PANCREATIC OUTFLOW OBSTRUCTION AS THE CRITICAL EVENT FOR HUMAN GALL STONE INDUCED PANCREATITIS

Opie suggested in 1901 that a common channel between the pancreatic du ct and the common bile duct is created when a gall stone becomes impac ted at the duodenal papilla. He proposed that bile would regurgitate i nto the pancreas and trigger pancreatitis. The case is reported of a 2 2 year old woman with an impacted stone at the duodenal papilla creati ng a common channel. The patient suffered from acute pancreatitis. Thr ee days before the onset of pancreatitis, however, a T drain had been inserted into the common bile duct from which bile had been flowing fr eely and continuously. Moreover, amylase activity in fluid from the T drain was 49 000 U/l at the onset of pancreatitis pointing to reflux o f pancreatic juice into the biliary tract. The amylase activity in bil e decreased rapidly after endoscopic papillotomy and retrieval of the stone. The events participating in the development of acute gall stone induced pancreatitis in this patient with a common channel situation permitted reflux of pancreatic juice into the biliary tract rather tha n bile into the pancreas. Impairment of pancreatic outflow by a gall s tone was probably the primary triggering event, rather than the regurg itation of bile into the pancreas. Preventive or therapeutic treatment in gall stone pancreatitis should be aimed at the urgent restoration of pancreatic flow rather than at the prevention of a hypothetical bil e reflux.