ULCERATIONS AND PERFORATIONS OF THE BILIARY PASSAGES.
These may occur anywhere along the biliary tract, and vary as between the superficial and the perforating, the former being sometimes multiple, the latter solitary. Of these lesions cholelithiasis is the most common cause, while typhoid and cancer should be ranked next. They are all of pathological import, because of their possible sequels, i. e., not merely perforations with fistulas, but possible strictures or hemorrhages, or peritonitis with sepsis. When ulceration is extensive a previous local difficulty may be supposed, with more or less adhesions, but as the trouble becomes more serious the local excitement will extend to the peritoneum, at least that of the area involved. In fact most cases of gallstone disease are accompanied by more or less peritonitis, and adhesions which are protective, although they may cause other troubles as well, such as dilatation of the stomach from displacement of the pylorus. Hemorrhage is not a frequent event, for thrombosis usually precedes erosion. Some degree of sapremia or septicemia will be present in nearly all cases.
Stricture of the ducts is the most common result, especially of the cystic duct. If this occur and the mucous membrane be still active the gall-bladder will become distended with pus or mucus, or both. These are the cases which perhaps give the best results after ideal cholecystectomy.
Perforation is a constant possibility whose menace cannot be estimated, but which is always actual, the great danger depending on the virulence of the extruded material and the consequences of delay in operating. Although healthy bile is but slightly toxic, these cases do not furnish it, and one may always look for consequences of infection. Nevertheless if diagnosis be made sufficiently early to bring about immediate operation prognosis is good. Occasionally during such an operation there will be found a gallstone endeavoring to extrude itself, but not yet completely escaped. It might be, in rare instances, possible to utilize the opening which it has partially made for subsequent drainage purposes.
It is not advisable to permit patients with distended gall-bladders to go unoperated, even in the absence of serious symptoms, because the risk of operation is small and that of rupture is large.
Acute intestinal obstruction due to gallstones will usually, but not invariably, involve the upper intestinal tract. It may be due to the actual occlusion of a large stone which has escaped from the gall-bladder or duct, or it may be caused by volvulus due to intense colic accompanying peristaltic effort, or it may depend upon adhesions after a local peritonitis due to previous disease of the gall-bladder or to stricture following ulceration; or again it may be purely paralytic, and in this way result from a local peritonitis. Impaction of a biliary concretion may happen at any point, but most often at the ileocecal valve, where the intestinal tube is narrowest. The size of the stone is not the only consideration. Obstruction depends perhaps as much upon spasm above and below as upon any local disturbance that its presence may have caused. Biliary concretions may enlarge as they pass downward, growing by accretion of calcareous and of fecal matter. The larger the calculus the more likely it is to obstruct the upper intestine. The majority of these calculi have escaped from the gall-bladder by a previous process of ulceration, and usually into the duodenum, rarely into the colon.
Symptoms.
—Symptoms of this condition, thus produced, will obviously be those of acute obstruction from any cause, the most marked features being severe pain and early frequent vomiting. Bile may be raised in quantities because of the biliary fistula so near the stone, and from which it is supposed to have escaped. The higher the exciting cause the more violent the symptoms and the less the distention of the abdomen by gas. A significant history may help in assigning the cause for the evident obstruction.
Treatment.
—Since more than half of these cases treated expectantly die without relief early operation is to be urged. It should always be preceded by lavage in order that the stomach may be thoroughly emptied. When a stone has been exposed within the intestine it is advisable to open the bowel a little below where it rests, so as to make the division at a point where the chances of repair are not compromised by previous excitement. In severe cases a temporary enterostomy may be made, but this should of necessity be high. The volvulus may be relieved by untwisting the kink or by an anastomosis. Obstruction due to adhesions will require separation of these adhesions, with perhaps an anastomosis.