The bile factor in pancreatitis

Abstract

We have investigated the bile factor in pancreatitis from two chief aspects, the anatomic and the experimental.

Anatomically, two mechanisms have been suggested whereby bile can be passed into the pancreatic duct. One is based on the possibility that an obstruction could occur at the exit of the common bile duct in a manner to convert the two ducts into a continuous channel. We studied the relationship of the common bile duct to the pancreatic duct and their mode of entrance into the duodenum in man in order to determine the percentage of instances in which there would be an anatomic basis for the foregoing hypothesis. Our data conclusively prove that the number of instances in which the anatomic arrangement in the relationship of the two ducts would permit bile to pass into the pancreatic duct is very small. The other possibility that the sphincter at the duodenal end of the common bile duct could contract and convert the two ducts into a continuous channel has been investigated. Our data show that in most instances in man the sphincter is located at a point where contraction will close both ducts and will not convert them into a continuous channel. In a very small percentage of instances a small bundle of muscle fibers is found in a position where possibly it could convert the two ducts into a continuous channel. While there is an anatomic basis for the possibility of converting the two ducts into a continuous channel, either by mechanical obstruction or possibly by the action of a sphincter muscle, the percentage of instances in which this could occur is very small.

Experimentally we followed three lines of investigation: (I) to estimate the possible pressure the existing physiologic mechanism could exert to inject bile into the pancreatic duct; this pressure we have found to be relatively low; (2) to inject sterile bile into the pancreatic duct at the maximal pressure that could occur in the common bile duct; this did not produce typical hemorrhagic pancreatitis, although definite damage of the pancreas sometimes occurred; and (3) to ligate the common bile duct in goats (a species in which the main pancreatic duct opens into the common bile duct); this does not produce acute pancreatitis.