Summary X-ray monitoring was used to confirm the accuracy of extradural block in

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Bile reflux into the pancreatic duct after impaction of a stone in a common pancreaticobiliary channel has been suggested to be the initiating factor in gallstone pancreatitis. Such reflux would require that the impacted stone be smaller than the length of the common channel. The incidence of common channels was studied and gallstone size was compared with common channel length in patients with gallstone pancreatitis and those with cholelithiasis or choledocholithiasis without pancreatitis. Sixty-seven per cent of patients with gallstone pancreatitis had a common channel present on intraoperative cholangiography versus 32% of patients with cholelithiasis or choledocholithiasis without pancreatitis (p less than 0.005). Common channel length was greater than the diameter of the smallest stone in nine of 27 patients with gallstone pancreatitis and in 13 of 109 patients with cholelithiasis or choledocholithiasis without pancreatitis (p less than 0.025). In conclusion, common channels are more frequent in patients with gallstone pancreatitis than in patients with other biliary tract disease. Furthermore, gallstone pancreatitis is associated with stones that are smaller than the common channel, which favors obstruction of both pancreatic and bile ducts while allowing reflux of contents between them.

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Interest in this work developed when it was found that there were patients with persistent abdominal pain, in whom no intra-abdominal cause could be found, who were relieved by peripheral block of the appropriate nerve in the abdominal wall. All these patients complained of pain, which was often severe, burning and intermittent, and was unrelieved by the usual mild analgesic drugs. Discomfort was, curiously, unaffected by rest or exercise. It was not commonly associated with a rise in temperature or nausea and vomiting. A definite onset was infrequently remembered but, once present, the pain continued intermittently for a long time, in some for a number of years. With further experience it was possible to locate a small area of acute tenderness, about the size of a pencil head, deep in the rectus sheath, close to its outer border. Direct injection into this painful zone has proved to be a simpler and more effective method of treatment. M A T E R I A L S A N D M E T H O DOne hundred and three patients were studied over a period of three and a half years. These are presented in table 1 with the clinical presentations and nerves involved. All these patients had been thoroughly examined to exclude an intra-abdominal cause before referral to the Pain Clinic.The trigger area was located by raising the patient's head and shoulders off the pillows, thereby tensing the rectus abdominis, and by pressure along its outer border. In this tender zone, through a skin bleb, the injecting needle was directed towards the posterior wall of the rectus sheath and the solution deposited in the lateral part of this compartment. Early trials with a local anaesthetic, such as lignocaine and a steroid, such as hydrocortisone, showed that pain-relief was only temporary. Repeat injections also failed to provide lasting relief. Eventually, 2-3ml of 5 % aqueous phenol was tried and this is the solution that has been used throughout this series. In this concentration a differential block, with the main impact on nonmyelinated and small myelinated pain fibres occurred'. 293. Many patients felt unwell for a day or two and some reported a dull burning sensation for a further day or two. This has been followed in most cases by complete