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Relationship between biliary tract distention and the blood flow in the aorta and right coronary and renal arteries
Relationship between Biliary Tract Distention and the Blood Flow in the Aorta and Right Coronary and Renal Arteries JOHN D. CORBITT, Jr, MD, Atlanta, Georgia JOEL M. LEVIN, MD, Atlanta, Georgia L. G. WALKER, Jr, MD, Atlanta, Georgia C. DOYLE HAYNES, MD, Atlanta, Georgia
Pain rising from the biliary tract, like that from other hollow abdominal viscera, occurs mainly as a result of distention. Biliary pain usually occurs in the right upper quadrant, and at times may be associated with chest pain. This chest pain may be the result of referred pain from the biliary tract distention or it may be from myocardial ischemia. Indirect evidence suggests the possibility of a reflex secondary to biliary pain which may cause coronary constriction with resulting angina. Investigation was designed to determine if a relationship between distention of the biliary tree and blood flow to the aorta and coronary and renal arteries could be demonstrated.
Material and Methods Ten mongrel dogs ranging from 22 to 30 pounds were anesthetized with Pentotbal@ and supported on the Harvard respirator. Through separate abdominal and thoracic incisions the aorta, one renal artery, and the right coronary artery were isolated. Flow probes were placed on the ascending aorta, the renal artery, and the right coronary artery. A polyethylene tube was placed in the fundus of the gallbladder and the common duct was ligated. The polyethylene catheter was then connected to pressure transducers and the gallbladder was distended to a pressure of 50 cm of water, which subsequently resulted in distention of the common duct. Recordings were made on a multichannel polygraph which recorded the changes in arterial blood flow in the aforementioned arteries. Three to five recordings were made on each dog. Two other dogs were anesthetized and flow probes placed on the same arteries. A Foley catheter was placed in the gallbladder through a cholecystostomy. The common duct in these two dogs was not ligated. The flow probes and the catheter were led through an incision on the side of the dog. The dogs were all,~wed to recover, thus eliminating the possibility or ~:ffe..~; of anesthesia on From the General Surgical Research L;,boratory, Veterans Adminlstra. tion Hospital, and the Department of Surgery, Emory University School of Medicfne, Atlanta, Georgia, Reprint requests should be addressed to Research Laboratories. VA Hospital. Atlanta, Georgia 30329.
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the blood flow in the aorta and the coronary and renal arteries. Recordings on these two doe,s were taken on two consecutive clays. When the catheter was distended to 30 cc, indications of distress were observed. ReeorcJings were taken of the flow in the arteries at this time. Results Both gallbladder and common duct were distended until either visually stretched beyond physiologic limits or distended to the point that the animal indicated painfu! stimulus, Indeed, on one of the anesthetized dogs the gallbladder ruptured when the pressure was under 50 cc of water. All recordings made on the aorta, right coronary artery, and renal arteries failed to demonstrate any change in blood flow. This was found to be true in both the anesthetized and the unanesthetized animal.
Comments A relationship between gallbladder disease and heart disease was first noted by Babcock [I] in t909. Subjective improvement of angina was noted to occur after cholecystectomy. Ravdin, Royster, and Sanders [2] also r e p o r t e d the production of angina-like pain as a result of distention of the common duct via the T tube in the postoperative patient, Objective conversion of abnormal T waves in the electrocardio, gram of six patients was reported by Fitz-Hugh and Wolferth [3] after the removal of gallstones. Autopsies have revealed gallbladder disease to be present twice as often in association with coronary artery disease as in the general population [4,5]. This latter factor is probably due to the aging factor and is not a significant difference. Cases have been reported in which inverted T waves have returned to normal after cholecystectomy. However, Glotzer and Barcham [6] failed to demonstrate any change in electrocardiogram before or after cholecystectomy or with traction on the g~llbladder at the time of surgery. Hodge and
The American Journal of Surgery
Biliary Tract Distention Messer [7] were unable to produce change in the electrocardiogram by distention of the common duct via T tube after cholecystectomy. Thus, reports concerning a relationship between the gallbladder and common duct and the blood flow, in the aorta, the right coronary artery and the renal artery have been conflicting and no definite relationship has been proved. Conclusions Our results fail to demonstrate any reflex mechanism involved between distention of the biliary tree and the blood flow in the aorta, the right coronary artery, or in renal arteries in healthy dogs. This does not deny a relationship" between biliary pain and anginal pain secondary to the psychological effects of biliary pain, especially in the patient with arteriosclerotic heart disease. However, we could not demonstrate a reflex mechanism in the dogs by the method used. Summary The gallbladder and common duct of anesthetized and unanesthetized dogs were distended while simul-
VoL 120, July 1970
taneous recordings of the blood flow through the aorta, the right coronary artery, and the renal arteries were made. Distention of the biliary tree failed to demonstrate any change in the blood flow of these arteries. References 1. Babcock RH: Chronic cholecystitis as a cause of myo, cardial incompetence. JAMA 52: 1904. 1909. 2. Ravdin IS, Royster HP, Sanders GB: Reflexes originating in common duct giving rise to pain simulating angina pectoris, Ann Surg 115: 1055, 1942. 3. Fitz-Hugh T Jr, Wolferth CC: Cardiac improvement i fol, lowing gallbladder surgery: electrocardiographic evidence in cases with associated myocardial disease, Ann Surg 101: 478, 1935. 4. Walsh BJ, Bland EF, Taguini AC, White PD: Association of gallbladder disease and of peptic ulcer with coro, nary disease: post.mortem study, Amer Heart J 21: 689, 1941. 5. Breyfogle HS: Frequency of co-existing g a l l b l a d d e r and coronary artery disease; statistical analysis of bio. metric ,evaluation of 1493 necropsies. JAMA 114: 1434, 1940. 6. Glotzer S, Barcha~ J: E f f e c t o f traction of gallbladder on electrocardiogram. New York J Med 55: 515, 1955. 7. Hodge GB, Messer AL: Electrocardiogram in bl!lary tract disease and during experimental b i l i a r y distention. clinical observations in 26 patients. Surg Gynec Obstet 8 6 : 6 1 7 , 1948.
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Pain rising from the biliary tract, like that from other hollow abdominal viscera, occurs mainly as a result of distention. Biliary pain usually occurs in the right upper quadrant, and at times may be associated with chest pain. This chest pain may be the result of referred pain from the biliary tract distention or it may be from myocardial ischemia. Indirect evidence suggests the possibility of a reflex secondary to biliary pain which may cause coronary constriction with resulting angina. Investigation was designed to determine if a relationship between distention of the biliary tree and blood flow to the aorta and coronary and renal arteries could be demonstrated.
Material and Methods Ten mongrel dogs ranging from 22 to 30 pounds were anesthetized with Pentotbal@ and supported on the Harvard respirator. Through separate abdominal and thoracic incisions the aorta, one renal artery, and the right coronary artery were isolated. Flow probes were placed on the ascending aorta, the renal artery, and the right coronary artery. A polyethylene tube was placed in the fundus of the gallbladder and the common duct was ligated. The polyethylene catheter was then connected to pressure transducers and the gallbladder was distended to a pressure of 50 cm of water, which subsequently resulted in distention of the common duct. Recordings were made on a multichannel polygraph which recorded the changes in arterial blood flow in the aforementioned arteries. Three to five recordings were made on each dog. Two other dogs were anesthetized and flow probes placed on the same arteries. A Foley catheter was placed in the gallbladder through a cholecystostomy. The common duct in these two dogs was not ligated. The flow probes and the catheter were led through an incision on the side of the dog. The dogs were all,~wed to recover, thus eliminating the possibility or ~:ffe..~; of anesthesia on From the General Surgical Research L;,boratory, Veterans Adminlstra. tion Hospital, and the Department of Surgery, Emory University School of Medicfne, Atlanta, Georgia, Reprint requests should be addressed to Research Laboratories. VA Hospital. Atlanta, Georgia 30329.
14
the blood flow in the aorta and the coronary and renal arteries. Recordings on these two doe,s were taken on two consecutive clays. When the catheter was distended to 30 cc, indications of distress were observed. ReeorcJings were taken of the flow in the arteries at this time. Results Both gallbladder and common duct were distended until either visually stretched beyond physiologic limits or distended to the point that the animal indicated painfu! stimulus, Indeed, on one of the anesthetized dogs the gallbladder ruptured when the pressure was under 50 cc of water. All recordings made on the aorta, right coronary artery, and renal arteries failed to demonstrate any change in blood flow. This was found to be true in both the anesthetized and the unanesthetized animal.
Comments A relationship between gallbladder disease and heart disease was first noted by Babcock [I] in t909. Subjective improvement of angina was noted to occur after cholecystectomy. Ravdin, Royster, and Sanders [2] also r e p o r t e d the production of angina-like pain as a result of distention of the common duct via the T tube in the postoperative patient, Objective conversion of abnormal T waves in the electrocardio, gram of six patients was reported by Fitz-Hugh and Wolferth [3] after the removal of gallstones. Autopsies have revealed gallbladder disease to be present twice as often in association with coronary artery disease as in the general population [4,5]. This latter factor is probably due to the aging factor and is not a significant difference. Cases have been reported in which inverted T waves have returned to normal after cholecystectomy. However, Glotzer and Barcham [6] failed to demonstrate any change in electrocardiogram before or after cholecystectomy or with traction on the g~llbladder at the time of surgery. Hodge and
The American Journal of Surgery
Biliary Tract Distention Messer [7] were unable to produce change in the electrocardiogram by distention of the common duct via T tube after cholecystectomy. Thus, reports concerning a relationship between the gallbladder and common duct and the blood flow, in the aorta, the right coronary artery and the renal artery have been conflicting and no definite relationship has been proved. Conclusions Our results fail to demonstrate any reflex mechanism involved between distention of the biliary tree and the blood flow in the aorta, the right coronary artery, or in renal arteries in healthy dogs. This does not deny a relationship" between biliary pain and anginal pain secondary to the psychological effects of biliary pain, especially in the patient with arteriosclerotic heart disease. However, we could not demonstrate a reflex mechanism in the dogs by the method used. Summary The gallbladder and common duct of anesthetized and unanesthetized dogs were distended while simul-
VoL 120, July 1970
taneous recordings of the blood flow through the aorta, the right coronary artery, and the renal arteries were made. Distention of the biliary tree failed to demonstrate any change in the blood flow of these arteries. References 1. Babcock RH: Chronic cholecystitis as a cause of myo, cardial incompetence. JAMA 52: 1904. 1909. 2. Ravdin IS, Royster HP, Sanders GB: Reflexes originating in common duct giving rise to pain simulating angina pectoris, Ann Surg 115: 1055, 1942. 3. Fitz-Hugh T Jr, Wolferth CC: Cardiac improvement i fol, lowing gallbladder surgery: electrocardiographic evidence in cases with associated myocardial disease, Ann Surg 101: 478, 1935. 4. Walsh BJ, Bland EF, Taguini AC, White PD: Association of gallbladder disease and of peptic ulcer with coro, nary disease: post.mortem study, Amer Heart J 21: 689, 1941. 5. Breyfogle HS: Frequency of co-existing g a l l b l a d d e r and coronary artery disease; statistical analysis of bio. metric ,evaluation of 1493 necropsies. JAMA 114: 1434, 1940. 6. Glotzer S, Barcha~ J: E f f e c t o f traction of gallbladder on electrocardiogram. New York J Med 55: 515, 1955. 7. Hodge GB, Messer AL: Electrocardiogram in bl!lary tract disease and during experimental b i l i a r y distention. clinical observations in 26 patients. Surg Gynec Obstet 8 6 : 6 1 7 , 1948.
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