Does Cholangiovenous Reflux Cause Cholangitis?

Using corrosion casting and scanning electron microscopy of the rat biliary tree, we investigated the site and size of the pathways that allow bacteria to reflux from bile to blood. Nonobstructed rat biliary trees were injected retrograde with methylmethacrylate resin at a constant rate of 0.04 ml/min to volumes of 40, 60, 80, 120, 160, and 200 μl. The infusion pressure was monitored and a pressure-volume curve was constructed. After polymerization and corrosion in 30 percent potassium hydroxide, the casts were examined with scanning electron microscopy. In addition, to identify the size of the reflux pathways, ceramic particles of 150 A, 1.7 μ, or 10 μ were added to the resin, and the studies were repeated. Finally, intact livers with casted biliary trees were processed and studied by scanning electron microscopy without corrosion. Scanning electron microscopy demonstrated fine anatomic detail of the cholangiovenous reflux pathway. At 40 μl (20 cm water pressure) normal biliary radicals were filled. Between 40 and 80 μl (20 to 50 cm water pressure), the cast material refluxed from the bile ductules into the spaces of Mall and Disse and then into the hepatic sinusoids. Filling of sinusoids continued at volumes between 80 to 160 μl, and filling of collecting veins was seen above 160 μl. Particles of 1.7 μ and smaller readily refluxed, but there was no sinusoidal reflux of casting material that contained particles of 10 μ. Casting without corrosion showed that the liver parenchyma remained intact. There was no evidence of reflux across hepatocytes. This study shows that cholangiovenous reflux occurs directly from bile ductules through the spaces of Mall and Disse into the hepatic sinusoids. The pathways measure between 1.7 and 10 μ. Since this is the path of least resistance, it may be of greater importance in the reflux of bacteria and toxins than other high-resistance pathways, for example, biliary canaliculi, tight junctions, or hepatocytes.