Demonstration of a Ball-valve Obstruction of the Common Duct

Abstract

Ball-valve obstructions and their mechanisms have been describe dmany times in the literature. They have been known to occur in the common duct, in which instance a stone, according to its position, may be the cause of intermittent, partial, or complete obstruction. The demonstration of stones in the common duct by means of opaque medium is now a relatively common occurrence, but the demonstration of a ball-valve obstruction in the common bile duct is unusual. Mrs. E. M., white, aged 68 years, entered the Franklin Hospital on May 21, 1938, complaining of severe pain in the right upper quadrant. She stated that during the previous two weeks she had had frequent attacks of pain in that area. Cholecystograms were done on May 24; the gall bladder could not be visualized and no evidence of stones could be seen. The past history was of no significance, except that a stone had been removed from her right kidney ten years previously. The patient was operated upon on May 28, 19.38. The surgeon's report of the operative findings stated that the gall bladder was markedly distended with bile-stained fluid; no stones were found. The biliary ducts were thickened and no stones were palpable. About one-third of the gall bladder was removed, the remaining portion being stitched together and, because the patient's condition did not warrant further operative procedure, a mushroom catheter was placed in the gall bladder and the wound closed. The patient did poorly; she continued to vomit and had repeated attacks of severe pain in the right upper quadrant. On June 21, she was taken to the X-ray Department and a small amount of lipiodol was introduced into the drainage tube under fluoroscopic control. A film was taken which showed the gall bladder and common duct to be well filled with opaque medium, the common duct to be dilated, and at about its center, a large non-opaque stone to be visible. As there was no lipiodol in the duodenum, more was injected until the patient complained of severe pain. A second film was taken which showed the stone to have moved to the lower end of the duct, completely blocking the flow of the lipiodol. The patient was again operated upon on June 24, and the stone was removed. She was unable to withstand the shock of the second surgical interference and died the following day. We wish to thank Dr. G. C. McCandless for his aid in performing the technical portion of this examination.