Gut, 1968, 9, 187-192 Gut: first published as 10.1136/gut.9.2.187 on 1 April 1968. Downloaded from Partial biliary obstruction with cholangitis producing a blind loop syndrome A. J. SCOTT AND G. A. KHAN From the Departments of Medicine and Microbiology, Royal Free Hospital, London The frequency with which bacterial cholangitis obtained results that suggest that such a parallel complicates choledocholithiasis or benign post- situation may indeed be present. operative biliary strictures has been the subject of several studies (Elkeles and Mirizzi, 1942; Anderson METHODS and Priestley, 1951; Edlund, Mollstedt, and Ouch- terlony, 1959; Scott and Khan, 1967). The magnitude Eleven patients were studied both before and during of the bacterial population present in this condition surgery. Five of these had calculous cholecystitis and had, however, been crudely assessed until in a recent choledocholithiasis. One patient had choledocholithiasis which had been previously treated by a cholecyst-duode- study it was shown that quantitatively the bacterial nostomy. The other five patients had benign postoperative population of an infected bile duct per gram of strictures involving hepatodochojejunostomy anasto- contents rivalled that of the colon as far as aerobic moses. The anatomical features in the 11 patients are organisms were concerned (Scott and Khan, 1967). summarized in Figure 1. All were jaundiced, with serum It therefore seemed possible that as bacteria multi- bilirubin values ranging up to 14 mg%, and all had had plied in bile and as the heavily infected bile was attacks of clinical cholangitis. These were recurrent at secreted into the intestine functional changes would the time of study in all but one. Two only had received be produced which would parallel those which follow antibiotic treatment in the six weeks that preceded the study. infestation of the small bowel in the 'blind loop http://gut.bmj.com/ Bile was obtained at operation by aspirating the con- syndrome'. In this paper we are reporting a study of tents of the common bile duct or common hepatic duct. 1 patients with partial biliary obstruction and Intestinal contents were obtained either preoperatively cholangitis. We have employed techniques of by oral intubation with a narrow bore tube (Kalser, investigation which have proved helpful in under- Cohen, Arteaga, Yawn, Mayoral, Hoffert, and Frazier standing the typical blind loop syndrome and have 1966) in the patientswith bile draining intothe duodenum, b c on September 30, 2021 by guest. Protected copyright. FIG. 1. The anatomical features in the 11 patients studied. five with choledocholithiasis (a); onze with cholecyst- duodenostomy (b); and five with hepatodochojejunostomy and enteroaniastoinosis (c). 187 188 A. J. Scott and G. A. Khan Gut: first published as 10.1136/gut.9.2.187 on 1 April 1968. Downloaded from or during the operation by passing a Levine tube into the (/, jejunum during the reconstruction of the hepatodocho- BILE I NTESTINALJUICE jejunostomy anastomoses in the five patients with benign 10 0 -l strictures. Bile and intestinal contents were immediately C') cultured on 10% blood and McConkey's agar aerobi- AA cally and anaerobically and viable bacterial counts were performed by the method of Miles and Misra (1938). 0 AA Urine indican was measured by the method of Curzon K and Walsh (1962). Thin-layer chromatography plates A were prepared by standard techniques (Hofmann, 1964) 8a0 - and in particular the development systems described by 0 Hofmann (1962) and by Gregg (1966) were used. Bile U A salts were detected by spraying the plates with 10% 7 0- molybdophosphoric acid in ethyl alcohol or 1 :1 methanol/ 0 concentrated sulphuric acid and identified by reference A to the mobility of standard substances after one- or A two-dimensional development. Vitamin B12 absorption U 6.0- 0 was detected by a standard tracer technique (Schilling I test) using 0.5 jug vitamin B12-Co58 orally and 1 mg stable vitamin B12 intramuscularly, with the urinary radio- 5.0 - A activity in the first 24 hours expressed as a percentage of the oral dose (normal greater than 12%). Hog intrinsic factor, 50 mg, was given with the oral dose. In six patients 4 0- the test was repeated after tetracycline, lg daily, had been given for the preceding three days. 0 To exclude the possibility that an abnormality might have been due to biliary obstruction or parenchymal liver disease per se urine indican was also measured in six patients with obstructive jaundice due to pancreatic * Choledocholithiesis cancers who had sterile bile and 14 patients with crypto- A Stricture genic or primary biliary cirrhosis. For the same reason the bile of 19 patients with pancreatic or biliary cancers FIG. 2. The concentrations of viable bacteria in bile and and obstructive jaundice, in whom the bile was free of intestinal contents plotted against a logarithmic scale. The http://gut.bmj.com/ bacteria, was examined by thin-layer chromatography. patient with the cholecyst-duodenostomy is includedamong the patients with strictures. RESULTS antibiotic treatment. In the other six patients the BACTERIOLOGICAL FINDINGS In Fig. 2 the concen- concentration of organisms in two was greater in trations of viable bacteria in the bile and intestinal the intestine than in the bile while in the remaining juice of the patients are plotted against a logarithmic four patients it was less. on September 30, 2021 by guest. Protected copyright. scale. The figures for bile ranged from 100,000 to The bacteria present in the bile samples and the 7,000,000,000 organisms per ml. The figures for frequency with which they were found are shown in intestinal juice cover a narrower range from 700,000 Table I. In no case was an organism isolated from to 200,000,000 organisms per ml. No comment can the intestinal samples which had not been cultured be made about the relationship of the bile and from bile. The reverse was not always so, however. intestinal juice figures in the patients with chole- docholithiasis since the two samples were taken at INDICANURIA The excretion of indican in a 24-hour different times and the bile sample was separated period by normal subjects, the patients under study, in time from the intestinal sample by a course of and three groups of control patients is shown in Figure 3. In normal subjects the range lay between 35 and 75 mg. In the patients forming the control TABLE I group and representing hepatocellular disease with FREQUENCY WITH WHICH BACTERIAL SPECIES WERE little cholestasis (cryptogenic cirrhosis), intrahepatic ENCOUNTERED IN THE BILE OF 1 PATIENTS cholestasis (primary biliary cirrhosis), and large Organisnm No. of Isolations duct biliary obstruction but with no biliary infection Escherischia coli 9 (malignant duct obstruction), the range is wider Klebsiella aerogenes 6 and values as low as 10 mg and as high as 110 mg Streptococcus faecalis 4 Proteus vulgaris 2 were found. Of the nine patients with infected bile in Pseudomonas aeruginosa 2 whom E. coli was found in the bile and intestinal Partial biliary obstructiion with cholanlgitis producing a blind loop synidrome 189 Gut: first published as 10.1136/gut.9.2.187 on 1 April 1968. Downloaded from 250 A~t 200- 150- 0 0 *ti 9 -C. 100- 0*- a o1m 0 l 50- 0 Cir 0 0 Q 0 Normal Cirrhosis Choledocholithiasis Malignant or Benign Duct Stricture Obstruction w Cryptogenic EPrim@ryBiliery -hour urinary indican excretion. A E. col i in bile FIG. 3. Twenity-four- juice, eight showed increases in urinary indican duct biliary obstruction due to cancers. Uncon- beyond this range. E. coli was the only indole- jugated bile acids were, however, present in six of http://gut.bmj.com/ producing organism isolated in this group. the 11 patients with biliary infection. Two of these were patients with choledocholithiasis, three had BILE ACIDS Unconjugated bile acids were not strictures, and one was the patient previously found in the sterile bile of the 19 patients with large treated by cholecystduodenostomy. The chromato- FIG. 4. Thin-layer on September 30, 2021 by guest. Protected copyright. chromatogram of bile acids. The inlected bile was from the patient *with a cholecyst- X duodenostomy. The 'normal' bile was from a patient wih carcinoma of the head of the ~~~~~~~~~~~~~~~. .. .. ...... .........;F''''''S' :-; ';' '' *.....-:.:i;. pancreas and ......;....,5 biliary obstruction ......but sterile bile. The development system is that of Gregg (1966) and the bile acids have been detected with 10% molybdophosphoric acid in ethanol. 190 A. J. Scott and G. A. Khati Gut: first published as 10.1136/gut.9.2.187 on 1 April 1968. Downloaded from INITIAL AFTER then one might expect these features to be indenti- RESULT fiable in patients in whom it occurs. Now patients ANTIBIOTICS with partial biliary obstruction and cholangitis 301 frequently do lose weight rapidly but it is difficult to assign the responsibility to such a mechanism 144 when such other factors as infection and biliary obstruction are also present. Steatorrhoea is common to both conditions but it too has an ambiguous significance. And sincejaundice draws early attention .1z 20- ,.A to the biliary obstruction the condition will never be present for long enough for overt vitamin B12 deficiency to appear. We have therefore confined our attention to those remaining features which seem relatively unambiguous in their interpretation. 144N It was first necessary to establish that bacterial . 10- contamination of the small bowel could reach c significant levels. Elkeles and Mirizzi (1942) had U) reported that culture of duodenal contents resulted in a heavy growth of bacteria when bacterial cholan- 0 gitis was present suggesting that this would prove 0 to be the case. And indeed in the 11 patients we 0 0 studied the values obtained for the concentration 0 of viable bacteria in intestinal contents are in the FIG.