows that glands develop as a re- witho~t Figure No. 2 sult of prolonged irritation as was moved, yet relief. He developed a spinal arthritis with lip­ pointed out in a previous paper (6). ping. There was also involvement of the right sciatic nerve with pain and areas of paresthesia. On examination a persistently tender The epithelial lining of the gall bladder IS of the same ongm as gall bladder was found which did not function normally, as was shown the epithelium of the liver. Liver epithelium has a high regenerative by the Graham-Cole test. At operation the gall bladder showed a power. This explains the formation of the adenoma-like masses definite chronic cholecystitis with a moderate secondary hepatitis in which maintain the normal liver function following extensive de­ the vicinity of the gall bladder. The gall bladder was removed with struction of liver substance as is seen in certain cirrhosis.. After a the desired effect. Today he feels better than he has felt for years. prolonged irritation of the epithelium lining the gall bladder, hyper­ Of the local complications, hepatitis is the most frequent and plasia occasionally occurs with a prolongation of epithelial masses probably of the greatest significance. Charcot was the first to call outward along the courses of the attention to the constancy of liver involvement with gall stone. Char­ blood vessels that penetrate the cot's observations were post mortem and depended upon a group of muscularis to reach the mucosa. patients which we would now classify as neglected. As has been These epithelial tubes (Fig. 3) con­ pointed out, especially by Graham, a considerable proportion of the tinue to grow down into the mus­ patients that we operate upon have more or less involvement of the cularis where growth may stop, liver in the immediate vicinity of the gall bladder. In some cases and in which case they remain as this may be very extreme. I recently operated upon one patient in mere ducts, or they may continue which there was an area approximately 10 em. in diameter on the to grow on into the fibrosa form­ superior surface of the liver adjacent to the gall bladder, in which ing acini and becoming complete the superficial liver substance had been so completely replaced with mucous glands similar to those scar tissue that there was no liver substance visible. seen normally in the cystic and Figure No. 3 common ducts.. Obstruction to the duct of these glands may result 'Graham (16, 17, 18) has shown that hepatitis is practically always in cystic formation. These glands were first described by Luschka present in chronic cholecystitis. He is of the opinion, however, that and are known as the Luschka glands or ducts. Adeno-carcinoma cholecystitis is secondary to hepatitis. If this be true, it is difficult originates either from these glands, adeno-papillomata, or the fundus to understand why the most marked hepatitis is usually found in adenoma which may be of congenital origin. patients with long standing cholecystitis. It is also difficult to un­ Papillomatous carcinoma is'less common. This is difficult to ex­ derstand why, if Graham's contention is correct, the liver improves plain for papillomata of the gall bladder are more frequent than are after cholecystectomy. Were the cholecystitis the effect of hepatitis the Luschka glands or other adenomata. Cylindrical-celled, squa- the removal of the effect would not have so marked beneficial results upon the cause, but if the hepatitis is secondary to cholecystitis then all the bile passed through a circuit route in the pancreas in order to the removal of cholecysitis should be followed by relief, and such is be discharged into the duodenum (Fig. 4). Mann (8) and Giordano (10) have shown, however, that in a considerable percentage the rela­ the case. In 1909 (1,2,3) I reported experimental work thCl;t I had done on tionship is such that regurgitation of bile into the pancreas is im­ rabbits in which I showed that when the bacillus pyocyaneus was possible. Klippel (11 and 12) in 1899 suggested the lymphatic route injected into the blood stream it could be recovered from the gall as a method by which infection from the biliary apparatus reached bladder in a very short time if the cystic artery was not ligated, but the pancreas.