Colecistitis

THE RELATION OF CHOLECYSTITIS TO PATHOLOGIC CHANGES IN THE LIVER * RALPH COLP, M.D., HENRY DOUBILET, M.D.
AND

ISADORE E. GERBER, M.D. t
NEW YORK CITY, N. Y.
FROM THE SURGICAL SERVICES AND THE LABORATORIES OF THE MOUNT SINAI HOSPITAL, NEW YORK

CONTROVERSY still exists as to the relation of inflammation of the gallbladder to concomitant pathologic changes in the liver. While some believethat cholecystitis is the result of a primary hepatitis, others advance the view that the hepatic changes are secondary to the disease of the gallbladder. A third group of observers holds that inflammation of the gallbladder and pathologic changes in the liver are independent of each other. A review of the various contributions shows much which is contradictory and raises many questions for furtherelucidation. Riedel,' in i888, first called attention to the fact that there appeared to be an enlargement of the right lobe of the liver in cholelithiasis. This observation was subsequently confirmed by others. However, the investigation of the presence of liver pathology in acute and chronic cholecystitis received little attention until I9I8. Graham,2 at that time, published his observationsand microscopic findings in sections removed from the liver edge near the gallbladder in thirty consecutive cases of biliary tract disease. The microscopic sections disclosed the presence of hepatitis, consisting of infiltrations of polymorphonuclear leukocytes and lymphocytes in the interlobular spaces and often a mild fatty metamorphosis of the cells. The intensity of the hepatic changes seemedproportionate to the severity of the cholecystitis. The liver in cases of chronic cholecystitis often revealed lesions typical of early biliary cirrhosis. In I92I, Peterman, Priest, and Graham3 confirmed the latter's previous observations and conclusions. Graham's statement that cholecystitis is constantly accompanied by hepatitis, and that infection of the gallbladder results from a primaryhepatitis, has been widely accepted. Tietze and Winkler,4 Genkin,5 Genkin and Dmitruk,6 Murayama,7 Pettinari,8 Vilardell and Llort,9 MacCarty and Jackson,10 Hadley,1 Heilmann12 and many others, have reported the constant presence of liver changes in diseases of the biliary tract. Judd, Nickel and Wellbrock13 stated that hepatitis and cholangitis occurred routinely in the presence of cholecystitis. Whilemany others agreed that the gallbladder lesions were accompanied by hepatitis, several have questioned which organ was primarily involved. Koster, Goldzieher and Collens,14 in a similar study, confirmed the presence
*

Read before the New York Surgical Society, February 27, I935.

t George Blumenthal, Jr., Fellow in Pathology. 202

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Volume 102

PATHOLOGY OF LIVER INCHOLECYSTITIS

of a hepatitis, but felt that the inflammation of the gallbladder was primary. Else, Rosenblatt and Davis15 believed that the liver was involved by direct extension from an infected gallbladder. Heyd, MacNeal and Killian16 concluded that hepatitis was almost always associated with gallbladder disease but that it might be primary or secondary. In spite of the evidence apparently supportingthe dictum that hepatitis invariably accompanies cholecystitis, other investigators not only expressed doubt as to whether the cholecystitis or the hepatitis was the primary lesion, but whether an actual relationship existed between the lesions of the gallbladder and those observed in the liver. Martin17 called attention to several pertinent facts, well known but apparently neglected in previousdiscussions of this problem. He pointed out that one of the main functions of the liver was the destruction and disposal of bacteria and toxic substances brought to it throughout the life of the individual. Some of these were destroyed without evident reaction, but that all forms of an appreciable reaction, from a mild to a severe hepatitis, might occur. He felt that the hepatitis found with acute...