Current management of the gallbladder after endoscopic sphincterotomy for common bile duct stones

Background: Traditionally, a cholecystectomy is performed after successful endoscopic sphincterotomy and removal of common bile duct (CBD) stones, except in patients of advanced age or with substantial comorbidity. In practice, however, the gallbladder is left in situ more frequently now in patients without contraindications for surgery. The criteria by which patients are selected for an elective cholecystectomy are unclear. The aim of the present study was to establish the proportion of patients for whom a “wait-and-see” strategy was advised and to determine which, if any, patient characteristics had influenced this decision. Methods: This study included 71 patients, all younger than 80 years of age, with both CBD stones and a gallbladder containing stones in whom endoscopic clearance of bile duct stones was achieved. Results: Three patients underwent a cholecystectomy within 1 week because of acute cholecystitis. Among the remaining 68 patients, cholecystectomy was recommended for 42 patients and a wait-and-see strategy was advised for 26 patients. Patient characteristics were identical in both groups except for the American Society of Anesthesiologists Physical Status (ASA) score. The ASA score was higher in the wait-and-see group, but 69% of the patients in this group had an ASA score of I or II. Six patients in the wait-and-see group had symptoms; five patients underwent cholecystectomy. The outcome of surgery was no worse in this group than in the cholecystectomy group. Conclusions: Selection of patients for either elective cholecystectomy or wait-and-see was not based on established criteria but mainly dependent on preference of the specialist. The outcome of surgery, indicated in 23% of the patients in the wait-and-see group was comparable with elective cholecystectomy. A controlled trial comparing both treatment options in patients younger than 80 years of age should be performed. (Gastrointest Endosc 1997;46:514-9.)     

Sphincter of Oddi dysfunction in patients addicted to opium: an unrecognized entity

BACKGROUND: Opiate-induced sphincter of Oddi dysfunction (SOD) as a clinical entity has not been described. METHODS: Eight chronic opium addicts (all men, mean age 61.3 years, mean duration of addiction 24.75 years) presenting with pancreatobiliary pain and a dilated bile duct with or without dilated pancreatic duct on abdominal US were studied. All patients underwent ERCP and biliary sphincterotomy. In addition, pancreatic sphincterotomy was performed in 4 patients with a dilated pancreatic duct. OBSERVATIONS: At ERCP, the bile duct was dilated in 8 and pancreatic duct in 4 patients. There was delayed drainage of contrast (>45 minutes) from the bile duct in all 7 patients studied, whereas delayed drainage from the pancreatic duct (>9 minutes) was incidentally observed in 3 patients. In 6 patients followed after sphincterotomy for at least 2 years, there was marked relief of symptoms. Transabdominal US at 2 years follow-up revealed a normal bile duct in 5 and persistent albeit minimal dilatation in 1 patient. Acute pancreatitis developed in 4 patients after ERCP and sphincterotomy, which was fatal in one. No patient had any abnormality in the gallbladder on initial or follow-up transabdominal US. CONCLUSION: SOD in opium addicts is a distinct clinical entity, mainly seen in men in this population, that is characterized by a long history of opium addiction and the absence of prior cholecystectomy or associated gallstone disease. Most patients are seen with the classic clinical picture of SOD with marked long-term improvement in symptoms after endoscopic sphincterotomy.     

Classification of choledochocele

BACKGROUND/AIMS: Choledochocele is a rare abnormality of cystic or diverticular dilatation of the terminal intramural portion of the common bile duct. Because its anatomic form does not fit the criteria for pancreaticobiliary maljunction, reflux of bile or pancreatic juice has not been discussed in relation to choledochocele. Considering the flow of bile and pancreatic juice, the authors developed a new classification of choledochocele, and investigated associated pancreaticobiliary diseases. METHODOLOGY: We reviewed 82 cases of choledochocele, and classified them into three groups on cholangiopancreatographic findings; Type A (n=27): cystic dilatation of the common channel, Type B (n=31): cystic dilatation of the intramural bile duct forming the common channel, Type C (n=24): cystic dilatation of the intramural bile duct opening into the duodenum separately from the pancreatic duct. RESULTS: Biliary carcinoma was associated with 2 cases of Type A and 1 case of Type B choledochocele. Acute pancreatitis occurred in 10 Type A and 6 Type B choledochoceles. Biliary pancreatic reflux was reported in 4 cases of Type A and 1 case of Type B. Marked elevation of amylase in the bile was reported in 5 Type A and 5 Type B choledochoceles. CONCLUSIONS: In choledochoceles forming a common channel (Type A and B), two-way regurgitation may occur, and induce acute pancreatitis and biliary carcinoma. This classification of choledochocele is useful for analysis of pathophysiology and determination of therapeutic strategy.     

Endoscopic retrieval of proximally migrated biliary and pancreatic stents: experience of a large referral center

Background: Proximal migration of a biliary or pancreatic stent is an infrequent event but its management can be technically challenging. Methods: Review of all cases of proximally migrated biliary and pancreatic stents over a 10-year period at a referral pancreatic-biliary center. Data abstracted from patient records included indication for stenting, method of presentation, success of attempt, and method used. Successful methods were determined by reviewing procedure reports. Follow-up was attempted in all patients in whom stent retrieval had failed. Results: Thirty-three proximally migrated bile duct stents, and 26 proximally migrated pancreatic duct stents were identified. Most of the patients were without symptoms. Eighty-five percent of common bile duct stents and 80% of pancreatic duct stents were successfully extracted endoscopically. Seventy-one percent (34 of 48) were retrieved with a basket or balloon. Of the stents not retrieved, two patients did not return for repeat ERCP, three patients with malignant common bile duct strictures were managed with placement of a second stent, three patients with pancreatic duct stents have remained without symptoms with no further retrieval attempts, and three patients with proximally migrated pancreatic duct stents required surgery because of pain and failure of multiple endoscopic retrieval attempts. Conclusion: Over 80% of proximally migrated bile duct and pancreatic duct stents may be extracted endoscopically. Few patients will require surgery. (Gastrointest Endosc 1998;47:486-91.)     

Endoscopic Sphincterotomy for Suspected Choledocholithiasis in Patients With and Without Stones

Objective : To characterize a subgroup of patients treated with endoscopic sphincterotomy (ES) for a suspected common bile duct lithiasis (CBDL) that was not confirmed and to compare it with the subgroup with confirmed CBDL. Methods and Results : Over 18 months, ES was successful in 245 consecutive patients (age 23–97, mean 75 yr, SE 17 yr) with suspected CBDL; 159 patients had CBDL (group 1), and 86 did not (group 2), as confirmed by CBD exploration. Fifty-nine percent of the patients in group 1 and 76.7% of the patients in group 2 had gallbladder in situ . Both groups were different for age ( p < 0.001), prevalence of chronic alcoholism ( p < 0.001), gallbladder in situ ( p < 0.01), and gallbladder stones ( p < 0.05). Patients from group 1 had two or more presenting symptoms suggestive of CBDL more often than patients from group 2 ( p < 0.05), and pancreatitis was a more frequent presenting manifestation in group 2 ( p < 0.0001). Overall morbidity and mortality were not different between groups, but acute cholecystitis developed in six patients from group 2 and in one patient from group 1 ( p < 0.01). In a univariate analysis, only elevated alkaline phosphatase and a dilated common bile duct were positively discriminant for the diagnosis of CBDL; chronic alcoholism was negatively discriminant for the diagnosis of CBDL. In a multivariate analysis, only chronic alcoholism and a dilated bile duct were found to be independently discriminant. Conclusion : The risk of ES-related complications in the group without CBDL suggests that the selection of patients should be improved by a better use of preoperative criteria.     

Assessment of occult pancreatobiliary reflux in patients with pancreaticobiliary disease by ERCP

Background The aim of this study was to evaluate the degree of occult pancreatobiliary reflux by measuring the biliary amylase levels in the common bile duct (CBDA) and gallbladder (GBA) at endoscopic retrograde cholangiopancreatography (ERCP).Methods Eligible patients included 86 consecutive cases of pancreaticobiliary disease with prospective implementation of bile collection during an ERCP procedure. Patients with pancreatobiliary maljunction (PBM) were excluded. Nineteen cases of eligible patients had simultaneous collection of gallbladder bile. Bile was further collected by cholecystectomy in 8 cases.Results Twenty-two cases (26%) revealed a CBDA level higher than serum amylase (high bile amylase level, HBA group) and 64 cases exhibited a CBDA level lower than serum (LBA group). The mean values of CBDA in the HBA and LBA groups were 5502IU/l and 29IU/l, respectively. The rate of HBA was significantly higher in patients who were elderly, had a dilated common bile duct, and those with choledocholithiasis (P < 0.05). Three cases (16%) showed a CBDA greater than twice the GBA. Eleven cases (58%) exhibited a GBA higher than the CBDA. The values of GBA obtained during ERCP and cholecystectomy were consistent.Conclusions These findings suggest that even non-PBM cases can exhibit occult pancreatobiliary reflux, which can thereby cause biliary disease.     

Recurrence of biliary symptoms after endoscopic sphincterotomy for choledocholithiasis in patients with gall bladder stones

BACKGROUND: There are a few reports regarding the long-term results of endoscopic sphincterotomy (EST). However, little data is available on the recurrence of biliary symptoms after EST for choledocholithiasis, in patients with gall bladder stones. METHODS: All patients had gall bladder and common bile duct stones (n = 60; age 32-84 years, median age 55 years), and had received an EST. One group of these patients had a laparoscopic or open cholecystectomy (n = 39; group A), while the other group did not (n = 21; group B). The follow-up- period ranged from 5 to 54 months (average 22 months). RESULTS: Complications included the recurrence of common bile duct stones, recurrent acute cholecystitis, postoperative bile leakage and papillary stenosis. Nine patients (15%) had a recurrence of biliary symptoms. Two significant prognostic factors for the recurrence of biliary symptoms were identified by multivariate analysis; namely an intact gall bladder and a dilated common bile duct. The recurrence rate of biliary symptoms in group B was 20.4%, while in group A it was 10.3% (P< 0.01). Patients with a larger than average common bile duct diameter (mean diameter 14 mm) were more prone to the recurrence of symptoms than those with a smaller common bile duct diameter (mean diameter 10 mm, P< 0.016). The hospital stay period was 8.9 +/- 3.1 days in group A and 2.8 +/- 1.9 days in group B (P< 0.01). CONCLUSIONS: Biliary symptom recurrence occurred in a considerable proportion of patients after EST for the treatment of choledocholithiasis, in patients with gall bladder stones. The prognostic factors associated with the recurrence of biliary symptoms were an intact gall bladder and a dilated common bile duct diameter. Regardless of their short stay in hospital, non-cholecystectomy patients had a higher rate of recurrent biliary symptoms than cholecystectomy patients.     

Prospective evaluation of early endoscopic ultrasonography for triage in suspected choledocholithiasis: Results from a large single centre series

BackgroundEndoscopic ultrasonography is accurate, safe, and cost-effective in diagnosing common bile duct stones, thus suggesting the possibility to avoid invasive endoscopic retrograde cholangiopancreatography.AimTo prospectively evaluate the diagnostic and therapeutic performance of early endoscopic ultrasonography in suspected choledocholithiasis.Patients and methodsAll consecutive patients presenting to the Emergency Department with suspicion of choledocholithiasis between January 2010 and January 2012 were evaluated and categorized as low, moderate, or high probability of choledocholithiasis, according to accepted criteria. Endoscopic endosonography was carried out within 48 h from the admission and endoscopic retrograde cholangiopancreatography was performed soon in case of confirmed choledocholithiasis.ResultsOverall 179 patients were included: 48 (26.8%) were classified as low, 65 (36.3%) as moderate, and 66 (36.9%) as high probability of choledocholithiasis. Of the 86 patients with common bile duct stones at endoscopic endosonography, endoscopic retrograde cholangiopancreatography confirmed the finding in 79 (92%). By multivariate analysis only the common bile duct diameter proved an independent predictor of common bile duct stones.ConclusionsEarly endoscopic endosonography is accurate in identifying choledocholithiasis allowing immediate endoscopic treatment and significant spare of unnecessary endoscopic retrograde cholangiopancreatography. This approach can be useful as a triage test to select patients not needing endoscopic retrograde cholangiopancreatography, allowing, in selected cases, their early discharge.     

IgG4-related sclerosing cholangitis and autoimmune pancreatitis: histological assessment of biopsies from Vater's ampulla and the bile duct

Background and Aim: Autoimmune pancreatitis is commonly associated with immunoglobulin (Ig) G4‐related sclerosing cholangitis (IgG4‐SC). The discrimination between IgG4‐SC and pancreatobiliary malignancies or primary sclerosing cholangitis (PSC) is now an important issue. The present study was carried out to examine the usefulness of endoscopic biopsies from Vater's ampulla and the bile duct to diagnose IgG4‐SC. Methods: The present study included 29 IgG4‐SC patients (26 with both pancreatitis and cholangitis, and 3 with cholangitis only), 6 PSC patients, and 27 pancreatobiliary carcinoma patients. All patients underwent endoscopic biopsies from Vater's ampulla and the common bile duct. Biopsied specimens were histologically examined using immunostaining for IgG4. Results: For the ampullary and bile duct biopsies, the IgG4‐SC samples had a significantly greater number of IgG4‐positive plasma cells than the PSC or pancreatobiliary carcinoma specimens. In addition, bile duct biopsies from five patients (17%) with IgG4‐SC showed diffuse inflammatory cell infiltration with irregular fibrosis corresponding to the histological features of lymphoplasmacytic sclerosing pancreatocholangitis. Based on the threshold of 10 IgG4‐positive plasma cells per high power field, the diagnostic rates of the ampullar and bile duct biopsies were both 52% (15/29 cases). Twenty‐one patients (72%) had more than 10 IgG4‐positive plasma cells in at least one biopsy. The bile duct biopsy was significantly valuable for IgG4‐SC patients with swelling of the pancreatic head. Conclusion: The present study suggested that ampullar and bile duct biopsies are useful for diagnosing IgG4‐SC.     

Echo-endoscopy versus endoscopic retrograde cholangiography for the diagnosis of choledocholithiasis: the influence of the size of the stone and diameter of the common bile duct

BACKGROUND: Endoscopic retrograde cholangiography is highly accurate in diagnosing choledocholithiasis, but it is the most invasive of the available methods. Endoscopic ultrasonography is a very accurate test for the diagnosis of choledocholithiasis with a risk of complications similar to that of upper gastrointestinal endoscopy. AIM: To compare the accuracy of endoscopic ultrasonography and endoscopic retrograde cholangiography in the diagnosis of common bile duct stones before laparoscopic cholecystectomy and to analyze endoscopic ultrasound results according to stone size and common bile duct diameter. PATIENTS AND METHODS: Two hundred and fifteen patients with symptomatic gallstones were admitted for laparoscopic cholecystectomy. Sixty-eight of them (31.7%) had a dilated common bile duct and/or hepatic biochemical parameter abnormalities. They were submitted to endoscopic ultrasonography and endoscopic retrograde cholangiography. Sphincterotomy and sweeping of the common bile duct were performed if endoscopic ultrasonography or endoscopic retrograde cholangiography were considered positive for choledocholithiasis. After sphincterotomy and common bile duct clearance the largest stone was retrieved for measurement. Endoscopic or surgical explorations of the common bile duct were considered the gold-standard methods for the diagnosis of choledocholithiasis. RESULTS: All 68 patients were submitted to laparoscopic cholecystectomy with intraoperative cholangiography with confirmation of the presence of gallstones. Endoscopic ultrasonography was a more sensitivity test than endoscopic retrograde cholangiography (97% vs. 67%) for the detection of choledocholithiasis. When stones >4.0 mm were analyzed, endoscopic ultrasonography and endoscopic retrograde cholangiography presented similar results (96% vs. 90%). Neither the size of the stone nor the common bile duct diameter had influence on endoscopic ultrasonographic performance. CONCLUSIONS: For a group of patients with an intermediate or moderate risk with respect to the likelihood of having common bile duct stones, endoscopic ultrasonography is a better test for the diagnosis of choledocholithiasis when compared to endoscopic retrograde cholangiography mainly for small-sized calculi.     

Long-term follow-up after endoscopic sphincterotomy for bile duct stones in patients younger than 60 years of age

Background: Little is known about the long-term effects of endoscopic biliary sphincterotomy. Methods: We retrospectively evaluated the rate of late complications after endoscopic sphincterotomy (EST) for bile duct stones. Patients had to meet the following inclusion criteria: (1) treated between 1976 and 1980, (2) complete stone removal after EST, (3) prior cholecystectomy or elective cholecystectomy within 2 months after EST, and (4) 60 years old or younger at the time of ERCP. A total of 100 patients were identified. Information was obtained from general practitioners and patients by telephone. Patients completed a postal questionnaire and a blood sample was obtained for liver function tests. Results: Information was obtained for 94 patients (in the majority of cases [87%] from multiple sources). There were 26 men and 68 women with a mean age of 51 years at the time of ERCP (range, 23 to 60 years). Early complications (<30 days) occurred in 14 patients (15%). One patient died of a retroperitoneal perforation secondary to EST. During a median period of 15 years (range, 3 to 18 years), 22 patients (24%) developed a total of 36 late complications. There were 21 patients with symptoms of recurrent bile duct stones and one patient with biliary pancreatitis. Other late complications, such as recurrent ascending cholangitis or malignant degeneration, were not observed. An ERCP was performed in 20 of the 22 patients with late complications and demonstrated bile duct stones in 13, combined with stenosis of the EST opening in 9 patients. Late complications were initially managed endoscopically and/or conservatively. One patient underwent surgery after failed endoscopic treatment and one patient died of cholangitis before she could undergo an ERCP. Twelve other patients died of unrelated causes during follow-up. Conclusions: After EST for bile duct stones, late complications occur in a significant proportion of patients. Stone recurrence remains the most important problem, but can in general be managed endoscopically. (Gastrointest Endosc 1996;44:643-9.)     

Endoscopic ultrasound-guided gallbladder bile aspiration in idiopathic pancreatitis carries a significant risk of bile peritonitis

Background: Direct microscopic examination of bile for the presence of microlithiasis is often performed during the evaluation of patients with idiopathic pancreatitis. Bile sampled from the duodenum and/or the common bile duct may not represent gallbladder bile, and thus may be inadequate for the diagnosis of microlithiasis. Aim: We sought to determine the safety and efficacy of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) of gallbladder bile in patients with idiopathic pancreatitis. Methods: Patients with idiopathic pancreatitis underwent EUS with a linear echoendoscope. After excluding potential causes of pancreatitis such as common bile duct stones or pancreatic lesions, the gallbladder was identified. The gallbladder lumen was entered using a 22-gauge FNA needle via the duodenal wall. Bile was aspirated and analyzed for the presence of cholesterol monohydrate crystal, calcium bilirubinate granules, calcium carbonate microspheroliths and mucin gel strands. Results: Three patients underwent EUS-guided FNA of gallbladder bile. Two of these patients developed bile peritonitis within one hour of the procedure prompting us to discontinue the study. One patient's gallbladder bile contained microlithiasis. This patient had bile aspirated from the common bile duct via ERCP 3 weeks prior to EUS. However, analysis of that bile sample failed to show microlithiasis. Conclusion: Unfortunately, transduodenal EUS-guided FNA of gallbladder bile using a 22-gauge needle carries a significant risk of bile peritonitis.     

Ductal stones recurrence after extracorporeal shock wave lithotripsy for difficult common bile duct stones: Predictive factors

Background & purposeExtra-corporeal shock wave lithotripsy (ESWL) can be considered in difficult common bile duct stones (DCBDS), with a success rate greater than 90% but data on stone recurrence after ESWL are limited. We performed a retrospective analysis to evaluate long-term outcomes in patients who underwent ESWL for DCBDS.MethodsFrom May 1992 to October 2012, patients who underwent ESWL treatment for DCBDS, not amenable to endoscopic extraction, were included. Data on long-term outcome were collected through phone interviews and medical records.ResultsA total of 201 patients with a successful clearance of DCBDS after ESWL were included. During a median follow-up period of 4.64 years, 40 patients (20%) developed a recurrence of bile duct stones. Logistic regression analysis showed that the common bile duct diameter, gallstones presence and the maximum stone size were significantly associated with recurrence.ConclusionsWe observed a recurrence rate of 20% over a median follow-up of 4 years. Gallbladder stones, stone size and a dilated common bile duct diameter are risk factors for recurrent stone formation, while ursodeoxycholic acid treatment did not influence recurrence in our population.     

Sphincterotomy in patients with gallstones, elevated LFTs and a normal CBD on ERCP

BACKGROUND/AIMS: To determine whether an endoscopic sphincterotomy affects outcome in patients with symptomatic gallstones, elevated liver function tests and a normal common bile duct on endoscopic retrograde cholangiopancreatogram. METHODOLOGY: A total of 163 patients with symptomatic gallstones and elevated liver function tests, and found to have a normal common bile duct on endoscopic retrograde cholangiopancreatogram were included in the study. Endoscopic sphincterotomy was performed in 78 (47.8%) patients, while 85 (52.1%) patients did not have an endoscopic sphincterotomy. The two groups were compared for detection of small unseen common bile duct stones/debris, endoscopic retrograde cholangiopancreatogram related complications, and biliary complications after cholecystectomy. RESULTS: Small common bile duct stones/debris were recovered in 11/43 (25.5%) patients who had instrumentation of the common bile duct performed after endoscopic sphincterotomy. Common bile duct instrumentation was not performed in any of the patients without endoscopic sphincterotomy. No patient had any biliary complication after cholecystectomy, both in the immediate postoperative period and on a follow-up of 37.5 +/- 13.6 months (range 17-66). Endoscopic retrograde cholangiopancreatogram related complications occurred in 8 patients who had an endoscopic sphincterotomy and in 2 without endoscopic sphincterotomy (p < 0.05). CONCLUSIONS: Performing an endoscopic sphincterotomy in these patients increases the detection of small unseen common bile duct stones/debris without changing the clinical outcome after cholecystectomy. It also increases the endoscopic retrograde cholangiopancreatogram related complication rate, and therefore may not be necessary.     

Air in the main pancreatic duct: A case of innocent air

Air in the main pancreatic duct has been reported only rarely and might be associated with either a spontaneous or a surgically induced alteration of the anatomy of the biliary tract. We report a case of “innocent” air found incidentally in the main pancreatic duct. To our knowledge, this is only the third such case reported. A 54-year-old woman presented with hemoptysis that had lasted for 3 d. She underwent a chest computed tomography scan, which revealed not only focal bronchiectasis in the left lower lobe, but also air in the main pancreatic duct and dilatation of the common bile duct. She was managed conservatively for the hemoptysis and no further problems developed. She had no specific gastrointestinal symptoms and had no history of surgery or medication. Her laboratory parameters were normal. Magnetic resonance cholangiopancreatography also demonstrated air in the main pancreatic duct and a dilated common bile duct (CBD). Duodenoscopy revealed separate biliary and pancreatic orifices with patulous openings and some air bubbles appearing in the pancreatic orifice. Endoscopic retrograde cholangiopancreatography (ERCP) showed the dilated CBD and pancreatic duct with some air bubbles, but no other abnormal lesions. She was discharged with no further problems. Most patients with air in the main pancreatic duct have had a pancreatobiliary disease, or a history of pancreatobiliary disease, pancreatobiliary surgery or sphincterotomy. If the air is innocent, as in our case, ERCP should be performed to evaluate any altered sphincteric function or anatomy such as patulous openings.     

Guidewire cannulation increases the success rate of needle‐knife fistulotomy for difficult bile duct access

Background and Aim: Selective bile duct cannulation is a prerequisite for performing therapeutic endoscopic biliary intervention. This study aimed to evaluate if using a soft‐tipped guidewire to cannulate the bile duct would increase the success rate of needle‐knife fistulotomy for difficult bile duct access. Methods: We reviewed sixty 60 patients with difficult bile duct access who underwent conventional cannulation with radiocontrast dye (29) or guidewire cannulation (31) after needle‐knife fistulotomy. Results: There were no significant differences in the demographic data between the two groups. The initial success rate of selective bile duct cannulation was significantly higher in the guidewire cannulation group compared with the conventional cannulation group: 100% versus 79.3%, P = 0.009. The success rate of selective biliary cannulation in the patients with non‐dilated common bile duct (< 8 mm) was significantly higher in the guidewire cannulation group compared with the conventional cannulation group: 100% versus 68.4%, P = 0.003. The incidence of post‐endoscopic retrograde cholangiopancreatography pancreatitis was not significantly different between the two groups. No serious complications occurred in either group. Conclusions: In this retrospective and small case series, guidewire cannulation after needle‐knife fistulotomy increased the success rate of selective bile duct cannulation in patients with difficult bile duct access.     

Endoscopic management of a large choledochocele associated with choledocholithiasis

Choledochocele or type III choledochal cyst is a very rare lesion, defined as a cystic dilatation of the distal common bile duct protruding into the duodenal lumen. Abdominal pain, biliary disorders, and acute pancreatitis are frequently observed but malignant degeneration is rare. A 70-year-old man had a history of epigastralgia associated with abnormal liver function tests suggesting gallstones. During laparoscopic cholecystectomy, intraoperative cholangiography showed a 40-mm-diameter choledochocele associated with choledocholithiasis. A transcystic drain was placed after cholecystectomy had been completed. Endoscopic retrograde cholangiopancreatography confirmed the diagnosis and a 45-mm-long endoscopic sphincterotomy successfully treated both lesions as confirmed by a transcystic cholangiogram showing a thin-walled common bile duct with no residual stones. This case illustrates that the diagnosis of choledochocele remains difficult in clinical practice and confirms that endoscopic retrograde cholangiopancreatography is the best available diagnostic tool. Coexistent choledocholithiasis is observed in about 20% of choledochocele. Endoscopic sphincterotomy is feasible and effectively treats both lesions even in larger choledochoceles.     

Endoscopic retrograde cholangiopancreatography in elderly patients.

BACKGROUND: the presentation of common bile duct disease, value of investigations and treatment outcome in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) were assessed. METHODOLOGY: the clinical presentation, liver function tests, full blood counts, abdominal ultrasound and ERCP results were assessed retrospectively in 101 patients (59 women, 42 men; mean age 83 years, range 75-100) sequentially investigated for possible common bile duct disease. RESULTS: 59 patients had common bile duct gallstones, 35 had malignant biliary obstruction (13 with co-existing common bile duct stones) and seven had other outcomes. In the malignant-alone group 68% of those who had jaundice presented painlessly compared with 24% in the gallstones-alone group; 49% of the gallstones-alone group had pain compared with 28% of the malignant group. In the gallstones-alone group 43% had atypical presentations (non-specific symptoms or painless jaundice). Non-specific symptoms were found in 19% of the gallstones-alone group but in only 5% of the malignant group. Of the patients who had common bile duct stones, 18% had pancreatic or biliary malignancy. The co-existence of gallstones and malignancy was emphasized by eight patients in whom the clinical and ultrasound diagnosis was of common bile duct stones but malignancy was detected by ERCP. The sensitivity of ultrasound was 86% for detecting dilated common bile ducts was 86%, but only 69% for diagnosing gallstones within the common bile duct and 67% for diagnosing pancreatic masses. Ultrasound and ERCP were in agreement in 60 patients (60%). Endoscopic clearance of common bile duct gallstones was successful in 53 of 54 attempts (98%). Palliative ERCP treatment was performed in 30 patients who had malignant biliary obstruction and was successful in 22 (73%); in a further four patients (13%) an endoprothesis was successfully inserted percutaneously. The commonest complication of ERCP was cholangitis (four patients); pancreatitis and biliary perforation occurred in one patient each. Twenty-two patients (63%) who had malignancy died during follow-up, the mean survival being 11.3 weeks (range 3 days-2 years). Carcinoma of the ampulla was associated with a relatively good prognosis (three patients survived 18 months or more). CONCLUSION: in elderly patients, common bile duct stones often present atypically and co-existence with malignancy is not unusual; ampullary carcinoma has a relatively good prognosis and ERCP is a safe and effective procedure in the management of biliary obstruction.     

ERCP in patients with periampullary diverticulum

BACKGROUND/AIMS: Duodenal diverticula, discovered incidentally in patients during endoscopic retrograde cholangiopancreatography, are usually asymptomatic, but can be the source of significant morbidity. The aim of this study was to evaluate the indications for endoscopic retrograde cholangiopancreatography, the course of this procedure and complications after this procedure in patients with periampullary diverticulum. METHODOLOGY: Clinical, laboratory, ultrasonographic, and endoscopic retrograde cholangiopancreatography data of 626 patients from a single endoscopy center were retrospectively analyzed. RESULTS: The periampullary diverticulum was identified in 72 patients (11.5%). The difficulty in cannulation of papilla of Vater was encountered in 57 patients (79.2%) with diverticulum compared to 54 patients (9.7%) without diverticulum (P < 0.001). Cannulation of common bile duct was successful in 592 patients (94.6%). Cannulation of common bile duct failed in 8 patients (11.1%) with diverticulum compared to 26 patients (4.7%) without diverticulum (P = 0.046). Patients without diverticulum (n = 168, 31.9%) had two-times more often dilated common bile duct > or = 6 mm without stone on ultrasound compared to patients with diverticulum (n = 12, 17.6%) (P = 0.017). Patients with diverticulum presented 1.8-times more often with retained stone in the common bile duct than patients without diverticulum (16.7% vs. 9.7%). 17.3% of patients developed post-endoscopic retrograde cholangiopancreatography complications, which did not significantly differ in both groups. However, the patients who presented with retained common bile duct stones had higher post-endoscopic retrograde cholangiopancreatography complications (P = 0.011). CONCLUSIONS: Cannulation of the common bile duct is more difficult in patients with periampullary diverticulum and requires more skills. Periampullary diverticulum is also associated with higher risk of retained stones in the common bile duct which may lead to higher post-endoscopic retrograde cholangiopancreatography complication rate.     

p53 gene mutation and p53 protein overexpression in a patient with simultaneous double cancer of the gallbladder and bile duct associated with pancreaticobiliary maljunction

Pancreaticobiliary maljunction (PBM) is associated with the occurrence of biliary cancer due to pancreatobiliary reflux. We present a case of simultaneous double cancer of the gallbladder and bile duct. A 77-year-old woman who had jaundice, intra- and extra-hepatic biliary ductal dilatation and a space-occupying lesion in the gallbladder and lower bile duct underwent pancreatoduodenectomy. The gallbladder cancer showed papillary carcinoma without mutation of the K-ras gene and with p53 non-sense mutation of CCA (Pro) to CA (Stop) on codon 301 in exon 8. The bile duct cancer revealed a well-differentiated adenocarcinoma without mutation of the K-ras gene and with p53 miss-sense mutation of GTG (Val) to GAG (Glu) on codon 272 in exon 8. There were no mutations of either the K-ras or p53 gene in non-cancerous epithelia. In contrast, only the mucosa of the common channel had p53 protein accumulation and high cell proliferation activity. Therefore, the genetic pathway might be the same in both the gallbladder and bile duct cancer, and a high potential for carcinogenesis might be present in the epithelium of the common channel in patients with PBM.