| IntroductionThe emptying and filling of gallbladder plays an important role in biliary motility as well as the contraction and relaxation of sphincter of Oddi ( SO) , which regulates the direction and velocity of bile flow. Sphincter of Oddi, which locates at the end of biliary and pancreatic duct, regulates the passage of bile and pancreatic fluid into duodenum and prevents reflux of duodenal contents into the ducts as a valve. During fasting, the tension of SO increases and the gallbladder ia relaxation, which results in the passage of bile into gallbladder;And during postprandial period, the SO is relaxation and the gallbladder contracts, which leads to the passage of bile into the duodenum. The the function disorder of SO can produce an abnormal biliary kinesics - - - biliary dysmotility, and many biliary diseases may relate to it. In order to evaluate the SO function of cholelithiasis and the influence of the SO disorder on gallbladder motility, and to discuss the relationship between the SO disorder and the formation of stones, three methods were used to research the biliary kinesics changes of bile duct stones, gall stones and normal controls. They are choledochoscope manometry, hepatobiliary scintigraphy and fatty meal ultrasound.Materials and methods1. materials(1) The choledochoscope manometry was performed on 216 patients with bile duct stones, all of whom had suffered bile duct exploration and T tube drainage with a mean time about 2 months(1.5 -4 months) before. There were 98 males and 118 females with mean age 54. 6yr{26 -78yr) .(2) Fatty meal hepatobiliary scintigraphy was performed in 24 gall stone patients and 12 normal controls. Among the 31 patients, there were 8 males and 16 females with a mean age 50. 4yr(35 -76yr). And the normal controls included 7males and 5 females, with a mean age 41.8yr(25 -60). None of the patients suffered biliary colic, and the screening ultrosonography indicated that no gallbladder was atrophy, the wall of the gallbladder was normal , and no bile duct stones and the dilation of bile duct coexisted. The screening biochemical lab tests were also normal.(3) 31 normal controls(17 males and 14 females;mean age 22. 6yr,range 21 -35) undergoing fatty meal and drug — load ultrosonography was studied.2. drug and equipment( 1 ) PC polygraph HfI and relevant program, triple lumen polyethylene ma-nometry catheter, hydraulic capillary infusion system, Nitrogen pump, and PENTAX LX - 750 p choledochoscope were needed during manometric performance.(2) TOSHIBA GCA7200A/DI SPECT system and "mTc04" EHIDA were needed during scintigraphy. And the standard fluid fatty meal was made by Ensure, in which 250ml could provided energy 250 Kcal( protein 14% , fat 31.5% and carbohydrate 54. 5% )(3) Three - dimensional sonography scanner, Morphine and 654 - 2 were needed during sonography exam. And the standard fluid fatty meal was the same as above.3. method(1) All the patients kept an overnight fasting before manometry. And after the computer manomery system was ready (the pressure of nitrogen was 40KPa and sterile water was at a flow rate of 0. 5ml/min) , the choledochoscop was inserted into the bile duct through the sinus tract of T tube. After the exploration of bile duct system, manometry catheter was introduced via side - pore of choledochoscope into duodenum directly. When the tracings of the pressure were stable , duodenal pressure - curve were recorded into the computer. It was then withdrawn in a stepwise fashion, and recorded the pressure - curve of SO and common bile duct respectively.(2) After a fastingperiod of 8 h, all of the gallstone patients and normal controls undergone fatty meal hepatobiliary scintigraphy exam. First they supi-nated on the exam table of SPECT, 370 -555mBq (10 - 15mCi) 99mTc - EHI-DA was injected intravenously. Digital images were obtained in the anterior projection , at one frame per minute for 60minutes, then about 250ml standard fluid fatty meal was intaken in 3 -5 minutes and another 40 minutes digital images was obtained. All the records was stored in the computer.( 3 ) Each subject underwent, after a fasting period of 8 h, ultrasonographic assessment of the gallbladder volumes and the diameter of common bile duct in basal onditions , and 30min, 45minand 60min after intaking a standardized 250mL,250 Kcal liquid fatty meal respectively three times. The first time is in normal condtion, while during the 2n and 3 test, different drugs (654 -2, lOmg each case and morphine, 0. lmg/kg for every one) were injected intramuscularly according to a random and double blind principle just after the basal exam and the fatty meal was intaken lOmin later. Then the cases were divided into two groups: 654 - 2 group ang morphine group.4. observation parameters(1) All of the 216 cases were devided into four groups according to the SO basal pressure ( SOBP);those whose SOBP was lower than 5mmHg were group A (SO hypotonus group) , whose SOBP was between 5mmHg and 15mmHg were group B ( normal SOBP group) , whose SOBP was between 15mmHg and 30mmHg(SOBP a little higher group) were group C and those whose SOPB was higher than 30mmHg was the group D (SO hypertonus group). The observation parameters includes: SO pressure ( SOP) , amplitude of SO contractions ( SO-CA) , frequency of SO contractions ( SOCF) , duration of SO contractions (SOCD) , duodenal pressure (DP) , common bile duct pressure ( CBDP), and the percent of propagate directions. DP was referred as the zero point. SOBP = SOP - DP.(2) The visualization time of common bile duct(TCBD) ,gallbladder(TGB) and duodenum (TD) was recorded by reviewed the images on computer, and Hepatoduodenal transit time(HDTT) was calculated by TCBD and TD, HDTT = TCBD -TD. Regions of interest( ROIs) were placed over the gallbladder, com-mon bile duct and the small intestine ( SI) to generate time - activity curves (TAC). According the different radiocountings at different time, we could acquire the following datas: A, the peak time of common bile duct ( TcMmax);B, the 60min and lOOmin excretive fraction of common bile duct - - cbdEFt = ( Acbdmax - Acbdt)/ Acbdmax x 100% , Acbdmax means the radiocountings of common bile duct at TcbdmM Acbdt means the radiocountings of common bile duct at t time;C, the ejection fractio of gallbladder(gbEFl00) and the common bile duct excretive fraction ( cbdEF60 - 100) of 40min after fatty meal intaken. gbEFlOO = ( Agb60 - Agbl00)/AGB60 x 100% , Agb60 and AgblOO means the radiocountings of gallbladder at 60min and lOOmin respectively;cbdEF60 -100 = ( Acbd60 - AcbdlOO /Acbd60 x 100% , Acbd60 and AcbdlOO means the radiocountings of common bile duct at 60min and lOOmin respectively;D, the percent of bile flowing into gallbladder ( PerGBt) and small intestine ( Per-SI), perGBt= Agbt/ (Agbt +Asit) 100% and perSIt = Asit/ (Agbt + Asit) 100% , Agbt and Asit mean the the radiocountings of gallbladder and small intestine at 60min lOOmin respectively, t represents 60min and lOOmin.(3) The largest longitude(Dl) , width(D2) and anteroposterior diameter (D3 ) of gallbladder was recorded as well as the diameter of common bile duct during each performance. The volume of gallbladder was calculated at different time by ellipse formula;VGBt = tt/6 x(D1 xD2xD3). And the the GBEF was calculated through the the volume at different time: GBEFt ( % ) = ( VGB0 -VGBl)/ VGB0 x 100% , VGB0 means the fasting volume of gallbladder and VGBt represented the postprandial volume of gallbladder at t time after fatty meal in-taken.5. Statistical AnalysisStatistical analysis was performed using SPSS statistical software ( standard version 11.5) , and the results were presented as mean standard deviation. The t test was performed to compare results between the groups. A p value less than 0.05 was considered statistically significant.Results1. The results of manometry.(1) The groupingOf all the 216 cases, there were 70(32.14% ) cases whose SOBP was lower than 5mmHg with a mean 1. 91 mmHg, which was group A - SO hypotenuse group;group B (normal SOBP group) contained 100(46. 3% ) cases with a mean SOBP about 8. 61 mmHg;group C (SOBP a little higher group) contained 29(13.43% ) cases with a mean SOBP 20. 25mmHg;and group D (SO hyper-tenus group) contained 17(7. 87% ) cases whose mean SOBP was 46. 08mmHg.(2) the changes of contractive phase parameters of each groupThe mean SOCA in group A was 62. 32 ±32. 13 mmHg, and was much lower than the other three groups ( P <0. 01);the mean SOCD of group A was shorter than group B and group C (P <0. 01);the mean SOCF of group A was not significantly different from group B and group C, but was smaller than group D (P <0. 05);the mean CBDP of group A was 3. 89 ±8. 10 mmHg, which was much lower than group D (P < 0. 01) , but higher than SOBP. The SOCA in group D was 97.02 ±51.76 mmHg, and was apparently higher than group A (P <0.01) , which was not significantly different from group B and group C but with a tendency to increasing;the mean SOCD of group D was shorter than group C (P <0. 05) and there was no apparent difference between the other two groups;the mean SOCF of group D was much faster than the other three groups (P <0. 01 vs group A and B , P <0.05 vs group C);the mean CBDP of group D was 10.41 ± 12. 37 mmHg and was higher than group A and group B (P <0. 01) , but was not statistically different from group C.( 3 ) The percent of propagate directions of each group.There were no no statistical difference about the percent of propagate directions among group A, B and C except there was a fewer simultaneous contractions (sc) in group B than in the other two groups. As to group D, there was a tendency to decreasing the percent of anterograde peristalsis (ap) and increasing the percent of retrograde peristalsis ( rp ). The percent of retrograde peristalsiswas much more than that in group A and group B(p <0.05). 2. The results of scintigraphy(1) Gall stone group and normal controls groupThe visualization time of common bile duct, gallbladder and duodenum was longer than that of the normal control group (p <0.05) , as well as the the peak time of common bile duct( p < 0. 01). And HDTT of gall stone group was also longer than the normal control group(p <0. 05). These indicated that there was biliary motility disorder exsiting in the gall stone patients.The cbdEF60 of gall stone group was much more decreasing than the normal control group( p < 0. 01) , and as well as the cbdEFlOO ( p < 0. 01). Although the cbdEF60 -100 was no significant difference between the two groups, but in the gall stone group it was larger than cbdEF60 ( p < 0. 01). gbEFlOO of gall stone group was smaller than that of normals,p <0.01.69% bile flowed into gallbladder and 31% bile flowed into small intestine in normal control group according the results of PerGB60 and PerSI60. and there was no significant difference between gall stone group and normals (p =0. 512). but there was significant difference in PerGBlOO and PerSIlOO between the two groups, the PerGBlOO of gallstone group was larger than that of normal control group (p < . 01 ) , which indicated that the residual volume of gall stone group was larger than the normals.(2) The results of groups divided by HDTTThe gall stone group was divied into two subgroups by HDTT-.the group of HDTT > mean and the group of HDTT < mean. There no difference in TCBD and Tcbdmax between the two groups (p >0. 05) , while there was a contrary result of TGB and TD in the two groups: TGB was longer than TD in the group of HDTT < mean and TGB was shorter than TD in the group of HDTT > mean;while TGB of the group of HDTT < mean was larger than that of the group of HDTT > mean ( p <0. 05 ) and TD was a contrary result( p <0.01).cbdEF60 of the group of HDTT < mean was smaller than that of the group of HDTT > mean(p <0.05) , while there was no difference in cbdEFlOO bettween the two groups( p = 0.219 ). cbdEF60 - 100 of HDTT < mean group was smaller than that of HDTT > mean group and gbEF of HDTT < mean group was largerthan that of HDTT > mean group( p <0.01).PerGB60 of HDTT > mean group was significantly larger than that of HDTT < mean group(p <0. 01) , PerGBlOO of both group was larger than that of normal control group and it was more larger in HDTT > mean group group than in HDTT< mean group(p <0. 05) , which was consistented with gbEF.3. The results of ultrosongraphy(1). The volume and ejection fraction of gallbladder of normal, 654 - 2 and morphine groups.The gallbladder volume of normal group was decreased at 30min,45min and 60min after fatty meal. The volume at 45min was the smallest, it was increased a little at 60min, but was still smaller than 30min. The same change was occurred in 654 — 2 group, but the changing amplitude of the volume was more smaller than in normal group (p <0. 01). While a contrary change was ocuured in morphine group, the volume of this group at 30min,45min and 60min was increased progressively, there was a significant difference between this group and the other two groups( p <0.01).The GBEF of normal group at 30min,45min and 60min after fatty meal were 45. 53 ± 17. 04,63. 01 ± 12. 13 and 48. 50 ± 17. 97 respectively. The GBEF of 654 -2 group was smaller than that of normal group ( p <0. 05), and about the morphine group, GBEF was even a negative value.(2). The common bile duct diameter change in three groups.There was no significant difference in common bile duct diameter at 30min and 60min after fatty meal between the normal and 654 -2 groups, but at 45min after fatty meal, the diameter of 654 - 2 group was smaller than that of normal group. But there was a significant difference between the morphine group and the other two groups, the common bile duct diameter in morphine group after fatty meal was more larger than that in the other two groups ( p <0.01).Conclusion1. Two type SO disorders were occurred among bile duct stone patients after operation: SO hypomotility and SO hypermotility, which could be diagnosed? 13 ?effectively by choledochoscopic manometry. The SO disorder may has a relationship with the formation or/and recurrence of bile duct stones.2. The gall stones patients had biliary dysmotility induced by SO disorders, which could further decrease the excretion of common bile duct, induce a overfull state of fasting gallbladder and a decreased ejection fraction of gallbladder and a increasing residual volume of gallbladder. All of these was a cause of gall stone formation.3. A normal fasting gallbladder was in a state of filling ang emptying simul-taneouly. After morphine loaded, the SO was in a hypertenus state, which could cause a overfull state of fasting gallbladder, a decreased ejection fraction of gallbladder and an increased diameter of common bile duct. After 654 - 2 loaded, the gallbladder emptying function was decreased compared with normal controls. |
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