James A. Gregg

Pancreas divisum: Its association with pancreatitis

Thirty-three patients with pancreas divisum studied by endoscopic retrograde cholangiopancreatography (ERCP) are described. Documented pancreatitis was present in fifteen patients, and another eleven had recurrent episodes of pain typical of pancreatitis. The major papilla was cannulated in all patients, but the duct of Wirsung was opacified in only twenty-eight and showed changes of pancreatitis in one. Attempts were made to cannulate the minor papilla in fifteen of the thirty-three patients and were successful in four. The duct of Santorini showed typical changes of pancreatitis in one. One patient had pancreatic cancer, and the duct of Wirsung demonstrated only nonspecific abnormalities. In only two cases was pancreatitis due to alcohol abuse. The high incidence of pancreatitis and pancreatic-like pain in patients with pancreas divisum, may be due to the very small ampulla of the duct of Santorini which in these patients drains the majority of the pancreas, creating a marked relative stenosis of the ampulla. Surgery for relief of pain was required in five patients. The operation of choice, when pancreatitis involves the dorsal pancreas, appears to be distal resection with drainage.

Effects of sphincteroplasty and endoscopic sphincterotomy on the bacteriologic characteristics of the common bile duct

Forty-five patients with sphincter of Oddi stenosis had specimens of common bile duct cultured during ERCP before either sphincteroplasty or endoscopic sphincterotomy. All had sterile bile before sphincter ablation. Bile was recultured 6 to 36 months later during endoscopy at which time 70 percent of the sphincterotomy and 76 percent of the sphincteroplasty patients had bile colonized principally by enteric organisms. Growth was heavy to moderate in most of the patients and contained few nasopharyngeal organisms. Despite bactobilia, no patient had symptomatic cholangitis, presumably due to excellent drainage of bile. The most likely source of the bactobilia is from direct extension of duodenal organisms into the common bile duct.

New approaches to the management of severe acute pancreatitis

A recent experience with seventy-seven patients admitted to Boston City Hospital for acute pancreatitis permitted us to identify thirteen patients (17 per cent) whom we diagnosed as having severe protracted acute pancreatitis. These alcoholic patients obviously had fulminant pancreatitis similar to that reported by others in two instances and pancreatic abscesses in two additional instances, but nine of the patients did not fulfill the criteria usually used by others as a basic for surgical intervention. Specific preoperative diagnosis was obtained in these patients by the aggressive use of endoscopic cannulation of the pancreatic ducts, which documented the presence of surgically correctable lesions. These patients had sustained significant malnutrition, which was corrected only by protracted therapy extending an average of two months and involving all modalities currently available for nutritional support of the severely ill patient. After proper preoperative identification of a specific lesion and correction of the malnutrition, the eleven patients without fulminant disease were operated on with no deaths or significant complication. Nine of the patients had elective procedures, which included six distal pancreatectomies and one total pancreatectomy. Thus, severe protracted acute pancreatitis can be identified, and once categrorized, it can have therapeutic implications.

Pancreas divisum: Results of surgical intervention☆

The embryologic defect that results when the ventral and dorsal anlages of the pancreas do not fuse has been referred to as pancreas divisum. ERCP has made it possible to recognize this anomaly in patients undergoing investigation for otherwise unexplained abdominal pain. Of 70 patients in whom recurrent epigastric pain and pancreas divisum coexisted, sphincteroplasty of both papillae was carried out in 19 because of intractability of symptoms. In six patients, surgery was performed subsequent to failure of other biliary tract surgery. There was one postoperative death. In the remaining 18 patients, initial results were good to excellent in 13 and fair in 1. In four patients, however, recurrence of symptoms developed within periods that ranged from 1 to 6 months; therefore, reasonably permanent relief was limited to 10 patients. Of the remaining eight patients with recurrent or continuing symptoms, a variety of subsequent procedures led to satisfactory results in only three. In only seven patients was there even minimal chemical or microscopic evidence to suggest active pancreatitis. Similarly, pancreatograms in 17 patients with this anomaly revealed no abnormalities except for minor ones in 2 patients. Thus, if this is a syndrome that is due to relative stenosis of the lesser papilla and duct, the anomaly does not often result in documented pancreatitis. The definite but limited success rate from sphincteroplasty suggests that relative stenosis of the lesser papilla may be the cause of a syndrome but surgical refinements will be necessary to achieve a better operative success rate.

Importance of common bile duct stricture associated with chronic pancreatitis: Diagnosis by endoscopic retrograde cholangiopancreatography

Twenty-one patients with common bile duct strictures associated with chronic pancreatitis are described in whom ERCP was the principal diagnostic method used. In 5 of the 11 patients who had had previous pancreatic or biliary surgery, a common bile duct stricture was overlooked. Nine patients had one or more attacks of cholangitis which were severe in seven and caused death in one. Endoscopically aspirated bile cultures showed heavy gram-negative infection in four patients with previous cholangitis. Two patients developed stones above the strictures, and in one this led to obstruction of a previous cholecystjejunostomy. Although strictures may be discovered at an asymptomatic stage, there should be careful follow-up to detect the appearance of any symptoms or objective signs of stricture progression, when surgery should be offered without delay. Direct biliary-enteric anastomosis is the procedure of choice when possible to relieve symptoms and prevent the potentially life-threatening complications of cholangitis and septicemia.

Postcholecystectomy syndrome and its association with ampullary stenosis

Fifty-six consecutive patients returning with recurrent or persistent upper abdominal pain after cholecystectomy were studied by endoscopic retrograde cholangiopancreatography, abdominal ultrasound and morphine neostigmine test. In 44 patients, pain recurred within 6 months after cholecystectomy. Forty patients were demonstrated on endoscopic retrograde cholangiopancreatography to have moderate to marked ampullary stenosis, which occurred as an isolated abnormality in 32 patients and in association with pancreatitis in 8. Thirteen patients were found to have pancreatitis, and 6 had retained common duct stones. In five patients no definite abnormality was demonstrated. The morphine neostigmine test was positive in 16 of 17 patients with isolated ampullary stenosis and in only 1 of 8 with pancreatitis. This test may be helpful in patients who are to undergo cholecystectomy. In those with positive results, endoscopic retrograde cholangiopancreatography would help assess the size of the ampullary sphincter so that sphincteroplasty could be done at the time of cholecystectomy in appropriate patients.

Rhythm abnormalities of the biliary and pancreatic sphincters: Diagnosis by endoscopic manometry

Abnormal phasic wave activity was noted in the biliary duct sphincter, pancreatic duct sphincter, or both in 43 patients. This abnormality consisted of a tachyrhythmia in 40 patients and absent phasic wave activity in 3 patients. Tachyrhythmia was encountered in patients with elevated basal sphincter pressures. In four patients with tachyrhythmia, administration of intravenous naloxone failed to modify phasic wave activity. Three patients with normal basal sphincter pressures had absent phasic wave activity. This abnormality occurred in two patients with cirrhosis and in one patient with suspected cirrhosis. In one patient with cirrhosis, administration of intravenous morphine did not induce phasic wave activity.

Percutaneous fine needle aspiration biopsy of pancreatic carcinoma

Carcinoma of the pancreas was diagnosed in 13 patients by percutaneous fine needle aspiration. The tumor was localized by angiography in eight, ultrasound in five, and endoscopic retrograde pancreatography in three patients. In four patients aspiration was performed using two of the three localizing techniquesCytological diagnosis of carcinoma of the pancreas can be made accurately by percutaneous fine needle aspiration of the tumor and operative intervention avoided in those patients who do not require operative bypass procedures. Percutaneous fine needle aspiration can be used with equal facility with arteriography, ultrasound, or endoscopic retrograde pancreatography. There have not been complications due to fine needle biopsy, and one can expect a 77–86% positive diagnostic yield.

Endoscopic measurement of pancreatic juice secretory flow rates and pancreatic secretory pressures after secretin administration in human controls and in patients with acute relapsing pancreatitis, chronic pancreatitis, and pancreatic cancer

Secretory flow rates were measured inside the main pancreatic duct during endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute relapsing pancreatitis, chronic pancreatitis, and pancreatic cancer and in controls after intravenous administration of secretin. Peak secretory flow rates in these groups were 5.04 +/- 1.74, 0.71 +/-1.28, 0.60 +/- 1.37, and 4.13 +/- 0.88 ml/min, respectively. Peak secretory pressures were also measured intraductally in patients with acute relapsing pancreatitis and pancreatic cancer and in controls and were 402 +/- 69, 75 +/- 161, and 403 +/- 99 mm pancreatic juice, respectively. Peak secretory flow rates and pressures measured in controls during constant administration of secretin were similar to those measured when secretin was administered as a bolus.

Pancreatic hypersecretion in liver disease

Abnormally large duodenal aspirates have been reported in a large percentage of patients with cirrhosis of the liver. The source of this fluid has been variously ascribed to the liver and/or pancreas. The present study was undertaken to clarify its source. Eleven patients with cirrhosis of the liver and one with cholestatic hepatitis underwent an intraductal secretin test during endoscopic cannulation of the pancreatic duct. Six patients with cirrhosis had pancreatic hypersecretion ranging from 7.8 to 26.0 ml/min, while three patients demonstrated low secretory flow rates.Bile flow was negligible or nonexistent in ten patients, while in two others, larger but unmeasurable amounts of bile secretion were present. This study conclusively demonstrates that pancreatic hypersecretion may occur in patients with cirrhosis during secretin stimulation. Impaired metabolism of secretin or the associated pancreatic hypersecretion of early pancreatitis may be responsible for this finding.