RARE OR OBSCURE CASES 327

CYSTIC DILATATION OF THE COMMON BILE-DUCT : RECORD OF AN EXAMPLE.

BY JULTAN TAYLOK, 'UCIh'l'E SURGEON TO USIVICRSITY CUL E lI03l'ITbL, L O S D O N .

AT tlie present time (A4pril, 1928) i t appears from perusal of the most reccnt I)iiblicwtion rcfrrring to this malady1 that, whereas i t has once been recorded :is recwgnized hcfore operation in a fatal case,2 there is no published account o f a corrcct diagnosis followed by snccessful operation. The following is the record of such a case. Tlic writer is indebted to the bibliographic tables of the American ituthors for a summary of the literature of the diseasc, and to a substantially similar collection niacle recently by Professor Choyce, Ilirector of tlie Surgical Unit of University College Hospital, that he has been privileged to read in manuscript.

CIA-ICAI, HISTOKY.-K. Y., female, age 23, was seen by the writer in consultation with Ih. Charles Bolton on Oct. 3, 1927. She had had attacks of pain, vomiting, and jaundice ever since she could remember-certainly since she was a small child.

Pain was felt right across the upper abdomen, in the lower chest, and in the hack, but riot in citlier shoulder. It came on in attacks of severity 1.arying from slight to severe, and lasting from a few hours to a day or so. Nothing. dietary or other, had been noted to precipitate the attacks, wdiich came on a t any time of the day or night and had increased in frequency latterly. Often the pain persisted as a dull onc having the same distri- bution as in the attacks, and for some months she had hardly been free from it.

Vomiting always acm)nipanied the painful attacks and was incessant while t,liey lasted. Nothing appeared to control it, although a t tinics i t seemed to relax the severity of the pain.

Jaundice always f'ollowcd the attacks at somcthing less than a day's interval ; slight a t the onset, i t a t times became deep. when it was usually accompanied by itching of the skin. She had been seen by several observers on different occasions since May. 1927, and though on none of these had she heen deeply jaundiccd, only once had she been free from a tinge.

Her appetite for all foods had always been bad. Constipution had always been present, and she had difficulty in opening

The stools were pale and the urine was dark

She had never noticed any swelling of the abdomen, but during the attacks She was first observed by th5writer a few

Ox EsaMrxATIoN.-she was seen to be thin, ill, and lethargjc. She was slightly jaundiced in the skin, mucous membranes, and mnjunctivie. The tongue was clean. In tlie abdomen a vague mass could be felt below the right costal margin, immobile with respiration, but too indefinite to permit the recognition of any special characters other than that i t seemed to be

hcr bowels with purgatives. when the jaundi~e was severe.

the upper abdomen was tender. days aEter one of the attacks. \

328 THE BRITISH JOURNAL O F SURGERY

deeply placed arid that thc abdonicii o\ cr it was resonant to percws5ion. The liver was not felt. Her temperature was normal; the pulse SO and of poor voliimc ; blood-pressurc 116.

h diagiio45 of cystic dilatation of the coninion bile-duct was 5uggestec1, :ind the following examinations wcre niade : C'holecystography (after oral administration of G grm. of tetraplieriolsu1pIioiiephtllaleiri) : no gall-bladder \hadow was visible, but part of the drug \\a\ eikient in the colon wiabwrbcd.

Corpiiscular fragility was fourid to he witliin normal limits. Hcd and white blood-cell counts wcre normal. I7an den Bergh's reaction was directly biphasic, indirectly positive.

She was admittcd to University College Hospital on Oct. 19, 1927, whcn she was found to hc suffering from an alveolar absccss that was associated with pain, swelling, and pyresia amounting to 101.6'. It was neccssary to extract an upper molar tooth, after which her jaw cleared u p slowly,

RARE OR OBSCURE CASES 329

but. a s is sccn f'roni her chart (Fig. 283) the fcvcr did not. Apart from her tlcntal condition. no physical signs of disease were now appreciable. othcr tlian :I \ t.ry slight tinge of jaundice. There n a s 1 1 0 ahdoniiiial swelling.

0 1 1 the iiight of' Oct. "3 slits lind :in attack like those desc~ibcd in her nicdicd liistory. Thc pain \ \ a s felt in the upper abdonicn. lower chest. and bacsk. but not in either slioulder or scapular region. It was severe. and she was gi\ en niorpliia. On cuaniination of thc abdomen tlierc was now aii indefinite globular mass palpablc in tlic nqt i t Iiypoclioritlriiiirr. crossing the middle line and extcnding for 24 in. k l o w the riglit co\tal n~argiri. It wa5 tender. ininlobile with rcspiration, arid resonant on percu\sion. Tlicrc was also diffuse tenderness over the ujiper half of tlic abdorncn. On Oct. 24 the jaiuidicc had i i i c r e a d and the temperature row to 102.2". The at)doniirial niass. which wa\ still terider, WR\ now :t little inore definite and was thought to be about the Gze of a lawn-tennis ball. omiting c~oritiiiriecl for two days arid the jaundice persisted.

On Oct. 28 there was anotlier attack. this time associated with a tempera- ture of 104.4" arid :i rigor. the jaundice subsequently becoming intense. the stool5 c*lay-colouretl. and the urine dark with bile. The pulse frequency now rose t o I(<(). and did not fall below 1%) until after her operation. count now showed :L lcucocytosis of 11,500 per c.nim., and of thesc 74 per (wit were polyniorplioiiiielear.

1,aparotonip Iiad been decidcd upon, but, owing to the supervention of uliat w a s clearly an aciitc infccti\ e cliolaiigitis, was postponed as it was thought desirable that the infeeti\ c cbontlition sliould subside if it would hcforc opcration. Oii Nov. 1. Iiowe\ er. she had another rigor with fnrther high fe\ er :inti pulse o f 130. arid she appeared to be going tlownhill. Operation was tlirrcforc deferred 110 longer.

Siucc her :ttltnrssion to hospital culciuin elrloride had been administered by the rriontli. bccmisc it wa4 thouglit, in \riew of the knowii danger froin Iixmorrhage in tlicsc cases, that no pre-opcrativc precaution should bc omitted, howc\ cr doubtful it4 T 'I ' 1 ue.

OPEN i~ ros . -On Nov. 3. lier temperature a t tha t time being 102" and the pulse 1 'LO, the abdomen was opcncd under ether by a right paranicctiari incision. KO adhesions were found. hut the gall-bladder was scen to he ciilarged. Hattcned. slackly tli5teiided. and thickened, being 44 in. long and 2 ; in. broad in its widest part. On displacing the gall-bladdcr and liver upwards. a globular distention of the common bile-duct was seen, about t h e 41zc of il Tangerine orange, extending upwards as far as the entrance of the cystic duct, anti downwards behind the second part of the duodenum. Thr cystic duct was short. wide, and straight, and apparently entered the upper part of tlie cyst of the bile-duct. On reflecting the peritoneum covering the cyst, h:cmorrhage from a network of thin-walled and distended veins occurred, and on an attempt to isolate the cyst Prom its surroundings the bleeding became free and difficult to stop except tcmporarily by gauze pressure. The wall of the cyst was friable and did not come easily away from surrounding structures. A similar experience was met with in attempting to define

There was incessant bilious vomiting and retching.

The

,I blood

330 THE BRITISH JOURNAL O F SURGERY

accurately the junction of the cystic duct with the cyst. The acconi1)anyiIlg diagram (Fig. 28%) shows the operative findings, but thc csact nature of the distention, whether fusiform, lateral, or saccular, was not ascsertained for the reason fii\.cn, nor was the possible presence of stricture of the bile papilla in\-es t iga t ed .

In view of the small s i x of t,lie cyst and of tlie troublcsome k)leeding attending its slightest manipulation, arid in view of tlie evil condition of the

patient resulting from biliary infection, i t was decidcd to join the gall-bladder to the

DLr(DDC" stoniach, a procedure w1iic.h would be COf*MOIV H E I 4 T I ' D U c T quick and easy, and need not involve

DlLRTE D bloodshed. A plug had bccn placed over CYST1 C the cyst for hxmostasis, and after coni-

pletion of tlie anastomosis this was "ODfmVIV removed, but considerable bleeding per-

sisted from a large vein near the junction of the cyst with the cystic duct. In an unsuccessful attempt to catch the vessel with forceps the cystic duct was puiic-

catgut. A plug was placed on the bleeding tured. This opening was closcd with fine

resscl and a tube in the wound, which was then closcd with catgut. A culture taken from bilc aspirated from the cavity of the gall-bladder yielded a pure growth of Bacillus di.

The patient stood the operation well, and by the following day tlie itching that had becn present was relieved. The teniperaturc came slowly and irregularly down during the succeeding days. The plug was taken out on the fourth day, rcrnoval being followed by a free discharge of bile.

The jaundice cleared up slowly but completely during the ensuing fort- night, and bile gradually ret.urned t o the stools. The biliary fistula persisted until Nov. 21, when its closure resulted in an attack of slight pain arid a rise of temperature to 102". Another copious discharge of bile was followed by gradual subsidence of the fever. The fistula finally closed on Nov. 29, and the patient left hospital healed on Der. 7 .

L 4 ~ ~ ~ ~ ~ - ~ r ~ ~ ~ ~ ~ t ~ .-Three and a half rrioritlis later (March, 1928) she was well, all symptoms having disappeared. There was no trace of jaundice, she had a good appetite for the first time in her life, could 'eat anything', and, having been previously thin, was now noticeably fattcr. Constipation had completely disappeared and she no longer took purgatives. As an individual she was brighter, and the lethargic mentality previously obvious was not now tlisccrnible.

IL*TE D yD -

P FIG. ?84.--Conditioii found at operation.

( / jeprodueed jrollL ~~t~~~~~~~~ diaarallL.)

COMMENTS. I n view of the large number of writings dealing with this malady tha t

have appearcd in rcccnt years, and in particular in view of that of Professor Choyce, so far unpublished but referred to here in the opening paragraph, the writer refrains from discussing the disease a t length, but the following observations may be permitted.

RARE OR OBSCURE CASES 331

Diagnosis.-Neugehauer’s case was that of a woman of 21 with seven nionths’ history of abdominal pain arid one month’s of abdominal swelling and jaundice. She had a cyst in the abdomen that was easily palpable as a largc fluctuating swelling that proved a t operation to contain 3+ litres of dark iluid. The cnornious sizc to which the cyst had grown was probably responsible for the ill fortune of the event.

In the present example the abdominal swelling was always indefinitc, and, though undoubtedly palpable. its nature could not have been recognizcd without the presence of other features of the disease. The development of a tiimour while an attack was under observation clinched a diagnosis already the one most probable. The writer would thus emphasize the clinical history as the essence of the diagnosis of t.liis malady, and to t,his cnd he has describcd a t some length that of one case. The essential dinical features appear to be those of attacks of abdominal pain felt also in the back but not in either shoulder, accompanied by continual voniiting and followed by jaundice. If occurring in young women or if dating from early childhood, such attacks should suggest the disease in question as their cause.

Infection.-While this patient was under observation there occurred serious infection, so that her life was jeopardized. It is possible that cases arise where infective cholangitis with cholecytitis are recognized and treated by drainage of the gall-hladderl the underlying cause of cystic dilatation of the common bile-duct escaping observation owing to the dilatation of the gall- bladder that usually accompanies the condition, and to the necessity for the adoption of a quick arid simple procedure in patients seriously ill. This might easily have occurred in the present example had the patient not been seen previously both in a quiesccnt period and when suffering from biliary obstruction without infection.

Treatment.-In this girl the distention of the common bile- duct was moderate and could be recognized ; but an accurate dissection. showing exactly the type of dilatation, whether fusiform, globular, or saccular, and invcstigating the condition of the bile papilla, was impossible. because an attempt resulted in free bleeding, an increase of which wa.s unjustifiable on account of the precarious condition of the patient arising from infection. It is likely that a part of the bleeding was duc to the infected state of the wall of the cyst, which was adhcrcrlt to surrounding structures and was unpleasantly friable. The real difficulty of hemorrhage thus made it unjusti- fiable to attempt anything but the easy anastomosis of the gall-bladder to the stomach. The subsequent history shows that in this girl’s case at any rate, where the cyst was small, cholecystgastrostorny was adequate. Hzmorrhage has accounted for a proportion of the deaths that have followed operations for this malady, and the writer is of opinion that once it has been recognized, cithcr before or at operation, where the cyst is small, anastomosis of the gall- bladder to the stomach or duodenum is the proper treatment, because with such a procedure there can be no danger whatever of bleeding from the veins around the cyst, and because it has certainly given this patient complete relief. The operation widely advocated for cyst of the comnion bile-duct is that of anastomosis of the cyst to the duodenum. Rut where a cyst. exists

Operative

332 THE BRITISH JOURNAL O F SURGERY

the gall-bladdcr is as a rule dilatcd, and it is possibly better t o short-circuit, thc bile from its first tlistrntlrtl reservoir. a s it may be that :I recwrrcnt residual c-holecystitis will arise later where tlic second distended reservoir. tIic cystic. comnioii duct, has k e n drained into tlic alinientary canal and tlic gall-bladder left alonc.

IZEFEREXCES.

.Junu, S , ~ A R R , nnd GR X I ~ ~ I ~ A I ~ E R , F., Rei!

S N T ~ . Gyuccol. nud Obsf., 1928. ski, 317. r., 19%, csxsi, 418.

A CASE OF NON-ROTATION OF THE MID-GUT. ~ 3 1 7 .r. w. THOAXSON,

HO\i( l l iLI1Y SUH(II <!\ I 0 1 H I CL4\7P( lV H O S P I 1 4 1 , \\ t h l F l t T I ) .

DIX~YLIXLYT\ of thc second stage of intestinal rotatioii arc divided, as dcscribed by Norman Dott i l l the BnrTrsrr .JOI-RYAI, 01.' S L ~ I ~ G C I ~ Y , vol. xi, 1). 266, into three groups : ( 1 ) Son-rotation of tlic mid-gut loop ; (2) Rcrcrsed

rotatioii of tlic mid-gut loop ; (3) Jlal-rotation of the mid-gut loop. 1 have to record :t case of the Lint gro11p.

adinittcd to the \Vakciicld Hospital on .7unc 3 0 , 1927.

quite well until the age of 18, wlicn symptoms rcferablc to tlic digcstil e organs set in. Her coii- ditioii gradually deteriorated. pain after food increased in sc\ erity, aiid voniiting became more frc- (limit till only siilall quantities of food could be retained. Prolonged medical treatment had gi\ren iio relief.

TIov.-Tlie first part of the duo- denum pa5sed soniewliat vertically upwards, aiid tlic second part passect downwards almost parallel with the first, forming an acute

FT~:. 285 --'rtlc duodeniirn 15 reen parmg to ttle ang~llation a t tlleir juncation. Slight right, and the jejunum and ileum arr owlpylng traction on t h e secon(1 part brought iliac rcgioiis i t into immediate contact with the

first part. The duodenum thcn bccaine freely movahlc and passed outwards to the right t o join the jejunum. Thc jejunum, with the ileum, occupied the right hypochondriac, right lumbar,

1). G., fccnialc, agc 23, Was

III5TOIiY. Tllf.' patlent T\BS

cO;\ 01'1 L O & FOL \-I> iT OPCIL-

the right h~pochondrld~, Ilght h l l l l b~ l , d1ld llght