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

49

* 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 an

illness characterized by right upper quadrant pain,jaundice, anorexia and vomiting, with pale stoolsand dark urine. This was thought to represent an

attack 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 was

found 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 upper

quadrant 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 a sign of chronic pancreatitis (Fig. 8). Accord-ingly, the cannula was left in the pancreatic ductand brought out through a gastrostomy after the

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Fsc. 5. Case 3. Hyperplastic papilla of Vater seenon gastro-intestinal series.

tube had been maneuvered through the pyloricsphincter. External drainage of the pancreas wascarried out for approximately six days after whichthe tube was withdrawn. This patient has gainedweight and is free of complaints 12 months afteroperation.

2. Obstruction Within the Body of thePancreas

Case 5. L. S., U.H. #339352: This 46-year-old white male was first seen at the UniversityHospital in May of 1952, at which time his com-plaints were severe epigastric pain associated withnausea and vomiting precipitated by a bout ofheavy drinking ten days previously. The pain waspersistent, severe and radiated to the back. He de-scribed a similar episode 18 months previously.During this admission (1952) he was found to bemildly icteric and appeared acutely ill with tender-ness and rebound in the epigastrium. Serum am-

ylase was 590 units, serum bilirubin, total 5.5mig.%o. A diagnosis of acute pancreatitis was madeand he was explored during a quiescent phase. The

lhea(l of the pancreas was found to be hard andinduirated. A cholecystectomy and exploration ofthe common bile duict was performed but no stoneswere found. He was again admitted in December1956, with a similar history again precipitated bya bout of heavy drinking. Again he was icteric, theurine was dark and stools pale, serum amylase was

235 units, bilirubin 4.5 mg.%7, alkaline phosphatase92.4 K.A.U. Again he responded well to nonopera-tive management. Gastro-intestinal series showedanterior displacement of the stomach strongly suig-gesting pancreatic enlargement. In January 1957,he was readmitted for elective surgery. The bileducts were found to be of normal size. A sphinc-terotomy was performed and the pancreatic ductappeared entirely normal though opening sepa-rately about 5 mm. from the papilla. Catheteriza-tion of the duct revealed clear pancreatic juice.However, the catheter could not be passed more

than 4 cm. At this point there appeared to be a

stricture. Accordingly, the stricture was carefullydilated with small catheters and finally a catheterwas passed through the stricture. Immediatelythere was a gush of purulent, yellowish fluid. Apancreatogram was taken on the operating table(Fig. 9). It will be seen that the pancreatic ductin the head of the pancreas is strictured, hugelydilated and tortuous proximal to the stricture.There is also dilatation of the duct radicals andopacification of the parenchyma. Culture of thepancreatic juice revealed Proteus and E. coli inlarge numbers. The stricture was well dilated andthe duodenotomy closed leaving a catheter in thepancreatic duct to drain exteriorly. During the im-mediate postoperative period the catheter becameplugged by pus and the patient experienced an

attack of acute pancreatitis, the amylase levelreaching 675 units. This subsided promptly on

withdrawal of the catheter. Postoperatively he wasfree of symptoms for 12 months but then beganto have recurrent attacks of abdominal pain andfever associated with leukocytosis. Accordingly a

retrograde pancreato-jejunostomy was performed.He has obtained an excellent result. On the basisof the pancreatogram, retrograde decompressionshould have been done in the first instance.

3. Multiple Obstruction Within the Sub-stance of the Pancreas

Case 6. L. S., U.H. #880202: This 47-year-old white male developed bouts of left upperquadrant pain in December 1953, associated withmalaise and weight loss. Exploration in another

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SITES OF PANCREATIC DUCT OBSTRUCTION 53

FiG. 6. Case 3. Operative pancreatogram showing hugely tortuous pancreatic duct in a 14-year-old girl with chronic pancreatitis due to obstruction at the papilla of Vater.

hospital at that time revealed a cyst of the pan-

creas. Postoperatively his wound broke down anddischarged watery and occasionally bile-stainedfluid. He was again re-explored in September 1954,but again the wound broke down and a purulentfistula developed. The fistula fluid contained158,000 units of amylase. Flat plate of the ab-domen revealed calcification within the head ofthe pancreas. He was again explored in March1955, at which time a cholecystectomy was per-

formed and the common bile duct drained. Post-operatively drainage of the fistulae persisted. Thepancreatogram illustrated in Figure 9 was per-

formed through the fistulous tract in 1955. Thisdemonstrated a pseudocyst in the left subdiaphrag-matic area, also multiple strictures and dilatationsthroughout the ductal system. In April 1956, hewas again explored. A retrograde anastomosis ofthe fistulous tract was made to the stomach. It was

hoped to perform a retrograde pancreaticojejunos-tomy but the body of the pancreas was so firnlyfused to the posterior wall of the stomach that itcould not be adequately mobilized. Postoperatively,he did well for 12 months then developed a tinyfistula which drains about 5-10 cc. of purulentmaterial daily. This case illustrates the occurrence

of multiple strictures throughout the pancreatic

ductal system in a patient with advanced chronicpancreatitis. It seems doubtful that adequate drain-age can be secured in this case.

Fic. 7. Case 4. Intravenous cholangiogram showingreflux up a slightly dilated pancreatic duct.

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FIG. 8. Case 4. Operative pancreatogram show-

ing opacification of the tail of the pancreas, a radio-logic sign of chronic pancreatitis.

Annals of SurgeryJuly 1959

4. Obstruction Both at the Papilla and inthe Head of the Gland

Case 7. W. Z. #849789: This 57-year-old den-tist was admitted to the University Hospital inFebruary 1958, with the complaint of intermittentattacks of severe abdominal pain over an 8-year-period, increasing in frquency and severity in theyear prior to his admission, and at times necessitat-ing relief by opiates. The onset of the pain was

generally gradual, epigastric and radiating throughto the back with no definite precipitating factors.Past medical history revealed an occasional traceof sugar in his urine 6 months previously and an

aLnormal glucose tolerance curve. Physical exami-nation was negative. X-rays of the abdomen re-vealed a calcified area in the right kidney and twosmaller areas of calcification overlying the vertebralcolumn in the region of the head of the pancreas.Exploratory operation was carried out, at whichtime the pancreas was found to be induratedthroughout. Cannulization of the pancreatic ductby way of the ampulla brought forth purulentjuice, and an obstruction thought to be a calculus,

FIG. 9. Case 5. Operative pancreatogram. The catheter has traversed a stricture in the headof the pancreas about 4 cm. from the orifice of the main pancreatic duct. A markedly dilatedductal system can be seen. Grossly purulent material drained from these dilated ducts andculture revealed alpha streptococcus and Escherichia coli.

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SITES OF PANCREATIC DUCT OBSTRUCTION

could be felt 4 cms. from the orifice, though nodefinite stone was indicated on pancreatograms.Culture of this pancreatic juice revealed Esch. coliand alpha streptococcus. Drainage of the mainduct was achieved by side-to-side anastomosis ofthe duct proximal to the site of obstruction to aRoux-Y jejunostomy. The postoperative course wasuneventful with rapid recovery. He has gainedweight and has been entirely free of symptomspostoperatively.

5. Postoperative Pancreative Duct Ob-struction

Case 8. L.H.S. #896724: This 53-year-old manwas first admitted to the University Hospital in 1956.At that time, he complained of marked weaknessand recurrent attacks of abdominal pain. The pa-tient had undergone a Type II Billroth gastrectomyfor gastric ulcer in 1945. Following operation hewas asymptomatic for 2 years but since thenhas had bouts of abdominal pain, particularly inthe year prior to his admission. He was markedlyanemic with a hemoglobin of only 6 Gm.%. Fur-ther laboratory studies suggested the probabilityof malabsorption, possibly due to gastrectomy andpancreatic insufficiency, and medical therapy was

instituted to remedy this condition. However, hewas readmitted in 1958 because of pruritus, gen-eralized weakness and steatorrhea. On this admis-sion he did not give any history of abdominal pain.

FIG. 10. Case 6. Pancreatogram made througha fistulous tract in the abdominal wall. Multipleductal strictures and dilatations are shown as wellas pseudoeyst formation in the tail of the pancreas.

r.:.:So. `

FIG. 11. Case 7. Operative pancreatogram per-formed through the duodenal orifice after sphinc-terotomy shows a slightly dilated pancreatic ductin the head of the pancreas with complete obstruc-tion to dye and probe by an area of calcificationoverlying the intervertebral space between Li andL2. The duct proximal to this area of obstructionmeasured 1.5 cm. in diameter.

Physical examination was negative, but laboratoryinvestigation, which included a protein uptakestudy, again suggested the probability of pancreaticdysfunction. Laboratory studies at this time re-

vealed hemoglobin 7.7 Gm.% with macrocytosisand hypochromia. Serum amylase 225 Somogyiunits, fasting blood sugar 156 mg.%o and urinalysiswas normal. The patient was subjected to explora-tory operation in February 1958. Both the gall-bladder and bile ducts appeared normal. The duo-denal inversion had been exceedingly low andthere was an area of induration in the pancreas on

the medial aspect of the inversion. Probing of thepancreatic duct from the papilla revealed obstruc-tion in the head of the gland brought about byinflammatory reaction at the site of low duodenalinversion. A dilated main duct was palpable in thebody of the pancreas. A pancreatogram throughthis duct showed marked narrowing of the ductsin the head of the pancreas. Juice removed fromthe dilated duct contained an extremely high en-

zyme content. The obstruction was decompressedby a side to side Roux-Y jejunopancreatostomy.Pancreatic function studies in the postoperative

period showed considerable improvement. Sincedischarge he has gained weight and is now free ofhis previous symptoms.

DiscussionThese cases were selected to demonstrate

variations in the site of pancreatic duct ob-

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56 THAL, GOOTT AND MARGULIS Annals of Surgery

.....~~~~~~~~~~~~~~~~~~~~~~~~~~.I-

FIC. 12. Case 8. Operative pancreatogram per-formed through an incision in the main pancreaticduct in the body of the pancreas. There is markedattenuation of two pancreatic ducts entering theduodenum. This was brought about by inflamma-tory reaction following a low inversion of the duo-denal stump after a gastrectomy. The dye in theduodenum is largely a residual of an operativecholangiogram performed immediately prior to thepancreatograimi.

struction. Treatment was aimed at relievingthe duct obstruction, demonstrated by pan-creatogram. While the cause of pancreaticduct stricture is often obscure the effects ofsuch obstruction closely resemble the ef-fects of partial duct obstruction in otherexcretory glands. Bacterial infection prox-imal to the site of obstruction is commonlyfound when sought as shown in five of theeight cases discussed above. The role ofviral and bacterial agencies in the patho-genesis of various forms of pancreatitis maywell be a major one.

In actual practice chronic pancreatitiscommonly presents in its mildest formwhich probably results from a transientspastic or inflammatory obstruction to theorifices of the pancreatic ducts. 1-4 The clin-ical manifestations are marked only duringthe acute attack. In remission the patientmay be well or may present vague symp-toms of upper abdominal pain and flatulentdyspepsia. Gallstones are frequently pres-

ent and may well be the result as suggestedby Westphal 6 and by Wangensteen,5 andnot the cause of the altered function of thesphincter of Oddi. These patients respondwell to cholecystectomy and transduodenalsphincterotomy.The idea that cases of acute edematous

pancreatitis may progress to severe chronicpancreatitis is confirmed by the operativefindings in Case 1.The chronic stage of the disease responds

far less satisfactorily to treatment. In theadvanced stages there are multiple ductaland ductular structures. The gland is oftenchronically infected by coliform microor-ganisms. Nevertheless, prograde or retro-grade drainage, depending on the anatom-ical site of obstruction, appears to offer thebest chance of successful treatment.2 Wheresatisfactory enteric drainage of an ob-structed pancreatic duct is secured, con-siderable improvement in digestive activityhas sometimes been demonstrated. More-over, pain is often relieved.

SummaryEight cases illustrating pancreatic duct

obstruction at various anatomical sites aredescribed. The importance of using this an-atomic evidence as a guide to effective sur-gical drainage of the duct is stressed.

References1. Archibald, E.: Experimental Production of Pan-

creatitis in Animals. Surg., Gynec. & Obst.,28:529, 1919.

2. Cattel, R. B. and B. P. Colcock: Fibrosis of theSphincter of Oddi. Am. J. Surg., 137:797,1953.

3. Doubilet, H., M. H. Poppel and J. H. Mulhol-land: Pancreatography-Indications and Ob-servations. J.A.M.A., 163:1027, 1957.

4. Doubilet, H. and J. H. Mulholland: OperativeContrast Visualization of Pancreatic Disease.S. Clin. of North America, 36:385, 1956.

5. Wangensteen, 0. H.: Discussion of Papers onBiliary Tract Surgery. Am. J. Gastr., 26:284,1956.

6. Westphal, K.: Muskelfunction, Nervensystemund Pathologie Der Gallenwege. Ztschft. f.klin. Med., 96:22, 52, 95, 1923.