316 THE ABDOMEN AND PELVIS 



duct and cause pancreatitis. The bile-duct narrows slightly 

 just before opening into the ampulla of Vater, and stones may 

 become impacted in this situation, but in this case the pancreas 

 is not so likely to be affected. 



Considerable variation exists in the method of termination oj 

 the pancreatic and bile ducts, (i) The two unite, but the ampulla 

 of Vater is absent. (2) The two open independently into the 

 duodenum, either on the summit of a small papilla, or at the 

 bottom of a slight depression. In this case the impaction of a 

 stone in the bile-duct does not produce symptoms of pancreatic 

 obstruction (Fig. 98). 



The pancreatic part of the bile-duct may be examined by 



in 



IV 



FIG. 98. 



-Diagrams to show the Varying Modes of Termination of the 

 Bile-Duct and the Pancreatic Duct. 



I shows the normal arrangement, with the accessory pancreatic duct 

 opening independently into the duodenum at a higher level. 



gently pressing the second part of the duodenum against the 

 right side of the vertebral column, but if the head of the pancreas 

 is enlarged and hard owing to chronic pancreatitis, great difficulty 

 may be experienced in determining whether a stone is present 

 or not. To expose this part of the duct, it is necessary to free the 

 second part of the duodenum and turn it forwards and to the 

 left (p. 306). At the same time the head of the pancreas is 

 carefully separated from the inferior vena cava and exposed to 

 view. The bile-duct is then found at the upper border of the 

 first part of the duodenum, traced downwards and freed from 

 the pancreas. At this stage some haemorrhage may occur from 

 cut branches of the superior pancreatico - duodenal vessels. 

 After removal of the stone, satisfactory drainage of the region 



