Sites of Pancreatic Duct Obstruction in Chronic Pancreatitis '
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Sites of Pancreatic Duct Obstruction in ChronicPancreatitis '
ALAN P. THAL, M.D., BERNARD GOOTT, M.D., ALEXANDER R. MARGULIS, M.D.
From the Departments of Surgery and Radiology, University of Minnesota,Minneapolis, Minnesota
THE SPATIAL ARRANGEMENTS of the termi-nal pancreatic and common bile ducts varyso considerably from patient to patient thatstricture or spasm in this area may result inobstruction to either or both ducts. More-over in chronic pancreatitis the duct maybe obstructed in one or several areas withinthe substance of the pancreas at points dis-tant from the papilla of Vater. Treatmentaimed at the relief of pancreatic duct ob-struction depends upon the precise localiza-tion of the site of obstruction. This informa-tion may be obtained by careful palpationof the gland, by gentle probing of the mainduct or by operative pancreatography.A satisfactory pancreatogram may be ob-
tained during cholangiography especially ifthe papilla is made spastic by the instilla-tion of 0.1 N hydrochloric acid into theduodenum. However, in many patients withadvanced chronic pancreatitis visualizationis not obtained this way and a direct pan-creatogram may be necessary to identifythe site of obstruction. In our experiencethe safest method of performing direct pan-creatography is to insert a fine (4 F.) softpolyethylene catheter through the pancre-atic duct. Even in the presence of a highdegree of duct obstruction the fine cathetermay traverse the stricture and reach thetail of the pancreas. Small amounts of Reno-graffin (38%) are then allowed to refluxfrom the tail of the gland into the duo-denum. Satisfactory filling of the ductal
system is usually obtained. In general, pan-creatograms are necessary only where thereis resistance to the passage of a soft poly-ethylene catheter.The following cases illustrate several an-
atomic sites at which ductal obstructionmay occur.
1. Obstruction at the Ampulla of Vater
A. Acute Pancreatitis
The two cases described below illustratethe rarely documented but oft predicted oc-currence of obstruction at the ampulla ofVater during an attack of acute pancreatitis.
Case 1. R. F., U.J. #601239: This 43-year-old hospital orderly had been in good health apartfrom occasional episodes of heart burn and burn-ing substernal pain until the morning of admission.At this time he experienced the sudden onset ofsevere burning epigastric pain associated withvomiting. The pain radiated constantly to the back.Physical examination revealed generalized abdom-inal distention with diffuse tenderness and general-ized rebound tenderness. Maximum tenderness wasin the epigastrium. On admission his white bloodcount was 11,000 but after 5 hours it had risen to27,000. The admission serum amylase was reportedas 4,000 Somogyi units. Because of the rapid de-terioration in this patient's condition and the pos-sibility of perforated ulcer an exploratory laparot-omy was performed. At operation the peritonealcavity contained 500 cc. of serosanguineous fluid.The gallbladder was extremely tense, white andthick-walled. There was edema of all the tissuesin the upper peritoneal cavity and particularly ofthe adipose tissue around the pancreas and the freeedge of the lesser omentum. The pancreas wasfound to be edematous and indurated throughoutits whole length with very rare specks of fat necro-sis. The whole picture suggested combined acute
* Submitted for publication July 15, 1958. Re-submitted after revision, November 11, 1958.
Supported by U.S.P.H.S. Grant H-1902.
50 THAL, GOOTT AND MARGULIS
FIG. 1. The various sites of pancreatic ductobstruction. Arrows 1 and 2 indicate the commonsite of early pancreatic duct obstruction in thepapillary sphincter or at the site of origin of themain pancreatic duct. Obstructions at sites 3 and4 are seen only in advanced disease.
cholecystitis and acute edematous pancreatitis.Cholecystostomy was performed to drain the gall-bladder and the peritoneal cavity, lavaged withsaline. The patient improved considerably afteroperation. Cholecystocholangiogram performed inthe immediate postoperative period demonstratedsome regurgitation of dye into a dilated pancreaticduct (Fig. 2). Indeed, the pancreatic duct was oflarger diameter than the common bile duct in thisarea. About 6 weeks after his initial attack he wasonce more admitted to the emergency room witha very transient episode of similar abdominal painwhich was rapidly relieved by nitroglycerine. Dur-ing this episode which lasted only one hour theserum amylase level reached 500 units.
Subsequently, he was re-operated upon withthe object of relieving the pancreatic duct obstruc-tion. Cholangiogram at the time of operation dem-onstrated a markedly dilated pancreatic duct (Fig.3). The pancreas at this time was diffusely swollenand markedly indurated. A sphincterotomy wasperformed and the dilated pancreatic duct exposed.Cannulization of this duct produced grossly pu-rulent pancreatic juice which on smear and culturerevealed alpha hemolytic treptococci. In spite ofthe radiologic evidence of reflux there was no traceof bile in the pancreatic juice. The pancreatic ductcatheter was left in place and exteriorized througha gastrostomy. Postoperatively, the patient drainedas much as 500 cc. of grossly purulent pancreaticjuice daily. After about 5 days, the juice becamecrystal clear and the tube was subsequently with-
Annals of SurgeryJuly 1959
drawn. He is free of symptoms one year afteroperation.
Case 2. H. G., U.H. #903003: This 74-year-old Finnish male was admitted to the UniversityHospital complaining of intermittent attacks of ab-dominal pain and vomiting. He had several pre-vious attacks over the past seven years and on afew occasions there was associated jaundice. At thetime of admission he was febrile and icteric. Therewas marked rebound tendemess in the epigastrium.Hemoglobin 14.9 Gm.; BUN 15 mg.; serum am-ylase 820 units. His general condition and cardiacstate were poor but he responded for a few daysto electrolyte therapy and suction. Then there wasa sudden deterioration in his condition with in-crease in abdominal pain and generalized reboundtendemess. At operation the gallbladder was foundto be packed with gallstones and extremely thickwalled. The common bile duct was dilated andcholangiogram performed on the operating table(Fig. 4) demonstrated a complete obstruction atthe ampulla of Vater with regurgitation up thepancreatic duct. The ampulla failed to admit thesmallest Bakes dilator. Consequently a transduo-denal sphincterotomy was performed and a T-tubeinserted into the common duct. The pancreas wasextremely indurated and swollen to approximatelytwice normal size. Culture of the peritoneal fluidrevealed gram negative bacilli identified as E. coli
FIG. 2. Case 1. Obstruction at the duodenalpapilla during an attack of acute pancreatitis.There is a slight reflux up a dilated main pancreaticduct and a minimal passage of dye into the duo-denum.
SITES OF PANCREATIC DUCT OBSTRUCTION
and culture from the common bile duct revealedboth gram negative bacilli and gram positive cocci.Postoperatively, the patient improved for severaldays but then developed further epigastric painand succumbed to a massive gastro-intestinal hem-orrhage followed by aspiration. Autopsy showed 4superficial ulcers on the lesser curvature of thestomach, extensive aspiration pneumonia and sub-siding pancreatitis.
B. Chronic Pancreatitis
Case 3. A. H., U.H. #882355: This 14-year-old girl entered University Hospital because of re-current bouts of right upper quadrant pain. Threeyears prior to admission she was treated for anillness characterized by right upper quadrant pain,jaundice, anorexia and vomiting, with pale stoolsand dark urine. This was thought to represent anattack of infectious hepatitis. One year prior to ad-mission she was seen because of a particularlysevere attack of pain. Gastro-intestinal x-rays re-vealed a constant filling defect in the second por-tion of the duodenum (Fig. 5). Four months priorto operation she was again admitted because ofsevere right upper quadrant pain, nausea, vomiting,jaundice and fever. All studies were negative at thetime of the final admission. At operation she wasfound to have a slightly dilated common bile duct,a markedly swollen papilla of Vater which couldreadily be palpated through the duodenal wall, and
FiG.. 3. Case 1. Cholecystocholangiogram per-formed during remission 6 weeks after the acuteattack showing ready passage of dye into the duo-denum with persistent reflux up a dilated pan-creatic duict.
FIG. 4. Case 2. Complete obstruction at thepapilla of Vater during an attack of acute pan-creatitis. There is slight reflux up a normal sizepancreatic duct.
pancreatogram (Fig. 6) demonstrated the tortuousdilation of the main pancreatic duct. Sphincterot-omy proved an adequate means of draining thisobstructed duct and when last seen 18 months afteroperation she was entirely symptom free.
Case 4. F. E., U.H. #749002: This 56-year-old white female was seen at the University Hos-pital because of recurrent pain in the right upperquadrant associated with nausea and vomiting.Cholecystectomy had been performed for gall-stones a year previously. Careful clinical studies ofthis patient were entirely negative with the excep-tion of the intravenous cholangiogram, which dem-onstrated retrograde filling of a dilated distortedpancreatic duct (Fig. 7). Because of this finding itwas thought that this patient probably had inter-mittent obstruction at the ampulla of Vater. Ac-cordingly, she was explored. The smallest Bakesdilator would not pass through the ampulla ofVater and a sphincterotomy was performed. Thepancreatic duct was cannulated and injection ofdye showed diffuse opacification of the paren-chyma of the pancreas which has been described 3as