Characteristics of Juxtapapillary Duodenal Diverticula (JPDD) in Patients Undergoing ERCP At a Tertiary Care Center

Abstract

Characteristics of Juxtapapillary Duodenal Diverticula (JPDD) in Patients Undergoing ERCP At a Tertiary Care Center Kuldip S. Banwait, Madhusudhan R. Sanaka, Maya Spodik, Leonardo Salese, Kuntal M. Thaker, David Loren, Thomas Kowalski Juxtapapillary duodenal diverticula (JPDD) are frequently encountered at ERCP with a reported prevalence of 9-27%. While often asymptomatic, JPDD may contribute to both pancreaticobiliary pathology and influence success of papillary cannulation. Data regarding complications and success of cannulation are conflicting with few studies of large patient cohorts. We are interested in further defining the relationship between JPDD, clinical presentation, and ERCP findings in a large patient group. Aims: The aims of this study were to investigate the prevalence of JPDD in patients undergoing ERCP and to determine the association of JPDD with clinical findings at ERCP. Methods: A retrospective analysis was conducted of consecutive ERCP procedures performed during the period 20002005 at our institution. All patients with JPDD were included and compared to the cohort of all ERCP examinations. Patient demographics, clinical indication, cannulation success rate, presence of choledocholithiasis, and distortion of the bile duct secondary to the diverticulum were analyzed. Results: JPDD were present in 264 of 2787 ERCP examinations (9.5%). The mean age of patients with JPDD was 70.5 yrs in comparison to 60 years in the entire cohort. The youngest affected patient was 17 years old. The gender distribution of patients with JPDD (54.9% females) was similar to that of the overall cohort (57.3% females). In patient’s harboring JPDD, abnormal imaging study was the most common indication for ERCP (53.8%) followed by abnormal liver-associated enzymes (14.4%), pancreatitis (13.6%), and abdominal pain (7.6%). The corresponding values in the overall cohort were 11.4%, 18.6%, 12.1%, and 10.7% respectively. In 37 (14%) patients with JPDD the ampulla was located within the diverticulum and in 50 (18.9%) the papilla was on the diverticulum margin. Distortion of the distal CBD attributed to the JPDD was present in 10.7%. Cannulation success for patients with JPDD was 94.3%. Of those with unsuccessful cannulation, 3/15 had intradiverticular papilla, and in 5/15 the papilla was on the diverticulum margin. Choledocholithiasis was seen in 45.1% of patients with JPDD compared to 12.8% of all patients undergoing ERCP. Conclusions: The prevalence of JPDD approaches 10% of all patients undergoing ERCP and are more prevalent in those with advancing age. When compared to all patients undergoing ERCP, choledocholithiasis occurs fourfold more frequently in patients with JPDD. Duodenal diverticula are associated with distortion of the CBD in the minority of patients. When performed in a high-volume tertiary center, successful ERCP is achieved in the vast majority of patients with JPDD.