Reflux of Bile Up the Duct of Wirsung Caused by an Impacted Biliary Calculus

Acute Pancreatitis

“…Of these, there were 30 in which the length of the diverticulum was greater than 0.5 cm. Cameron and Noble (1924), however, intro¬ duced a small biliary stone into the ampulla of Vater in fresh autopsy specimens and, by forcing fluid into the hepatic duct at a low pressure, noted that a reflux of bile into the pancreatic duct can anatomically occur in 66 per cent of normal specimens. Baldwin (1911) observed a common entrance of the ducts in 78 per cent of 90 cases, and Ruge (1908) observed it in 75 per cent of 43 cases, but Mann and Giordano (1923), working with 200 fixed specimens, concluded that in only 3.5 per cent of the cases did the junction of the ducts permit development of a common channel by obstruction at the papilla.…”

Pathogenesis of Acute Pancreatitis (Acute Pancreatic Necrosis)

“…Baldwin (1911) found that in 70 of a series of 90 cases, or 77 per cent, the ducts anastomosed before emptying into the duodenum. Cameron and Noble (1924) reported that in 75 per cent of people a calculus lodged in the ampulla could convert both ducts into a common channel and permit a reflux of bile into the pancreas. Cameron and Noble (1924) reported that in 75 per cent of people a calculus lodged in the ampulla could convert both ducts into a common channel and permit a reflux of bile into the pancreas.…”

“…The studies of Cameron and Noble (1924) were made on fresh cadavers, and the direct experiment of causing a small biliary calculus to lodge in the ampulla and then determining the patency or continuity of the bile and pancreatic ducts by making a cast of Wood's metal is convincing and should be less subject to error in interpretation than dissection observations on fixed tissues. However, even if we agree with these authors that in a majority of patients it is anatomically possible for the lodgment of a small stone to convert the common bile duct and duct of Wirsung into a common channel, it is not yet clear that bile will necessarily pass into the pancreas.…”

“…The conversion of the bile and pancreatic ducts into a common channel in the cases in which it is anatomically possible (in 75 per cent of cases in man according to Cameron and Noble, 1924) is most readily understood when a small gallstone has become impacted in the orifice of the ampulla. A difficulty arises, however, when we come to survey the literature dealing with the occurrence of such impacted calculi in cases of acute pancreatic necrosis.…”

Experimental Pancreatitis

“…They further stated that necrosis of the walls of neighboring arteries and veins transforms edematous pancreatitis into hemorrhagic pancreatitis. Archibald, 3 Cameron,4 and Opie 5 consider that obstruction at the papilla of Vater by stone or spasm with reflux of bile through a common channel into the pancreatic duct is the usual mechanism of acute pancreatitis. Thal and co-workers 6 convincingly demonstrated the effectiveness of ischemia in producing fulminant lethal hemorrhagic pan¬ creatitis; when the capillaries and ventiles of the pancreas were made to undergo throm¬ bosis by the local Shwartzman or Arthus phenomenon or were severely constricted by introduction of staphylococcic toxin through the duct, typical diffuse hemorrhagic necrosis ensued.…”