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An ancient art revived
GastQOlnt€stlnat ~ndOsCoPY Editor
WILLIAM S. HAUBRICH, M.D. Assistant Editor
ELLEN C. SHANNON, M.A. Editor for Abstracts
BERNARD M. SCHUMAN, M.D. Address all editorial correspondence to the Editor Hospital of Scripps Clinic 10666 North Torrey Pines Road La Jolla, California 92037
Editorial Consultants
J. EDWARD BERK, M.D. Irvine
H. WORTH BOYCE, M.D. Tampa
BASIL I. HIRSCHOWITZ, M.D. Birmingham
WILLIAM H. MAHOOD, M.D. Philadelphia
JOHN F. MORRISSEY, M.D. Madison
FRANCISCO VILARDELL, M.D. Barcelona
28
An ancient art revived The thing that hath been, it is that which shall be; and that which is done is that which shall be done; and there is no new thing under the sun. Ecclesiastes 1:9
The accuracy with which a diagnosis of calculous biliary tract disease can be made has been honed to a fine edge. Oral cholecystography provides convincing evidence of gallbladder disease in the vast majority of cases. Recent refinements in diagnosis have been made by echography, computed tomography, and percutaneous or retrograde cholangiography. But how could the clinician of 50 years ago substantiate his suspicion of biliary tract disease, short of subjecting his patient to surgical exploration? Before the application of Roentgen's rays, keeping in mind that Evarts Graham and Warren Cole did not advance their concept of cholecystography until 1924, the supposition was that a clue could be found in the patient's bile. What could be more logical? The problems were: how to obtain bile suitable for examination and what should be looked for. The first problem was solved, as best it could be, by aspirating the duodenum. S. J. Meltzer, in 1917, observed that applying a hypertonic solution of magnesium sulfate to the duodenal mucosa resulted in an outpouring of bile into the duodenal lumen. Following this lead, in 1919, B. B. Vincent Lyon found that bile, thus recovered, appeared in 3 fairly distinct fractions, identifiable by their physical characteristics. The first to appear, within a few minutes of the introduction of magnesium sulfate, was 10 to 30 ml of thin, light yellow bile. Lyon called this "A" bile, claiming that it represented emptying of the common duct. There then appeared 30 to 60 ml of darker, more viscous bile. This he called "B" bile, postulating that it had been stored in the gallbladder. Finally, a third or "C" fraction appeared. This was again light yellow, resembling "A" bile, and was presumed to come from the intrahepatic ducts. Lyon was most interested in the "B" bile which he subjected to intense scrutiny, too intense as it turned out. Speculation raged in regard to the significance of the presence or absence of "B" bile, whether it was turbid, what shade of brown it was, its volume, whether it contained leucocytes, and what it might yield on culture. Eventually, prudent observers concluded that the diagnostic significance of aspirated bile was limited to the finding of cholesterol crystals, bilirubinate pigment, or microspheroliths. This, of course, comes as no surprise to the modern reader who is well versed in the concept of supersaturated, lithogenic bile. Now, building on this foundation, Drs. Reisberg and Mabee (p. 6) have demonstrated that one can take advantage of having an endoscope in the duodenum by aspirating bile and examining it under the microsope. They have sensibly chosen the octapeptide of cholecystokinin as the stimulus to bile evacuation. This makes for a tidier procedure. As the authors clearly state, diagnostic biliary drainage is not intended to supercede cholecystography or other helpful measures. Rather, it may give substantive evidence of biliary tract disease in cases wherein other tests are equivocal or unrevealing. The bile sediment must be critically examined, and the limited criteria for abnormal constituents must be strictly observed. GASTROINTESTINAL ENDOSCOPY
WILLIAM S. HAUBRICH, M.D. Assistant Editor
ELLEN C. SHANNON, M.A. Editor for Abstracts
BERNARD M. SCHUMAN, M.D. Address all editorial correspondence to the Editor Hospital of Scripps Clinic 10666 North Torrey Pines Road La Jolla, California 92037
Editorial Consultants
J. EDWARD BERK, M.D. Irvine
H. WORTH BOYCE, M.D. Tampa
BASIL I. HIRSCHOWITZ, M.D. Birmingham
WILLIAM H. MAHOOD, M.D. Philadelphia
JOHN F. MORRISSEY, M.D. Madison
FRANCISCO VILARDELL, M.D. Barcelona
28
An ancient art revived The thing that hath been, it is that which shall be; and that which is done is that which shall be done; and there is no new thing under the sun. Ecclesiastes 1:9
The accuracy with which a diagnosis of calculous biliary tract disease can be made has been honed to a fine edge. Oral cholecystography provides convincing evidence of gallbladder disease in the vast majority of cases. Recent refinements in diagnosis have been made by echography, computed tomography, and percutaneous or retrograde cholangiography. But how could the clinician of 50 years ago substantiate his suspicion of biliary tract disease, short of subjecting his patient to surgical exploration? Before the application of Roentgen's rays, keeping in mind that Evarts Graham and Warren Cole did not advance their concept of cholecystography until 1924, the supposition was that a clue could be found in the patient's bile. What could be more logical? The problems were: how to obtain bile suitable for examination and what should be looked for. The first problem was solved, as best it could be, by aspirating the duodenum. S. J. Meltzer, in 1917, observed that applying a hypertonic solution of magnesium sulfate to the duodenal mucosa resulted in an outpouring of bile into the duodenal lumen. Following this lead, in 1919, B. B. Vincent Lyon found that bile, thus recovered, appeared in 3 fairly distinct fractions, identifiable by their physical characteristics. The first to appear, within a few minutes of the introduction of magnesium sulfate, was 10 to 30 ml of thin, light yellow bile. Lyon called this "A" bile, claiming that it represented emptying of the common duct. There then appeared 30 to 60 ml of darker, more viscous bile. This he called "B" bile, postulating that it had been stored in the gallbladder. Finally, a third or "C" fraction appeared. This was again light yellow, resembling "A" bile, and was presumed to come from the intrahepatic ducts. Lyon was most interested in the "B" bile which he subjected to intense scrutiny, too intense as it turned out. Speculation raged in regard to the significance of the presence or absence of "B" bile, whether it was turbid, what shade of brown it was, its volume, whether it contained leucocytes, and what it might yield on culture. Eventually, prudent observers concluded that the diagnostic significance of aspirated bile was limited to the finding of cholesterol crystals, bilirubinate pigment, or microspheroliths. This, of course, comes as no surprise to the modern reader who is well versed in the concept of supersaturated, lithogenic bile. Now, building on this foundation, Drs. Reisberg and Mabee (p. 6) have demonstrated that one can take advantage of having an endoscope in the duodenum by aspirating bile and examining it under the microsope. They have sensibly chosen the octapeptide of cholecystokinin as the stimulus to bile evacuation. This makes for a tidier procedure. As the authors clearly state, diagnostic biliary drainage is not intended to supercede cholecystography or other helpful measures. Rather, it may give substantive evidence of biliary tract disease in cases wherein other tests are equivocal or unrevealing. The bile sediment must be critically examined, and the limited criteria for abnormal constituents must be strictly observed. GASTROINTESTINAL ENDOSCOPY