The craniofacial pattern profile approach to dysmorphogenesis syndromes affecting the head and face combines graphic and numerical measures of pattern variability and pattern comparison. Selected dimensions of the head and face are expressed as Z-scores (standard deviation units) relative to standards for age and sex. As with the metacarpophalangeal pattern profile, this method identifies highly deviant but undiagnosed patterned departures from normal and allows comparison with individuals or groups of individuals with known diagnoses.

Major pancreatic injuries in children are uncommon but potentially very serious. They usually occur in active young boys following characteristic accidents. Despite this they frequently go unrecognized for prolonged periods. Four patients with delayed recognition of blunt pancreatic trauma are described. The presence of pancreatic injury was identified by hyperamylasaemia in every case. Ultrasound and CT scanning were helpful in identifying pseudocysts but accurate pre-operative diagnosis of main duct disruption required endoscopic retrograde cholangiopancreatography (ERCP). Surgical treatment involved a full exploration of the lesser sac with drainage of the cyst contents and identification of the site of extravasation. Two patients with proximal duct lacerations were treated by internal drainage into a Roux-en-Y loop with the addition of a distal pancreaticojejunostomy in one case. Two patients with distal lacerations were treated by distal pancreatectomy and oversewing of the remnant. All four patients recovered and were well at follow-up. Early ERCP is the only reliable method of identifying duct injuries which require urgent surgery. It should be considered in all children with blunt pancreatic trauma.

Patients who continue to have or who develop abdominal pain after apparently successful cholecystectomy pose diagnostic difficulties. This study reports 384 such patients, investigated by endoscopic retrograde cholangiopancreatography (ERCP). There were 146 patients with abdominal pain alone with no previous history of common bile duct (CBD) exploration, of whom only 17 (11.6 per cent) had CBD stones on ERCP. Bile duct calculi were present in 76 of 140 patients (54.3 per cent) with abnormal biochemical findings (raised alkaline phosphatase and/or amylase level) and in 34 of 57 (60 per cent) with an abnormality detected on ultrasonography or intravenous cholangiography. A combination of biochemical and radiological abnormalities was present in 37 patients and was associated with CBD stones in 28 (76 per cent). Patients who had undergone CBD exploration represented a special group, of whom the majority (75 per cent) had common duct stones at ERCP even in the absence of biochemical and radiological abnormalities. ERCP is a useful investigation in patients with persistent postcholecystectomy symptoms. Other features in addition to pain or a history of CBD exploration may be relevant to the decision to perform ERCP in the investigation of these patients.

Pancreaticoduodenectomy remains the operation of choice for carcinoma of the ampulla of Vater, but the presence of severe jaundice in almost all patients with ampullary neoplasia is a major contributory factor to the high incidence of complications and hospital mortality after the operation. To achieve biliary decompression in five patients endoscopic sphincterotomy was performed at the time of endoscopic retrograde cholangiopancreatography. The procedure was successful in achieving biliary drainage in all cases and was without appreciable morbidity. All five patients subsequently underwent identical resections, the interval to operation being decided by the speed of resolution of the jaundice; minor pancreatic leaks in two patients were the only complications. None of the patients died.These results suggest, therefore, that endoscopic sphincterotomy should be performed at the time of duodenoscopy if an obstructive ampullary tumour is found.

SUMMARY Chronic pancreatitis is an infrequently considered cause of gastrointestinal bleeding. Four cases are described who presented to a surgical unit in a year. One patient bled down the main pancreatic duct from a splenic artery pseudoaneurysm, one had a fatal haemorrhage from a superior mesenteric artery aneurysm which ruptured into the duodenum, and two were considered to have bled from vessels in the stomach or colon which were involved in the peripancreatic inflammatory tissues. The difficulties in diagnosing these patients are described and the report emphasises that the diagnosis should be considered in obscure cases of gastrointestinal bleeding especially where there is a history of alcohol abuse and left upper quadrant or epigastric pain.In the United Kingdom chronic pancreatitis is rarely considered in the diagnosis of gastrointestinal bleeding and often does not feature in reviews of the subject.' Our own experience and a review of the literature suggest that it may be a more frequent cause than is realised, a recent report being able to describe 12 cases of bleeding at one institution due to this cause, and to cite another 60 in the recent literature.2We report four cases who presented to a surgical unit in one year, three of whom had multiple investigations for their recurrent gastrointestinal bleeding, and were eventually found to have bled as a result of their chronic pancreatitis.Case 1 JD, a 50 year old man, had been previously fit and admitted to only moderate drinking. He complained of intermittent left upper quadrant pain radiating to his back for one year. Six months after the pain began he had a large haematemesis for which a laparotomy was performed at his local hospital and, though no cause for the bleeding was found, the pancreas was noted to be nodular and sclerosed. He subsequently had several more haematemeses associated with left upper quadrant pain and gastroduodenoscopy on two occasions failed to show any lesion to account for the bleeding.He was referred for endoscopic retrograde cholangiopancreatography (ERCP) but on the day before admission he had further pain and a large haematemesis causing his haemaglobin to fall to 5.6 g/dl.Received for publication 18 August 1981 Abdominal examination revealed a tender fullness in the right hypochondrium and it was noted that his serum amylase was raised to 1950 IU/1. ERCP was performed, and revealed a cyst two-thirds of the way along the main pancreatic duct which filled with dye and then rapidly emptied. In view ofthe known risks of injecting dye into pancreatic cysts at ERCP the patient underwent laparotomy the same day. At operation changes of chronic pancreatitis were found and the cyst was found to be a pseudoaneurysm of the splenic artery in communication with the main pancreatic duct. This was presumed to be the route of bleeding. A distal pancreatectomy was performed, resecting the aneurysm along with the tail of the pancreas and the spleen.Postoperatively the patient made a smooth recovery, has had no more bleeds, and maintai...