1. Look for the answers to the following questions:

   1. What does protracted elevation of serum lipid, especially choles­terol, lead to?

   2. When do ascites and edema usually appear?

   3. Who usually have a long- standing history and evidence of previ­ous biliary tract disease?

   4. What do most instances of secondary biliary cirrhosis result from?

   5. What do the obstructions usually suggest?

2. Approve or contradict:

   1. Periductal lymphocytes in liver biopsy specimens from patients with secondary biliary cirrhosis have been shown to form IgM immune globulins;

   2. Although not diagnostic, the early clinical course of primary bil­iary cirrhosis is quite characteristic;

   3. A circulating antibody (IgG) is absent in the serum of patients with primary biliary cirrhosis that reacts with mitochondria rich cells?

   4. Most instances of secondary biliary cirrhosis result only from long­standing total obstruction of the common bile duct iifs major branches; signs and symptoms of true cirrhosis appear slowly.

BILIARY DYSKINESIA

Under normal circumstances, food entering the duodenum stimulates smoothly integrated evacuation of bile from the biliary tree. The concept that pain may arise from a purely motor derangement has been postulat­ed since 1887, when Oddi stated that interference with the coordination of biliary kinetics, i. е., contraction of a gallbladder against a tonic sphincter, could result in pain, jaundice, or both. Since then a vast liter­ature has been accumulated concerning "biliary distress" without demon­strable organic lesions in the extrahepatic system. Biliary dyskinesia includes three different kinds of motor dysfunction: disturbances in evac­uation (dyskinesia), disorders of tone (dystonia), and disturbances of coor­dination (dyssynergia).

Biliary dyskinesia can be compared with the spastic colon syndrome, as both conditions share a negative clinical and laboratory evaluation. However, they differ in that many patients with biliary dyskinesia under­go surgical procedures based on operative biliary dynamics, including sphincterotomy, choledochoduodenostomy, vagotomy, or splanchnicecto- my. Few patients benefit from these procedures, and a lack of correlation among symptoms, pressure studies, and surgical results has evoked skep­ticism in the United States and Great Britain regarding biliary dyskine­sia as a disease entity.

The clinical manifestation of biliary dyskinesia may run the gamut of traditional symptoms of acute or chronic cholecystitis with the exception that fever, chills, and leukocytosis are rarely noted. The patients are usu­ally anxious women whose symptoms correlate well with emotional ten­sion, situational stress, and fatigue. Then past histories often include investigations for nau^a, headaches, giddiness, diarrhea, or constipation. Comprehensive evaluation of liver and pancreatic function together with conventional roentgenographic studies of the biliary system reveal no abnormalities. The following are used by enthusiasts to evaluate these patients: (1) Pain, indistinguishable from biliary colic, precipitated by morphine, is taken as evidence of sphincter dysfunction; (2) timed duo­denal drainage compares the appearance, volume, and duration of flow of various bile fractions (gallbladder versus hepatic bile); (3) cinecholecys- tography is used to compare structure and function of the biliary tree; (4) operative radiomanometry is considered in many areas of the world as a definitive investigation; (5) recreation of the patient's pain by cholecys- tokinin injection. Supported by delayed gallbladder or common duct emp­tying on cholecystography, is interpreted as evidence of cystic duct or sphincter spasm or fibrosis. These diagnostic approaches must be tested by properly controlled studies before they can be accepted as indications for surgical procedures on the biliary tract.

The management of patients suspected of having biliary dyskinesia requires careful assessment of the symptoms in relation to food, alcohol, chronic intake of medications, and tensions. Reassurance, phenothiazines, sedation, analgesics and anticholinergics, alone or in combination, should be tried on an empiric basis.