Acute Cholecystitis Associated With Pancreatic Reflux

Abstract

IN I901, Opie'4 reported a case of acute hemorrhagic pancreatitis in which autopsy disclosed a calculus, occluding the duodenal orifice of the ampulla of Vater, but so small that the orifices of the choledochus and pancreatic duct were unobstructed. The two ducts, therefore, were converted into a continuous channel. This made possible the retrojection of bile into the pancreatic duct which probably accounted for the acute pancreatitis present. Stimulated by Opie's observation, other instances of acute pancreatitis were reported in which the pancreatic tissues were bile stained.Interest was then aroused as to the different anatomic arrangements of the ducts in relation to the ampulla of Vater, and in which type of variation the lodgment of a small stone would convert both ducts into one continuous channel. Investigators have reported varying results. Mann and Giordano12 concluded that in 3.5 per cent of their dissections the termination of the ducts was such that a continuous channel could be effected if the papilla were obstructed. From roentgenologic studies of ducts injected with lipiodol, Schmieden and Sebening17 found that this anatomic arrangement was present in 20 per cent of their cases. Subsequently, by occluding the papilla with a small stone and pouring Woods metal into the choledochus, Cameron and Noble6 noted that the pancreatic duct was in the mold of 75 per cent of the preparations. If the biliary reflux is to be considered in the etiology of acute pancreatitis, there must be other factors causing papillary obstruction inasmuch as the incidence of a stone occluding the ampulla is small.In a collected series of I,278 cases of acute pancreatitis, Schmieden and Sebening found that the ampulla was obstructed by a calculus in only 4.4 per cent, and in a series of 5I cases of primary acute pancreatitis reported by one of us8 in I930, a papillary calculus was found in only one instance, although the common duct was definitely dilated in seven. The statement was made then that "the ampulla of Vater may be occluded either reflexly, or by the edema and spasm incident to the passage of stone in some cases, and in others by an inflammatory pancreatic enlargement."Undoubtedly, edema of the papilla and spasm of the sphincter of Oddi not infrequently convert the choledochus and duct of Wirsung into one channel. Balo and Ballon2 reported the necropsy findings in four cases of simple catarrhal jaundice without stone in which a retention of pancreatic juice and simultaneous jaundice was presumably due to swelling and edema of the t George Blumenthal, Jr., Fellow in Pathology. 67

Experimental inquiry into the significance of trypsin in bile peritonitis, with particular reference to the human secretions

“…of human hepatic bile (containing 0.5 ml. of duodenal agree with a considerable body of clinical experience (Copeland, 1813;Drysdale, 1861;Battle, 1894;Spencer, 1898;Garrett, 1900;Thompson, 1901;Willard, 1902;Ladd, 1913;Bowers, 1953) although most of the patients reported had suffered from injury to other viscera. Johnston (1961), after reviewing 13 cases of perforation of the common bileduct in infancy, concluded that the prognosis was good.…”

“…Dzienbowski (1931) presumed that his patient with this condition had pancreatic enzymes in the fluid and noted that these recently had been found in the peritoneal fluid of a patient reported by Siefert (1931). Colp, Gerber, and Doubilet (1936) reported 2 patients with acute sterile non-perforative biliary peritonitis in whom pancreatic enzymes were present in the bile. One patient had free bile-stained fluid in the peritoneal cavity; the other had a loculated layer of bile-stained fluid outside the gall-bladder.…”