Anatomy and pathology of the distal common duct

Anatomy and Pathology of the

Distal Common Duct Special Reference to Stenosing Odd#is

FERNANDO PAI'I.INO: M.I). , and .'~NAI)IL CAVALCANTI, M.D.

B II.IARY SUR(;ERY, h) rnmrly o r i e n t e d toward t r e a t l ne n t o[ the gal l

b l adde r , deals today with lesions ot the h e p a t i c and c o m m ( m bile dnc t its well. Because of this, there has been inc reas ing in te res t in the pa tho logy o[ t i le d is ta l c o m m o n duc t (intrapancreatic, t r a n s d u o d e n a l , and a m p u l l a of V a t e r ) , a reg ion which has been a p a r t i c u l a r l y con t rove r s i a l area in b i l i a ry surgery because of the c o m p l e x i t y of a n a t o m i c re la t ion- ships at td the d i t l i cuhy ot c l in ica l and r ad io log i c e x a m i n a t i o n . A l t h o u g h H e n d e r s o n in 1900 t and F l o r k e n in 1924" sugges ted the poss ib i l i ty of ben ign o rgan ic stenosis of the d i s ta l c o m m o n bi le duct , i t was De l fo r Del Val le a who, in 1928, p re sen ted the hest c l in ica l and p a t h o l o g i c de sc r ip t i on of s tenos ing lesions of the m a i n b i l i a ry ducts. Del Val le 4 stressed the <)c- cur rence o[ total as well as p a r t i a l obs t ruc t i ons o[ the c o m m o n bi le duc t r e su l t ing from chron ic c ica t r ic ia l i n t t a m m a t i o n . T h i s o b s t r u c t i o n was no ted wi th or w i t h o u t ass,,miated c o m m o n duc t s tone and was desc r ibed as sclerosing cho l edocho -odd i t i s ( sc lero-re t rac t i l c h o l e d o c h o - o d d i t i s ) . T h e

concu r r en t d e v e l o p m e n t ol/ the concep t of p u r e l y f u n c t i o n a l sph inc t e r i c p h e n o m e n a (b i l i a ry dyskines ia due to s p h i n c t e r spasm) has r e s u h e d not only in cons ide rab le confus io l l of the f unc t i ona l d i so rders o[ this reg ion wi th those ot organ ic pa thogenes i s , bu t has also d i s t r ac ted f rom fu r the r s tudy of the o rgan ic lesions of the area. T h i r t y years af ter Del Val le ' s classical work, Ca t t e l l el al:' p u b l i s h e d an a r t ic le c on f i rming Del Val le ' s conclusions. Cat te l l ' s work does not p resen t the h i s t o p a t h o l o g i c docu- m e n t a t i o n that w o u l d be des i rab le , b u t has ce r t a in ly con t r i l ) u t ed to a be t t e r u n d e r s t a n d i n g of o rgan ic stenosis of the d is ta l connnon duct .

O b s t r u c t i o n to the bi le flow at the d is ta l co ln lnon duc t may be produced e i the r hy a s tone ( in t r ins ic or i n t r a d u c t a l ) , by COlnpression of the

From the Sections of S~lrger} and l'athology of the Casa de Saude S. Miguel, Rio de Janeiro, Brazil.

Tile authors wish to express their appreciation to Drs. A. Paulino-Netto and David A. Dreiling of the Deparnnent of Surgery, The Nit. Sinai Hospital, New York, for the translation of this paper from Portuguese.

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Paulino & Cavalcantl

common duct by the head of the pancreas (extrinsic), or by stenosing benign or mal ignant lesions of the wall of the distal common duct and ampul la of Vater. This paper will be l imited to discussion of the benign organic stenosis of the distal common duct in order to stress the anatomic and pathologic aspects that have been neglected in recent medical liter- atuve.

M A T E R I A L AND M E T H O D S

Tile lack of available documenta t ion of the normal histologic appear* ance of the per iampul lary area of the common duct required a prelimi- nary anatomic and histologic study of this region. Accordingly to investi- gate the gross and microscopic anatomy of the ampulla , sections were taken as follows.

1. From the distal common duct and ampul la of 20 cadavers (15 adults and 5 children) aged 1 month to 71 years (Death in these patients was not due either to pancreatic or biliary tract disease.)

2. F rom the distal common duct and atnpulla of the surgically re- sected head at the pancreas in 2 patients who had pancreatic excisions because of cancer of the stomach that had be(o,ne adherent to the pancreas.

3. From biopsies of the ampul la of Valet and sphincter of Oddi from 23 patients operated upon for biliary-tract disease and who, at the time of explorat ion, displayed such marked narrowing of the ampul la of Vater that a 3-ram. dilator could not be passed from the choledochostomy opening through the ampul la into the duodenum.

In the autopsy specimens the sections made were tranverse to the long axis of the common duct in 6 cases, longitudinal or parallel to the axis of the common duct in 4 cases, and both longitudinal and transverse in 10 cases. T h e transverse sections were performed at intervals of 3-7 ram., and the longi tudinal sections in fragments of 1 cm.

T h e necropsy material and the two surgical specimens of patients without biliary-tract disease demonstra ted no inf lammatory infiltration, nmscular hyper t rophy, or fibrosis except for 1 case, in which there was an inf lammatory process involving the ampulla , the common duct, and the pancreat ic duct. This pat ient was a 2-month-old child who died of f ibrino-purulent peri tonit is produced by perforat ion of an intestinal ulcer in a case of severe enterocolitis.

T h e ampul la ry biopsies of the surgical cases with s.tenosis of the distal common duct were done by excision of a I0 to 15-mm. fragment of the anter ior wall of the ampulla . These fragments contained ampul la r and duodenal mucosa and the tissue between the two mucosas (Fig. 1). This excisional biopsy must be done with care since the duodenal mucosa is

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Distal Common Duct

more abundant than tile ampul la r wall. Inadequa te biopsies relnove only duodenal mucosa, providing material insufficient for microscopic recog- nition of the corresponding layers of tile distal common duct. In such biopsies the essential pathology may be missed.

M A C R O S C O P I C AND M I C R O S C O P I C A N A T O M Y OF T H E D I S T A L C O M M O N D U C T

T h e common duct, forlned by the confluence of the cystic and hepatic ducts, continues downward and slightly frontward, nnt i l it joins the duodenum at the ampul la of Vater. T h e classical division into pars retroduodenalis, pars pancreatica, and pars intramuralis , is adequate and useful in surgical nomenclature . When the cystic duct joins the hepatic duct at a high level, the common duct presents in addit ion a supradno- denal portion. However, not infrequent ly the cystic duct joins the common hepatic duct rather distally in the pars pancreatica, an anatomic variation that may lead the unsuspecting surgeon to per form a common duct explorat ion in the common hepatic duct and to miss calculi in an abnormal ly long juxtaductal cystic duct.

The . l eng th of the common duct varies between 3 and 9.5 cm., with an average of 6.3 cm. It is beyond tile scope of this paper to give detailed measurements of the different port ions of the common duct. These measurements vary with the patient 's consti tut ional type, the state of disten- tion or contraction of the duodenum, the volume of tile head of the pancreas, etc. Those interested in exact measurements of length, width, and other statistical data are referred to the works of Nuboer , ~ Smanio, 7 Hollinshead, s and Hornykiewytsch, 9 which contain extensive numerical references. T h e following description of the regional anatomy, however, has a practical purpose, and is based on more than 100 pancrea toduodenal mobilizations performed dur ing operations.

T h e re t roduodenal common duct is easily approached surgically by slight traction on the duodenum or by the pancrea toduodenal mobiliza- tion known as Kocher's maneuver. T h e common duct is in int imate relationship with the superior pancrea toduodenal artery, which crosses it anteriorly immediately above the superior border of the duodenum. When a choledochostomy incision is extended downward, this arterial branch should be avoided or ligated, s. a0

PARS PANCREATICA

The pars pancreat ica passes through pancreat ic tissue or lies oll a bed excavated f rom the posterior surface of tile pancreas. T h e existence of a slice of pancreatic tissue taking tile form of a l ingula covering the corn-

New Ser~es, VoL 5, No. 8, 1960 6 9 9

Fig.

1.

Tec

hnic

of

ampu

llar

bio

psy.

Distal Common Duct

mon duct is well accepted. The hee border oI this lingula may be easil} dissected in approaching the pars pancreatica of the common duct. Al- though the trans- and retropancreatic common duct may be freed from the pancreas and directly incised, in cases of impacted stones the ch,,)ledo- chotom} can be performed by incising both the pancreatic lingula and the comlnon duct, using the stone as a landmark and making the incision directly over it. At the inferior end of the pars pancreatica there are circular muscle fibers (Fig. 2) corresponding to the sphincter choled- ochus superior described by Boyden. 1. This [act was observed in serial sections of the region and is important in the interpretation of X-ray fihns and ill the performance of the sphincterotomy.

,~11 O O

12".

I I I ' l l A H

1

C 1 l) 7 2 % o/ [ / o

7

Jlt

#z Fig. 2. Millbourn's scheme On the variations of the pancreatic and comnlon bile dtlcts.

PARS ~NTRAMURALIS

The "pars intramuralis" varies in length from 0.7 to 2 cm. (average 1.4 cm.) and passes obliquely through the internal half of the posterior wall of the duodenum. The common duct joins the duodentnn at the inferior half of the descending portion in 73 per cent of the cases, at the horizontal portion in 8 per cent or the cases, and at a point between the above mentioned in 19 per cent of the cases.

The terminal port ion of the intramural common duct is covered by duodenal mucosa and, in 80 per cent of the cases, is joined by the main pancreatic duct (Wirsung) to form the ampulla of Vater. The different types of confluence of pancreatic and biliary ducts have been described in the literature with all their many variations. Figure 2 presents a complete scheme of the variations reported by Millbourn. ~a

The ampulla of Vater, when examined after duodenotomy, presents

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itself as an elevation among tile transverse folds of the duodenal mucosa and has a punct iform orifice that is not easily recognized. The longitudinal fold or "frenum ampullae" situated immediately underneath the opening makes the identification simpler. In sonie cases the ampulla is very easily identified as a sausage-shaped structure in the duodenal lumen, while in other cases there is coniplete absence of any elevation of the duodenal nIucosa (Fig. 3). The duodenal mucosa and tile ampullary orifice exhibit the same pink color imless there are pathologic alterations, which will be described subsequently. By careful palpation the consistency of tile normal ampulla is found to be soft and similar to that of the posterior duodenal wall. in cases of fibrosis of the sphincter of Oddi the consistency of the ampulla is firm and even wood-hard in some cases.

The benign stenosing lesions described in this paper are located at the intrantural portion of the co:;nnon duct and at the ampulla. These lesions can be recognized and interpreted only through a complete knowl- edge and understanding of the normal anatomy of the region.

HISTOLOGY

A complete description of" the histology of the ampulla and distal common duct includes evaluation of the mucosa and the nmscular, connective, and elastic tissues (Fig. 4).

Mucosa

The nlucosa in the adnlt is slightly folded and tormed by epithelimn and lamina propria or corium. The cells are cylindrical, disposed in one layer, with basal elongated nuclei and clear, transparent cytoplasm. The lamina propria of the mucosa is formed by vascularized connective tissue containing nmnerous mucoid-type glands found chiefly at the posterior wall of the ampulla. Glandular formations also occur in the hepatic and connnon ducts. The duodenal nmcosa is suddenly interrupted at the level of the ampullary ostium and replaced by the ampullary mucosa. Cellular inflammatory infiltration is almost never found in the lamina propria of the mucosa. Among 22 cases without stenosis of the ampulla only one presented inflalmnatorv infiltration.

Muscular Tissue

Muscular tissue is found at the distal end of the ampulla quite near its external opening and also between the glands. Its fibers are pre- doniinantly circular in type, al though longitudinal and even oblique bundles can be discerned. These fibers are more numerous and better developed at the anterior walt of the ampulla.

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Distal Common Duct

.6-

c~

Fig. 3. Letters a, b, and c represent normal ampulla. Pathologic ampullae found in our cases: d, fibrosis; e, papillary formations; ], enlarged ampulla. These pathologic variations were described by Del Valle in 1939. Fig. 4. Transverse and longitudinal sections of the normal ampulla of Vater. See text for description.

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Starting from the distal end of the ampulla, the muscle fibers progressively increase in number and caliber until the whole circumference is encompassed. The common duct is also encircled at its intramural portion (inferior sphincter of the common duct) by muscle fibers, pre- dominantly circular in type, which gradually disappear as the duct goes up toward the liver. At the distal intrapancreatic portion, well-developed mnscle bundles can be round (superior sphincter of the common duct) (Fig. 5). The muscle fibers, more numerous at the posterior wall of the

connnon duct near the duodenum, become more nuinerous at the anterior wall, as the duct goes away from the duodenum. They progressively disappear, and only rare fibers are found at the supraduodenal and proximal portion of the retropancreatic common duct.

The pancreatic duct is also surrounded by longitudinal and circular muscle fibers, but only for a short distance, and at its distal end near its junction with the common duct. Beyond this point the musculature is ahnost absent, and only rare fibers can be found along the intrapancreatic port ion of the duct. Very thin and scattered circular, longitudinal, and oblique muscle fibers can be demonstrated between the pancreatic and connnon bile duct.

In some cases there seems to be a complete separation between the ampullary and duodenal musculature. In others, however, the fibers are mixed, making it difficult and even impossible to identify the individual components. In the child the fibers are thinner and less mnnerous, but the arrangement is the same as in the adnlt.

Etastic Tissue

The elastic tissue is sparse at the level of the ampulla and becomes progressively more abundant in the proximal connllon duct. Here it constitutes one of the main elements of the wall and forms a tight mesh, with thin fibers toward the region of the lumen o[ the duct and a loose mesh with thick fibers toward the external region of the duct. The muscular and elastic tissues have an inverse distribution in the common duct. This relationship is similar in the adult and the child, although all the fibers are in general less developed in children.

Con nective Tissue

At the ampulla the connective tissue is not (lense but h)osely fills the space between the other tissues. At the common duct and pancreatic duct it forms a fibroelastic layer which, with the elastic tissue, constitutes a very important element o[ the wall.


Distal Common Duct

Fig. 5. A Longitudinal s e c .

tion of the common bile duct immediately above its junction with the duodenum. I-he strong muscle bundle forms the sphincter of the conlnlon duct.

B Proximal part of the retropancreatic common duct, with absence of muscle fibers.

C Cross-section of the common duct (right) just before its junct ion with the pancreatic duct (felt) .

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P A T H O L O G Y OF T H E D I S T A L C O M M O N D U C T

T h e histologic changes noted in the 23 biopsies obta ined at surgery ill patients with stenotic sphincters of Oddi include nmscular hypertrophy, mucosal proliferation, g landular hyperplasia, fibrosis, and cellular infiltration.

The re was nmscular hyper t rophy in 20 cases among the 23 studied. In 7 of these cases the hyper t rophy was intense, with a great prol iferat ion of tile muscle fibers that occupied ahnost all the ampul la ry wall, invaded the mucosa, and compressed the glandular elements (Fig. 6D). In another 9 cases the hyper t rophy was of moderate intensity. In the other cases it was minimal . Muscular hyper t rophy was the only alteration found in 4 cases, while in the remain ing it was associated with other pathologic changes such as nmcosal proliferation, fibrosis, and inf lammatory infiltration.

Mucosal prol i ferat ion was observed in 4 of the 23 biopsies. In one of these cases the nmcosal overgrowth was marked and directed toward the ampul la r lumen. Papil lary mucosal projections (Fig. 6C) were very evi- dent. T h e gross appearance in this case was that of a papi l loma with its villous projections occupying the ampul la ry lumen and pro t ruding into the duodenum through the papilla. These villous projections were lined by a cylindrical epi thel ium similar to the one normal ly found in this region. T h e epi thel ium covered a central connective-tissue core containing blood vessels and some nmscle fibers. The re were also intense muscular hyper t rophy and modera te connective-tissue proliferation. The pathologic diagnosis was papi l loma of the ampulla . T w o other cases showed less marked villous mucosal proliferation.

T h e m~cosal glands appeared normal or disclosed some tendency toward cystic degenerat ion in 12 cases. In 3 cases the glands were less numerous and were compressed by the hyper t rophic muscle tissue. In another case, however, there was intense hyperptasia of the glandular tissue, with cystic formations at the distal end of the glands which were lined by cylindrical and nmcoid cells.

Intense fibrosis was observed only three times, being associated once with muscular hyper t rophy and another t ime with lymphocytic infiltration. In 2 cases the fibrosis was moderate; in 3 other cases it was very slight and always associated with another pathologic process which domi- nated the histologic picture.

Cellular inf lammatory infil tration of lymphocytes, plasmacytes, and eosinophils, in proport ions varying from case to case, was predominant ly localized at the nmcosa, a l though it was sometimes observed between the muscular and connective tissues. Only once was the cellular infiltra-

706 American Journal of Diclestive Diseases

Distnl Common Duct

Fig. 6. A Normal ampulla. B Muscular hypertrophy and mucosal proliferation. (7 Extreme villous proliferation of the mucosa (papilloma) and muscular hypertrophy. D Marked muscular hypertrophy showing glandular tissue compressed by the hyper- trophic muscle fibers.

D

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t i o n m a r k e d a n d , i n thins c a s e , i t w a s a s s o c i a t e d w i t h a s e v e r e m u s c u l a r

h y p e r t r o p h y . I n 4 c a s e s t h e c e l l u l a r i n f i l t r a t i o n w a s m o d e r a t e a n d i n 11,

s l i g h t . T a b l e 1 s u m m a r i z e s t h e m o s t i m p o r t a n t h i s t o l o g i c a l t e r a t i o n s

f o u n d .

I 'ABI .E ]. I '_VIHO1.OGIC CHANGES OBSERVED IN H I S T O L O G I C STUDIES OF 23 BIOPSIES OF T H E A M P U L L A OF V A T E R

Hospital Muscular lnfiamnlatory Mucosal number hypertrophy Fibrosis inliltration proliferation Edema

1834 +-+- + + + - - - - 5349 -r- + - - - - - - 5420 q--r- + q - ' P + ~r- - - - - 6046 + -}- -p . . . . 6532 - - + - 4 - + -? - - -}- 6674 q-q- - - + - - - -

6 8 6 3 - - - - + - - - -

7 6 6 7 +q- - r - ~- - - - - - - 8073 + + + + - - - - - 8406 - - + + + q-q- - - - - 850[ + + - - + ~ - + - + + - - 8629 + + + + + - - - - 9881 +-}- q- ~- --}- q-- - -

10109 -4--}- - - + - - - - 10139 + + + + + + + + + + - - 10204 + - - & - - - - 10315 -~-+ - - - - - - + 10421 - [ -+ -~- -g-j- ~- + 10656 + - - + + - - 11267 + + + + - - 11577 + + + . . . . 11625 + + + . . . . 11684 -}-+ - - -+- + q - q - - -

Degree of pathologic change: + + + , intense; -+-+, modera te ; q-, slight.

D I S C U S S I O N A N D C A S E H I S T O R I E S

T h e e t i o l o g i c r e l a t i o n s h i p s b e t w e e n b i l i a r y d y s k i n e s i a , o d d i t i s (s te-

n o s i s o f t h e p a p i l l a ) , c h o l e c y s t i t i s , a n d c h o l e l i t h i a s i s a r e c o n t r o v e r s i a l a n d

s p e c u l a t i v e . A t p r e s e n t , o u r k n o w l e d g e o f t h e p e r i a m p u l l a r p a t h o l o g i e s

is s o l i m i t e d t h a t t h e o r i z i n g is u n w a r r a n t e d . A l t h o u g h b i l i a r y d y s k i n e s i a

m a y e x i s t as a c l i n i c a l e n t i t y , w e h a v e b e e n u n a b l e to d e f i n e i t s c l i n i c a l

o1" r o e n t g e n o g r a p h i c p a t t e r n d u r i n g a n e x t e n s i v e c l i n i c a l e x p e r i e n c e i n

b i l i a r y - t r a c t s u r g e r y o v e r a p e r i o d o f t w e n t y y e a r s . I t is m o r e p r o f i t a b l e 1o

d o c u m e n t t h e c l i n i c a l , X - r a y , a n d s u r g i c a l e x p e r i e n c e s w i t h t h e e n t i t y o f

s t e n o s i s o f t h e s p h i n c t e r o f O d d i , b y s u n n n a r i z i n g a t y p i c a l c a s e a n d re-

p o r t i n g b r i e f l y o n 3 p a t i e n t s .

T y p i c a l l y , t h e p a t i e n t is i n t h e f i f t h o r s i x t h d e c a d e s . F o l l o w i n g a

708 American Journal of Digesflve Diseases

Dis~'al Common Duct

c h o l e c y s t e c t o m y for cho lecys t i t i s a n d cho l e l i t h i a s i s , t he r e u s u a l l y has b e e n

an i n t e r v a l of n o r m a l h e a l t h . T h e n typ ica l b i l i a r y co l ic r e a p p e a r s w i t h o r

w i t h o u t r a d i a t i o n to t he back. T h e co l ic is o f t en i n c r e a s i n g in f r e q u e n c y

a n d i n t e n s i t y a n d assoc ia ted w i t h chi l ls , fever , a n d j a u n d i c e . V i s ib l e

j a u n d i c e , p r e s e n t o n l y in the e x c e p t i o n a l case, is n e v e r i n t e n s e a n d u s u a l l y

t r ans i en t . R a r e l y does it pe rs i s t for m o r e t h a n 48 h o u r s f o l l o w i n g the

onse t of acu te ly e x a c e r b a t e d pa in .

Phys i ca l e x a m i n a t i o n at i n t e r v a l s b e t w e e n a t tacks m a y r e v e a l o n l y

s l igh t t e n d e r n e s s to d e e p p a l p a t i o n in the r i g h t u p p e r q u a d r a n t . S e r u m

b i l i r u b i n a n d s e r u m a l k a l i n e p h o s p h a t a s e , t h o u g h n o r m a l at this s tage,

n tay be e l e v a t e d d u r i n g p a i n f u l crises. I n t r a v e n o u s c h o l a n g i o g r a p h y is

the mos t i m p o r t a n t d i a g n o s t i c p r o c e d u r e , r e v e a l i n g an o f t e n d i l a t e d ,

s tone- f ree c o m m o n d u c t w i t h d e l a y e d e m p t y i n g . T h i s l a t t e r p o i n t has

been s tressed by W i s e a n d O ' B r i e n :a a n d is best d e m o n s t r a t e d by the 2- h o u r f i lm of t he a b d o m e n .

A t o p e r a t i o n a t h i n - w a l l e d , d i l a t e d c o m m o n d u c t is f o u n d , c o n t a i n i n g

dark , i n sp i s sa t ed b i le b u t no stones. I n such cases it is i m p o s s i b l e to

c a t h e t e r i z e the s p h i n c t e r of O d d i , e v e n u s i n g a s m a l l 3-ram. d i l a t o r . T h e

d u o d e n u m m u s t be o p e n e d for i n s p e c t i o n a n d p a l p a t i o n of the p a p i l l a .

T y p i c a l l y , t he p a p i l l a a p p e a r s as a p u n c t i f o r m r e t r a c t e d orif ice, a n d pal-

p a t i o n discloses i n d u r a t i o n . T h e r e is a b n o r m a l r e s i s t ance to sec t ion w i t h

kn i fe o r scissors. A w e d g e - s h a p e d a rea a b o u t l cm. l o n g is exc i sed (see Fig. 1).

T h r e e i l l u s t r a t i v e case h i s to r i e s a re a p p e n d e d .

C a s e 1 (CSSM N o . 6532)

This 59-~ear-old white female was operated upon on Aug. 23, 1955, at which time a cholecvstectomv and common duct exploration were performed. The gall bladder contained stones, and the common duct was dilated but contained n o stones. There was great difficulty in passing a dilator through the sphincter of Oddi into the duodenum, but finally, with care and patience, it was possible to do so and the sphincter was dilated to 5 mm. Postoperative cholangiography showed a dilated common duct with a filiform appearance at the level of the sphincter of Oddi (Fig. 7A).

The patient returned to the office 6 months later with colicky epigastric and right upper quadrant pain radiating to the back. The ~ain became progressively worse, with frequent crises and dark-colored urine but no clinical jaundice. The serum bilirubin was elevated and the blood amylase was normal during the attacks. Intravenous cholangiogram disclosed a very dilated c o l n m o n duct with stasisl~ hut no stones (Fig. 7B).

The patient was reoperated upon on ,Jan. 15, 1957. The common duct was dilated and without calculi. No pathology was found in the cx, stic duct stump. At exploration of the common duct, the sphincter of Oddi was definitely stenotic and could not be passed by probing. The pancreas was normal. A transduodenal sphincterotomy was done with biopsy, after which a 9-ram. dilator could be easily introduced into the

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A

Fig. 7. Typical X-ray picture of stenosing odditis. A Postoperative cholangiogram showing dilatation of the common duct and stenosis of its distal portion (Case 1). B Intravenous cholangiogram in a patient with stenosing odditis proved by operation (Case 1), illustrating dilated common duct with stasis after 120 minutes. No stones are visualized.


Distal Common Duc¢

duodenuni. Pathologic diagnosis was inflammation and fibrosis of the sphincter of Oddi. This patient has been without complaint since sphincterotomy.

C o m m e n t

This is a typical case of long- s t and ing bi l iary- t ract disease with cholecys- tills, choleli thiasis, and in f l ammato ry stenosis of the sph inc te r of Oddi . At the first opera t ion , there was some d o u b t a bou t the necessity for sphinc tero tomy. I n retrospect, this p rocedure was s t rongly ind ica ted by

the d i la ted conmlon duct , absence of stones, and difficulty in passing the dilators th rough tile sph inc te r of Oddi . T h e sph inc te ro ton ly was no t done and the stenosis of the sph inc te r was p roved la ter by tile i n t r a v e n o u s cho lang iogram and by reopera t ion , with biopsy of the ampul la .

CASE 2 (CSSM No. 5420)

This patient was a 45-~ear-old white female with a 15-year history of bilia D colic. Ten years before, she had had an attack followed by jaundice, dark urine, and light- colored stools. The patient's symptoms had increased during the 6 inonth~ preceding examination, until there was ahnost persistent right upper quadrant discomfort and frequent attacks of pain with subclinical jaundice. On June 27, 1957, exploration disclosed a fibrotic atrophied gall bladder with stones and a dilated common duct containing large calculi. The sphincter could not be passed by the 3-ram. dilator. Duo- denotomy revealed a hard ampulla with a punctiform orifice. Histologic examination of a fragment of the ampulla showed muscular hypertrophy and fibrosis.

C 01'TI ~Tt e ~? t

T h i s is a case of long-s tand ing choleli thiasis , wi th its comple te pathologic p ic ture of sc leroat rophic cholecystitis, choledochol i thias is , and stenosis of the sphinc te r of Oddi . Pancrea t i t i s secondary to l i thiasis is fre- q u e n t in such cases b u t was no t f ound ill this one. T h e pancreas was n o r m a l by inspec t ion and p a l p a t i o n at the t ime o[ opera t ion .

O n the basis of the exper ience acqu i red in the last few years, tile cholecystectoiny and c o m m o n duct exp lo ra t i on were c o m p l e m e n t e d in this case with i tnmedia te sph inc te ro tomy. Histologic section of the ain- pu l l a r biopsy revealed an organic stenosis, which just if ied the necessity for a sphinc tero tomy.

CASE 3 (CSSM No. 10139)

This 71-year-old white male had a 3-year history of acute abdominal pain with fever (40°C.) , bad chills, but no jaundice. The pain was not severe and ne~er assunled the characteristics of typical biliary colic. Complete physical examination revealed no abnormality in the abdomen. Laboratory work-up showed a normal bilirubin with an elevated alkaline phosphatase of 29.1 Bodanskv units. A gall bladder series of roentgenograms disclosed stones. At operation the gall bladder was found to be enlarged with stones, and the common duct was dilated and contained a large calctdus.

New Series, Vo]. 5, No. 8, 1960 71 1

Paulino & Cavalcan¢i

l'alpation of the duo(tenuna revealed a papilla enl'nc, e d , m to the size of an almond. The duodenuln was opened. Papillary formations were seen protruding from the orifice of an ampulla that appeared to be four times the normal size. A resection of the ampulla was performed, with separate section of the common and pancreatic ducts and tetra- plantation of hoth into the duodemml. The pancreatic duct was dilated to the caliber of a pencil but contained no stones. "l-he histology in this case was reported as showing intense mncosal proliferation and glandular hyperplasia. There were ~illous projections partially obstructing the ampullary lumen and extending into the duodenmn.

C o m m e n t

In this case of chole l i th ias is and cho ledochol i th ias i s wi th a m p u l l a r

stenosis, the stenosis and obs t ruc t ing vi l lous p a p i l l o m a p r o d u c e d marked

stasis of the panc rea t i c and c o m m o n bile ducts.

S U M M A R Y A N D C O N C L U S I O N S

1. In o rder to s tudy the organic lesions ot the distal comnton bile

duct and a m p u l l a of Vater , the au thors p e r f o r m e d his tologic examina-

t ion of that r eg ion in 23 surgical cases. In most there had been persistence

of sylnl)tolns af ter cholecystectomy. Stenosis of the distal connllOll bile

duct had been d e m o n s t r a t e d by in t r avenous ch o l a n g io g ra p h y and surgi-

cal exp lo ra t ion .

'2. For an exact e v a l u a t i o n of the pa tho log i c changes e n c o u n t e r e d in

this region, a compa r i son was made between tlle f indings of these surgical

cases and the findings for 20 specilnens o b t a i n e d by autopsy in normal

subjects and 2 surgical specimens of pa t ien ts wi th no history of biliarv-

tract disease.

3. T h e study demons t ra tes and defines the lesions ( tnuscular hyper-

trol)hy and fibrosis) of the reg ion of the aml)u l la of Vater and distal

comlnon bi le duct that occur in pat ients wi th bi l iary- t ract disease in

w h o m it was not possible to pass a 3-ram. d i l a to r t h rough the papi l la into

the d u o d e n u n l (s tenosing odd i t i s ) . In 22 pa t ien ts w i t h o u t bi l iary-tract

disease no pa tho log ic changes were encoun te red .

["I-~RX.~,'~I)O PAt;LINO, M.D. l¢ua Co,de de lral'a No. 420

Rio de Janeiro, Brasil

R E F E R E N C E S

1. HENDI-RSON Cited by DEL VALLE. '.2 ). FLORKFN C i t e d bv DEL VAI.LE. 3. DH. VAIA.I;, D. Palologia del esfincter de Oddi. Rev. brasil reed. pharm. 4:489,

1928. 4. IIH. VALI~r:, D. Patologia } Cirurgia del Esfincter de Oddi. Buenos Aires, Argentina.

El ~teneo, 1939, vol . 1. 5. C.~'vrH~I., R. B., COLCOCK, B. P., and-POLLACK, J. L. Stenosis of the sphincter of

Oddi. New I'-ngland J. 3led. 256:429, 1957.

712. American Journal of Dicjesflve Diseases

Distal Common Duct

6. NtmOER, J. F. Die Y.l terverfindernngen der ex t r ahepa t i schen Gallenwege. ,V~ankftLrt Ztsckr. Park. 42:192, 1931.

7. SSIAXlO, T. Varying relat ions of the c o m m o n duc t wi th the poster ior face of pancreatic head in Negroes and white persons. J. InteTnat. Coll. Surgeons 22:150, 1954.

8. HOLLI:~SmCal), IV. H. T h e lower par t of the c o m m o n bile duct : A review. S. Clin. Nor th America, August , 1957, p. 939.

9. HORXrKZV, W~TSCn, T. Colangiografia intravenosa. Madr id , Spain, A lhambra , 1957, vol. 1.

]0. I'AH3XO. F., and PERXA_XIBt:CO, P. T6cnica da colecistectomia e coledocostomia. l¢ev. brasil cir. 31:319, 1956.

11. BoYI)EX, E. A. T h e a n a t o m y of the cho ledochoduodena l j unc t ion in man. Sto'g. (;ynec. L ~ Obst. 104:641, 19,57~

12. Cocv., W. H., and GROVE, W. J. Persis tence of s ymp toms fol lowing cholec~stectomv with speciat reference to anomal ies of the a m p u l l a of Vater. Ann. S , rg•. 136:73, 1952.

13. Mn.L~Ot:Ux, E. Gal lens te inchi rurgie : Eine Studie, au f Basis 419 Pat ienten , w//hrend eincr Zwei jahrper iode operiert . Fortschr. 3led. 73:57, 1955.

14. Wlsv, R. E., and O'BRIffN, R. G. In t e rp re t a t i on of in t r avenous cho lang iog lam. J.A.M,A. 160:819, 1956.

1'3. BA(;c.l:xs'ross, A. H. Major d u o d e n a l papilla: Var ia t ions of pathologic interest and lesions of the m u c o s a Arch. l 'atk . 26:853, 1938.

New Series, Vo], 5, No. 8, 1960 713

Documents

Anatomy and pathology of the distal common duct