Periampullary duodenal diverticula are known to be associated with an increased incidence of common bile duct stones. The nature of the association with gallstones remains uncertain. We have examined the incidence of periampullary diverticula and stones after cholecystectomy to determine whether the stones originate primarily in the common duct or migrate from the gallbladder under the influence of abnormal biliary motility. Six hundred and forty-one patients undergoing ERCP were studied. Ninety-five patients had diverticula (14.8%). Diverticula occurred more commonly in jaundiced patients, 47/95, (48.4%) than in patients with normal bilirubin 185/546 (33.8%) (p less than 0.01). Common duct stones were associated with the presence of a diverticulum in 41/95 patients (43%), compared with only 98/546 without a diverticulum (18%) (p less than 0.001). There was no difference in the incidence of common duct stones in association with a diverticulum between those who had had a cholecystectomy 20/41, and those with intact gallbladders, 21/54 (N.S.). Thus the absence of a gallbladder did not alter the high incidence of common duct stones. We conclude that the stones in the common duct are most likely to be primary stones which have formed as a result of periampullary dysfunction.

SUMMARY Pure pancreatic juice was obtained from within the pancreatic duct in 54 patients after endoscopic cannulation of the papilla of Vater. In all 20 normal subjects there was a brisk response to intravenous injections of GIH secretin in small dosage (1 and 4 CU). Peak bicarbonate concentrations occurred after a 4 CU stimulus, whereas volumes, and bicarbonate and protein outputs were greatest after 70 CU. Total protein and amylase concentrations were highest in the first specimens collected from each patient, and fell rapidly after stimulation. Plateau levels for all indices were achieved 10-20 minutes after starting infusions of secretin and pancreozymin. When normal patients and those with chronic pancreatitis were compared, there was considerable overlap in all indices (volume, bicarbonate and total protein concentrations) after bolus injections of secretin. Most patients with chronic pancreatitis achieved a peak bicarbonate concentration in excess of 100 mmol/l. The median concentrations were not significantly different from normal after any dose of secretin when pooled 10 minute samples were analysed. However there were significant differences in peak bicarbonate concentrations (after 1 and 4 CU, but not after 70 CU), when one minute samples were compared. There were also statistically significant differences in the median 10 minute responses for volume after 1 and 70 CU, for bicarbonate output after 1, 4, and 70 CU, and for protein output after 70 CU. The results ofjuice studies in patients believed to have early chronic pancreatitis did not differ significantly from those in normal subjects or those with chronic pancreatitis. Endoscopic duct cannulation cannot guarantee complete recovery of pancreatic secretions, and measurements of volume and output may be inaccurate. When standard biochemical indices are used, the diagnostic role of pure juice studies is limited; further research may reveal more specific disease markers.Much of our knowledge of human pancreatic exocrine function has been derived from standard pancreatic function tests, which involve the collection of duodenal contents after hormone stimulation. However, recovery in such studies in unpredictable, and pancreatic juice is necessarily contaminated by bile and other secretions. The fibreoptic duodenoscope now allows deep cannulation of the papilla of Vater in conscious subjects. The technique has mainly been used for diagnostic retrograde cholangiography and pancreatography (Cotton, 1977) but also permits the collection of uncontaminated pancreatic juice (and bile) (Cotton et al., 1974). We have explored the pure pancreatic juice response to graded doses of secretin and pancreozymin in normal subjects and patients with pancreatitis.

SUMMARY Endoscopic sphincterotomy was undertaken in 186 patients with common bile duct stones and an intact gall bladder who were considered unfit for surgery. One hundred and seventy one patients had jaundice of whom 18 also had clinical cholangitis. The mean age of treated patients was 79.7 years (range 27-92) and only 13 were aged less than 60. Sphincterotomy was successful in 185 (99%) and complete clearance achieved in 172 (92.5%). Early complications occurred in nine patients (4.8%) of whom three died (1.6%). The patients have been followed on average for 32 months (range six to 72 months). Eighteen patients have subsequently required cholecystectomy (9.6%), with six major complications, but no deaths. There have been 27 natural deaths and 156 patients remain alive and symptom free. Endoscopic treatment alone is safe and effective in the majority of frail and elderly patients and can reduce the need for surgery in this high risk group.Obstructive jaundice caused by stones is a common disorder of the elderly. Many of these patients are fit for surgery and are treated successfully by operative clearance of the bile ducts. Unfortunately, the risks of surgical exploration of the bile ducts increase with age. A high morbidity in the elderly, with mortalities of up to 10%, has been described.' The gradual rise in the proportion of very elderly in the population means a growing number of patients are not good candidates for surgery. We have experienced an increasing number of referrals of patients for endoscopic removal of bile duct stones in patients with gall bladders present. The subsequent management of these patients is controversial and the need for cholecystectomy is disputed. It has been suggested that elective surgery is essential because of a high risk of subsequent cholecystitis.2' Other authors have reported low rates of late biliary surgery without many complications in patients with retained gall bladders.`7 We have, therefore, examined the long term outcome of endoscopic biliary clearance without cholecystectomy in a larger series than previously reported, to attempt to determine the role of surgery after endoscopic clearance of the biliary tree.

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We describe a patient with extensive ischaemic necrosis of the ileum as a result of elastic vascular sclerosis (EVS). A 2 cm carcinoid tumour was located nearby with microscopic evidence of spread to regional lymph nodes. Severe intestinal ischaemia caused by carcinoid associated EVS may be the presenting feature of small carcinoid tumours resulting in their early diagnosis. Carcinoid tumours which have metastasised from GI tract to liver may present with the well known carcinoid syndrome, by which time definitive treatment is usually impossible. Surveys suggest that this syndrome is found in approximately 5% of carcinoid tumours,'2 the remainder being found incidentally or presenting with symptoms referable to their site of origin. Such symptoms may be the result of small bowel obstruction (partial or complete), intussusception or bleeding. The present report describes an alternative manifestation: intestinal gangrene caused by elastic vascular sclerosis (EVS). In contrast with previous reports the present case indicates that severe intestinal ischaemia may be the result of EVS in association with a small carcinoid tumour without macroscopic spread. Case report An 85 year old woman was admitted with a one month history of intermittent nausea and vomiting after meals. These symptoms had worsened two days immediately before admission and she had developed abdominal pain, initially in the lower abdomen but subsequently generalised. Her appetite had been poor with weight loss of an indeterminate amount, probably slight. Her bowel habit had been