The Relations of the Antrum and Cap to the Gall Bladder; Gastric and Duodenal Peristalsis as Factors in Emptying the Gall Bladder

Abstract

AFTER a controversy covering several years in regard to the emptying of the gall bladder, certain facts are now generally accepted, while others are still in dispute. Accepted Facts.—The gall bladder empties through the cystic duct into the common duct, thence into the duodenum. The Heisterian valves do not furnish serious obstruction to the passage of bile in either direction. There is a sphincter at the outlet of the common duct, the sphincter of Oddi, the function of which is to interpose a moderate barrier to the continuous passage of bile into the duodenum, thus allowing the gall bladder to fill. When the action of the sphincter is destroyed by inserting a cannula or by other means, the gall bladder does not fill. When the gall bladder is absent in animals or is occluded or removed by surgery in man, the secretory pressure overcomes the sphincter, the resistance of which is very low or absent under these conditions, and bile passes continuously into the duodenum. There would be no pressure in the biliary system if it were not for secretory pressure. The secretion of bile is more or less continuous but is more active during gastric digestion. The secretory pressure of the bile is equalized by the removal of the fluid element of the bile by the gall bladder so that the pressure of the bile is below the threshold of the sphincter of Oddi when it is intact. Bile passes into the duodenum intermittently, by spurts, during the presence of food in the stomach and in small amounts occasionally during coughing, deep respiration, straining, etc. Immediately upon taking food, the pressure in the gall bladder is raised, and in a short time the gall-bladder bile (black bile) passes by spurts into the duodenum. The function of the gall bladder is to receive, store, and concentrate the bile, to act as an equalizer of pressure in the bile duct system, and to deliver the bile periodically during early digestion into the duodenum. It does not normally empty in appreciable quantities when the stomach is empty. Points in Controversy.—There is considerable controversy over the rôle of the following factors in emptying the gall bladder: Muscular development of the gall bladder and the efficiency and nature of its contraction; elastic recoil; respiration; engorgement of the liver; dilution and interchange of bile in the gall bladder; variations in intra-abdominal pressure; influence of the nerve supply on the gall bladder and reciprocal action with the sphincter of Oddi; a gall-bladder hormone (cholecystokinin of Ivy and Oldberg), and intestinal peristalsis. Subjects Discussed in This Article.—There has been little or no discussion in the literature on the relation of the gall bladder to the antrum and cap, of the variations in the position of the gall bladder when the stomach is full and when it is empty, and of the relation of the antrum and cap to the gall bladder during peristalsis with a liquid meal and with a solid meal.