Iatrogenic Chymobilia— A Disease of the Nineties?

The last two decades have seen a strong swing towards preservation of some of the sphincters of the alimentary tract, namely, the pyloric and anal sphincters, while at the same time there has been increasing "vandalism" of the sphincter at the distal end of the common bile duct. Endoscopic papillotomy, first introduced in 1974, is a very useful procedure in selected patients but too liberal use of the technique may result in a harvest of new problems in years to come. The intact sphincter of Oddi prevents the entry of duodenal contents into the biliary tree; its division allows their free reflux. By the term ’chymobilia’ we mean the presence of chyme in the biliary tree. The Greek word chyme (juice) is combined with the Latin word bilis (bile) in a manner similar to the term haemobilia introduced by Sandblom in 19481. Following endoscopic sphincterotomy reflux of duodenal chyme occurs in most patients; aerobilia is seen in half and bacterobilia in all2. The results of surgical sphincterotomy are similar. The majority of these patients with bacterobilia do not develop classical symptoms of ascending cholangitis, namely pain, pyrexia, rigors and jaundice but 20 per cent have bouts of upper abdominal pain and associated elevation of the serum Gamma glutamyltranspepside3. Following biliary-enteric anastomosis both aerobic and anaerobic bacteria are involved4. Bacterobilia may not be as innocent as was initially thought, and for patients with immunosuppression, the risk of cholangitis is markedly increased5. In addition the reflux of chyme may set up chemical changes with resultant inflammatory reaction in the duct epithelium and periductal area. The clinical syndrome of ascending cholangitis often indicates outflow obstruction usually of an incomplete nature due to residual or recurrent stones or restenosis. However we have seen cholangitis in patients following sphincterotomy and other types of biliary-enteric anastomosis where a free-flowing, unobstructed biliary tree was demonstrated by percutaneous cholangiography and by retrograde barium and air studies of the ductal system. Goldman and colleagues reported on six patientswho suffered repeated episodes of cholangitis despite widely patent biliary-enteric anastomoses6. Debris is frequently seen in the duct following fenestration whether it be choledochoduodenostomy where the sump syndrome can occur, or after simple surgical or endoscopic sphincterotomy. These ductal filling defects are sometimes referred to as false calculi images. Escourrou and colleagues found evidence of reflux from the duodenum into the biliary tree in 65 per cent of patients after endoscopic sphincterotomy but state that they never observed clinical symptoms related to