A case of common bile duct stones with the complete separated orifices of commen bile duct and main pancreatic duct, successfully treated by endoscopic sphincterotomy (EST)

Abstract

A 79-year-old male was admitted to our hospital because of upper abdominal pain. He was diagnosed to have acute cholangitis due to choledocholithiasis, according to the results of blood tests, ultrasonography and abdominal CT. Endoscopic examination showed 2 separated papillae which had individual orifices, and a duodenal diverticulum was identified close to the oral side of the papillae. Endoscopic retrograde cholangiopancreatography (ERCP) revealed separated openings of common bile duct (CBD) and main pancreatic duct (MPD) . The opening of CBD was located on the oral side of that of MPD. According to these findings, he was also diagnosed as having the completely separated orifices of CBD and MPD, which could be differentiated from choledochoduodenal fistula. Endoscopic retrograde cholangiography (ERC) revealed several stones, 11 mm maximum in diameter, in the CBD. EST was performed safely, and CBD stones were thoroughly removed by means of endoscopic mechanical lithotripsy (EML) . No complications occurred after the removal of stones by EST and EML. The orifice of CBD separated from that of the pancreatic duct is seldom encountered, and was reported to exist with a frequency of fewer than 4% in Japan. Differentiation of the condition from choledochoduodenal fistula is necessary because the incision range during EST is basically different between these two conditions. The present experience indicates that EST is useful and safe for the treatment of CBD stones in the patients with the complete separated orifices of CBD and MPD, if it is possible to be differentiated from choledochoduodenal fistula and the orifice of CBD is not located inside the diverticulum.