Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Intussuscepted Cystic Duct Causing Common Duct Obstruction Wall M. Aseem & Peter J. Cohn To cite this article: Wall M. Aseem & Peter J. Cohn (1975) Intussuscepted Cystic Duct Causing Common Duct Obstruction, Postgraduate Medicine, 58:7, 125-128, DOI: 10.1080/00325481.1975.11714228 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11714228
Published online: 07 Jul 2016.
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Citing articles: 3 View citing articles
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Date: 18 August 2017, At: 16:49
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• A 35-year-old man was admitted to Suburban Community Hospital, Cleveland, on November 8, 1974, because of epigastric and right upper quadrant pain and occasional nausea and vomiting of three weeks' duration. He bad no history of previous attacks or of jaundice or acholie stools. Physical examination showed a well-developed, wellnourished man in no acute distress and with no remarkable findings except tenderness with deep palpation in the right upper quadrant and epigastric region. Laboratory workup showed the following values: hemoglobin 16.2 grn/ 100 ml; hematocrit 49%; white blood cell count 8,300/cu mm with 55% segmented neutrophils, 18% lymphocytes, and 5% eosinophils; serum amylase 98 Somogyi units/ 100 ml; and serum lipase 0.1 unit/ml. Repeat serum amylase determinations on November 14 and 15 showed levels of25 and 40 units/1 00 ml, respective! y. Because the patient was not jaundiced, no bilirubin determinations were made. Repeat and additionallaboratory tests were run on November 22 with the following results: hemoglobin leve! 16.7 gm/ 100 ml; hematocrit reading 51%; white blood cell count 13,900/cu mm with 76% polymorphonuclear neutrophils, 6% monocytes, and 4% eosinophils. Serum sodium, chloride, and potassium levels were normal; serum carbon dioxide was 19 mEq/liter. Chest x-ray films were normal. On cholecystography, the gallbladder and extrahepatic biliary system were not visualized with either a single or a double dose of contrast medium. An upper gastrointestinal series was unrevealing. The patient was scheduled for cholecystectomy and operative cholangiography. At surgery, an acutely inflamed, obstructed gallbladder containing numerous stones was found. The cystic duct appeared short, and Hartmann's pouch was adherent to the cornmon duct. The junction of the cystic and common duct was freed from the surrounding
Vol. 58 • No. 7 • December 1975 • POSTGRADUATE MEDICINE
case report INTUSSUSCEPTED CYSTIC DUCT CAUSING COMMON DUCT OBSTRUCTION Wall M. Aseem, MD Peter J. Cohn, MD Suburban Community Hospital Cleveland
tissue. No anomaly was found, but a small stone was palpable in the common duct just below the junction of the cystic duct. An attempt to pass a catheter through the cystic duct for cholangiography was unsuccessful, and the duct was ligated. Cholecystectomy was performed in a retrograde fashion, followed by a choledochotomy. It was found that the cys tic duct, containing a small stone, bad intussusscepted into the common duct and was causing a partial obstruction (figure 1). The intussuscepted cystic duct and stone were removed from the common duct through the choledochotomy opening. Further exploration and irrigation of the common duct did not reveal any other stones. A T tube was inserted and cholangiograms were taken. The films showed the right, left, and common hepatic ducts to be dilated proximally, whereas the common duct distal to the intussusception was of normal size (figure 2). Discussion
Intussusception of the cystic duct into the common duct secondary to an impacted stone in the cystic duct simulates mechanical cornmon duct obstruction from any other cause. It may result in hydrops of the gallbladder, acute obstructive cholecystitis, or partial or complete obstruction of the common duct. The mechanism of cystic duct intussuscep-
125
Downloaded by [Australian Catholic University] at 16:49 18 August 2017
Figure 1.1ntussusceptior.J of cystic duct into common duct. a.lmpacted stone in cystic duct. b. lntermediate stage of intussusception. c. Maximum limit of intussusception, with Hartmann's pouch resting against common duct. Right, left, and common hepatic ducts are dilated; common bile duct is normal.
tion is, we be lieve, similar to that of intestinal intussusception. Heister's valve, containing the impacted stone, and the distal part of the cystic duct form the intussusceptum, white the common duct becomes the intussuscipiens. During ingestion of food, the gallbladder normally contracts with a pressure of 300 mm H 2 0, spilling its contents through the cystic duct into the corn mon duct, which is the common path for migration of stones. If a stone is big enough to lodge in the cystic duct (figure la), the impacted stone will be driven di stail y, carrying the cystic duct with it toward the common duct, where the pressure is lower and the lumen is larger. Thus, the
126
rhythmic contractions of the gallbladder and ducts, plus the difference in pressure between the gallbladder and common bile duct, cause intussusception of the cystic duct into the common bile du ct (figure 1b). Unlike intestinal. intussusception, cystic duct intussusception is limited. It can progress only. to the point where Hartmann's pouch lies against the common duct (figure 1c). The overlapped cystic duct with its impacted stone in the lumen of the common duct is sufficient to cause partial or complete obstruction of the common duct, depending on the amount of tissue reaction surrounding the intussusception. If the cystic duct is corn-
POSTGRADUATE MEDICINE • December 1975 • Vol. 58 • No. 7
DARVOCET-N® 100 propoxyphene napsylate with acetaminophen Indication: For the relief of mild to modera te pain, either alone or accompanied by lever.
Downloaded by [Australian Catholic University] at 16:49 18 August 2017
case r e p o r t - - - - - - - - - - -
Contralndlcatlons: Hypersensitivity to propoxyphene orto acetaminophen. Warnlngs: Orug Oependence-Propoxyphene can produce drug depende nee characterized by psychic dependance and, Jess frequently, physical dependance and tolerance Propoxyphene will only partially suppress the withdrawal syndrome in individuals physically dependent on morphine or other narcotics. The abuse liability of propoxyphene is qualitatively similar to thal of codeine although quantitatively less, and propoxyphene should be prescribed with the same degree of caution appropriate to the use of codeine. Usage in Ambulatory Patients-Propoxyphene may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks. such as driving a car or operating machinery. The patient should be cautioned accord· ingly. Usage in Pregnancy-Sale use in pregnancy has not been established relative to possible adverse effects on letal development. Therefore, propoxyphene should not be used in pregnant women unless, in the JUdgment of the physician, the potential benefits outweigh the possible hazards. Usage in Chi/dren-Propoxyphene is not recommended for use in children, be· cause documented clinical experience has been insufficient to establish sa lely and a suitable dosage regimen in the pediatrie age group. Precautions: Confusion, anxiety, and tremors have been reported in a few patients receiving propoxyphene concomitantly with orphenadrine. The central-nervoussystem depressant effect of propoxyphene may be additive with thal of other C.N.S. depressants. Adverse Reactions: The most frequent adverse reactions are dizziness, sedation, nausea, and vomiting. These effects seem to be more prominent in ambulatory !han in nonambulatory patients, and some of these adverse reactions may be alleviated if the patient lies down. Other adverse reactions include constipation, abdominal pain, skin rashes, lightheadedness, headache. weakness. euphorie, dysphoria, and mi nor visual disturbances. The chronic ingestion of propoxyphene in doses exceeding 800 mg. per day has [om,.] caused toxic psychoses and convulsions.
DARVON® COMPOUND-65 propoxyphene hydrochloride, asp1rin. phenacetin, and caffeine
Figure 2. Operative T-tube cholangiogram showing normal-size common bile duct with abnormal dilatation of right, left, and common hepatic ducts.
pletely occluded for an extended time, hydrops of the gallbladder may be found. We believe the most helpful diagnostic procedure to be radiologie examination and visualization of the extrahepatic biliary system by transhepatic or intravenous cholangiography, which might show a normal cornmon bile duct, a filling defect in the midportion near the junction of the cystic duct, and nonvisualization of the gallbladder plus abnormal dilatation of the corn mon hepatic duct and its proximal branches. Definitive diagnosis can be made only by choledochotomy. We know of no prevjous report in the literature of intussusception of the cystic duct causing common duct stenosis or obstruction. • Address reprint re4uests to Wali M. Aseem. MD. 24950 Rockside Rd, Bldg 2, Apt 748, Bedford Heights, OH 44146.
Indication: For the relief of mild to moderate pain. Contralndlcatlon: Hypersensitivity to propoxyphene, aspirin, phenacetin, or cafleine. Warnlngs: Orug Oependence-Propoxyphene can produce drug dependance characte11zed by psychic dependance and, less frequently, physical dependance and tolerance. Propoxyphene w1ll only partially suppress the withdrawal syndrome in individuals physically dependent on morphine or other narcotics. The abuse liability of propoxyphene is qualitatively similar to thal of codeine although quantitatively less, and propoxyphene should be prescribed with the same degree of caution appropriate to the use of codeine. Usage in Ambulatory Patients-Propoxyphene may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks, such as driving a car or opera ting machinery. The patient should be cautioned accordingly. Usage in Pregnancy-Sale use in pregnancy has not been established relative to possible adverse effects on tetai development. Therefore, propoxyphene should not be used in pregnant women unless. in the 1udgment of the physicien, the potentiel benefits outweigh the possible hazards. Usage in Chi/dren-Propoxyphene is not recommended for use in children because documented clinical experience has been insufficient to establish safety and a suitable dosage regi men in the pediatrie age group. Salicylates should be used with extreme caution in the presence of peptic ulcer or coagulation abnormalities. Precautions: Confusion. anxiety. and tremors have been reported in a few patients receiving propoxyphene concomitantly with orphenadrine. The central-nervous-system depressant effect of propoxyphene may be additive with thal of other C.N.S. depressants. Phenacetin has been reported to damage the kidneys when laken in large amounts for a long lime. Salicylates may enhance the effect of anticoagulants and inhibit the uricosuric effect of uncosuric agents. Aclverae Reactions: The most frequent adverse reactions are dizziness, sedation, nausea. and vomiting. These effects seem to be more prominent in ambulatory than in nonambulatory patients. and some of these adverse reactions may be alleviated if the patient lies down. Other adverse reactions include constipation, abdominal pain, skin rashes, lightheadedness. headache. weakness, euphorie, dysphoria, and minor visual disturbances. The chronic ingestion of propoxyphene in doses exceeding 800 mg. per day has caused toxic psychoses and convuls1ons. [""'']
POSTGRADUATE MEDICINE invites submission of brief case reports for early publication. Illustrations and references should be included only when essential.
Additional information available to the profession on request. Eli Lilly and Company, lnc. Indianapolis. Indiana 46206 '500391
128
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
Intussuscepted Cystic Duct Causing Common Duct Obstruction Wall M. Aseem & Peter J. Cohn To cite this article: Wall M. Aseem & Peter J. Cohn (1975) Intussuscepted Cystic Duct Causing Common Duct Obstruction, Postgraduate Medicine, 58:7, 125-128, DOI: 10.1080/00325481.1975.11714228 To link to this article: http://dx.doi.org/10.1080/00325481.1975.11714228
Published online: 07 Jul 2016.
Submit your article to this journal
View related articles
Citing articles: 3 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Australian Catholic University]
Date: 18 August 2017, At: 16:49
Downloaded by [Australian Catholic University] at 16:49 18 August 2017
• A 35-year-old man was admitted to Suburban Community Hospital, Cleveland, on November 8, 1974, because of epigastric and right upper quadrant pain and occasional nausea and vomiting of three weeks' duration. He bad no history of previous attacks or of jaundice or acholie stools. Physical examination showed a well-developed, wellnourished man in no acute distress and with no remarkable findings except tenderness with deep palpation in the right upper quadrant and epigastric region. Laboratory workup showed the following values: hemoglobin 16.2 grn/ 100 ml; hematocrit 49%; white blood cell count 8,300/cu mm with 55% segmented neutrophils, 18% lymphocytes, and 5% eosinophils; serum amylase 98 Somogyi units/ 100 ml; and serum lipase 0.1 unit/ml. Repeat serum amylase determinations on November 14 and 15 showed levels of25 and 40 units/1 00 ml, respective! y. Because the patient was not jaundiced, no bilirubin determinations were made. Repeat and additionallaboratory tests were run on November 22 with the following results: hemoglobin leve! 16.7 gm/ 100 ml; hematocrit reading 51%; white blood cell count 13,900/cu mm with 76% polymorphonuclear neutrophils, 6% monocytes, and 4% eosinophils. Serum sodium, chloride, and potassium levels were normal; serum carbon dioxide was 19 mEq/liter. Chest x-ray films were normal. On cholecystography, the gallbladder and extrahepatic biliary system were not visualized with either a single or a double dose of contrast medium. An upper gastrointestinal series was unrevealing. The patient was scheduled for cholecystectomy and operative cholangiography. At surgery, an acutely inflamed, obstructed gallbladder containing numerous stones was found. The cystic duct appeared short, and Hartmann's pouch was adherent to the cornmon duct. The junction of the cystic and common duct was freed from the surrounding
Vol. 58 • No. 7 • December 1975 • POSTGRADUATE MEDICINE
case report INTUSSUSCEPTED CYSTIC DUCT CAUSING COMMON DUCT OBSTRUCTION Wall M. Aseem, MD Peter J. Cohn, MD Suburban Community Hospital Cleveland
tissue. No anomaly was found, but a small stone was palpable in the common duct just below the junction of the cystic duct. An attempt to pass a catheter through the cystic duct for cholangiography was unsuccessful, and the duct was ligated. Cholecystectomy was performed in a retrograde fashion, followed by a choledochotomy. It was found that the cys tic duct, containing a small stone, bad intussusscepted into the common duct and was causing a partial obstruction (figure 1). The intussuscepted cystic duct and stone were removed from the common duct through the choledochotomy opening. Further exploration and irrigation of the common duct did not reveal any other stones. A T tube was inserted and cholangiograms were taken. The films showed the right, left, and common hepatic ducts to be dilated proximally, whereas the common duct distal to the intussusception was of normal size (figure 2). Discussion
Intussusception of the cystic duct into the common duct secondary to an impacted stone in the cystic duct simulates mechanical cornmon duct obstruction from any other cause. It may result in hydrops of the gallbladder, acute obstructive cholecystitis, or partial or complete obstruction of the common duct. The mechanism of cystic duct intussuscep-
125
Downloaded by [Australian Catholic University] at 16:49 18 August 2017
Figure 1.1ntussusceptior.J of cystic duct into common duct. a.lmpacted stone in cystic duct. b. lntermediate stage of intussusception. c. Maximum limit of intussusception, with Hartmann's pouch resting against common duct. Right, left, and common hepatic ducts are dilated; common bile duct is normal.
tion is, we be lieve, similar to that of intestinal intussusception. Heister's valve, containing the impacted stone, and the distal part of the cystic duct form the intussusceptum, white the common duct becomes the intussuscipiens. During ingestion of food, the gallbladder normally contracts with a pressure of 300 mm H 2 0, spilling its contents through the cystic duct into the corn mon duct, which is the common path for migration of stones. If a stone is big enough to lodge in the cystic duct (figure la), the impacted stone will be driven di stail y, carrying the cystic duct with it toward the common duct, where the pressure is lower and the lumen is larger. Thus, the
126
rhythmic contractions of the gallbladder and ducts, plus the difference in pressure between the gallbladder and common bile duct, cause intussusception of the cystic duct into the common bile du ct (figure 1b). Unlike intestinal. intussusception, cystic duct intussusception is limited. It can progress only. to the point where Hartmann's pouch lies against the common duct (figure 1c). The overlapped cystic duct with its impacted stone in the lumen of the common duct is sufficient to cause partial or complete obstruction of the common duct, depending on the amount of tissue reaction surrounding the intussusception. If the cystic duct is corn-
POSTGRADUATE MEDICINE • December 1975 • Vol. 58 • No. 7
DARVOCET-N® 100 propoxyphene napsylate with acetaminophen Indication: For the relief of mild to modera te pain, either alone or accompanied by lever.
Downloaded by [Australian Catholic University] at 16:49 18 August 2017
case r e p o r t - - - - - - - - - - -
Contralndlcatlons: Hypersensitivity to propoxyphene orto acetaminophen. Warnlngs: Orug Oependence-Propoxyphene can produce drug depende nee characterized by psychic dependance and, Jess frequently, physical dependance and tolerance Propoxyphene will only partially suppress the withdrawal syndrome in individuals physically dependent on morphine or other narcotics. The abuse liability of propoxyphene is qualitatively similar to thal of codeine although quantitatively less, and propoxyphene should be prescribed with the same degree of caution appropriate to the use of codeine. Usage in Ambulatory Patients-Propoxyphene may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks. such as driving a car or operating machinery. The patient should be cautioned accord· ingly. Usage in Pregnancy-Sale use in pregnancy has not been established relative to possible adverse effects on letal development. Therefore, propoxyphene should not be used in pregnant women unless, in the JUdgment of the physician, the potential benefits outweigh the possible hazards. Usage in Chi/dren-Propoxyphene is not recommended for use in children, be· cause documented clinical experience has been insufficient to establish sa lely and a suitable dosage regimen in the pediatrie age group. Precautions: Confusion, anxiety, and tremors have been reported in a few patients receiving propoxyphene concomitantly with orphenadrine. The central-nervoussystem depressant effect of propoxyphene may be additive with thal of other C.N.S. depressants. Adverse Reactions: The most frequent adverse reactions are dizziness, sedation, nausea, and vomiting. These effects seem to be more prominent in ambulatory !han in nonambulatory patients, and some of these adverse reactions may be alleviated if the patient lies down. Other adverse reactions include constipation, abdominal pain, skin rashes, lightheadedness, headache. weakness. euphorie, dysphoria, and mi nor visual disturbances. The chronic ingestion of propoxyphene in doses exceeding 800 mg. per day has [om,.] caused toxic psychoses and convulsions.
DARVON® COMPOUND-65 propoxyphene hydrochloride, asp1rin. phenacetin, and caffeine
Figure 2. Operative T-tube cholangiogram showing normal-size common bile duct with abnormal dilatation of right, left, and common hepatic ducts.
pletely occluded for an extended time, hydrops of the gallbladder may be found. We believe the most helpful diagnostic procedure to be radiologie examination and visualization of the extrahepatic biliary system by transhepatic or intravenous cholangiography, which might show a normal cornmon bile duct, a filling defect in the midportion near the junction of the cystic duct, and nonvisualization of the gallbladder plus abnormal dilatation of the corn mon hepatic duct and its proximal branches. Definitive diagnosis can be made only by choledochotomy. We know of no prevjous report in the literature of intussusception of the cystic duct causing common duct stenosis or obstruction. • Address reprint re4uests to Wali M. Aseem. MD. 24950 Rockside Rd, Bldg 2, Apt 748, Bedford Heights, OH 44146.
Indication: For the relief of mild to moderate pain. Contralndlcatlon: Hypersensitivity to propoxyphene, aspirin, phenacetin, or cafleine. Warnlngs: Orug Oependence-Propoxyphene can produce drug dependance characte11zed by psychic dependance and, less frequently, physical dependance and tolerance. Propoxyphene w1ll only partially suppress the withdrawal syndrome in individuals physically dependent on morphine or other narcotics. The abuse liability of propoxyphene is qualitatively similar to thal of codeine although quantitatively less, and propoxyphene should be prescribed with the same degree of caution appropriate to the use of codeine. Usage in Ambulatory Patients-Propoxyphene may impair the mental and/or physical abilities required for the performance of potentially hazardous tasks, such as driving a car or opera ting machinery. The patient should be cautioned accordingly. Usage in Pregnancy-Sale use in pregnancy has not been established relative to possible adverse effects on tetai development. Therefore, propoxyphene should not be used in pregnant women unless. in the 1udgment of the physicien, the potentiel benefits outweigh the possible hazards. Usage in Chi/dren-Propoxyphene is not recommended for use in children because documented clinical experience has been insufficient to establish safety and a suitable dosage regi men in the pediatrie age group. Salicylates should be used with extreme caution in the presence of peptic ulcer or coagulation abnormalities. Precautions: Confusion. anxiety. and tremors have been reported in a few patients receiving propoxyphene concomitantly with orphenadrine. The central-nervous-system depressant effect of propoxyphene may be additive with thal of other C.N.S. depressants. Phenacetin has been reported to damage the kidneys when laken in large amounts for a long lime. Salicylates may enhance the effect of anticoagulants and inhibit the uricosuric effect of uncosuric agents. Aclverae Reactions: The most frequent adverse reactions are dizziness, sedation, nausea. and vomiting. These effects seem to be more prominent in ambulatory than in nonambulatory patients. and some of these adverse reactions may be alleviated if the patient lies down. Other adverse reactions include constipation, abdominal pain, skin rashes, lightheadedness. headache. weakness, euphorie, dysphoria, and minor visual disturbances. The chronic ingestion of propoxyphene in doses exceeding 800 mg. per day has caused toxic psychoses and convuls1ons. [""'']
POSTGRADUATE MEDICINE invites submission of brief case reports for early publication. Illustrations and references should be included only when essential.
Additional information available to the profession on request. Eli Lilly and Company, lnc. Indianapolis. Indiana 46206 '500391
128
