Clinical Significance of Duodenal Papillae in Patients with Separate Orifices for Bile and Pancreatic Ducts

Abstract

Background: Separate orifices for bile and pancreatic ducts (SO) are rarely encountered and the clinical significance of SO has not been elucidated. The aim of this study was to determine the clinical significance of SO. Methods: Patients with SO that underwent endoscopic retrograde cholangiopancreatography (ERCP) as well as endoscopic biopsies of duodenal papillae were studied. Both the endoscopic features and the histopathological findings using COX-2 and ki-67 immunostaining were reviewed retrospectively. The findings of cases with SO (n=8) were compared to those without SO (n=22). Results: The features of duodenal papilla in SO cases were classified endoscopically into 3 types. Type IA: the incomplete type, in which both orifices were found within one major papilla (interposed septum); type IB: incomplete type, in which the major papilla was divided into two orifices; type II: complete type, in which a hooding fold was interposed between the two orifices. The distribution of the types was as follows: of the 8 cases with SO, 2 were type 1A, 3 were type 1B, and 3 were type II. In 1 of type IB cases and all of type II cases, papillae were located in the vicinity of the diverticula. One type IB and 2 type II cases with choledochlithiasis had a long protrusion over the orifice for the bile duct. Two type IB cases and 2 type II cases were complicated with choledochlithiasis. One type IB case was complicated with a Klaskin tumor. The endoscopic biopsy specimens showed that 4 of the 6 SO cases had papillitis in the background of plasma cell infiltration as well as epithelial hyperplasia; cases without SO had no epithelial hyperplasia. There were no significant differences between the SO cases and those without SO with respect to the intensities of the COX-2 and ki-67 labeling index. The intensities of the COX-2 staining of the SO cases tended to be stronger than those of cases without SO. The protrusions of 3 SO cases with choledochlithiasis were long and exposed over the orifice for the bile ducts. Conclusion: Patients with SO tended to have chronic papillitis in the background of epithelial hyperplasia and also the orifice for bile duct was covered with a long protrusion, both of which suggested impairment of bile duct out-flow. Our results strongly suggested that SO is a risk factor for choledochlithiasis. Background: Separate orifices for bile and pancreatic ducts (SO) are rarely encountered and the clinical significance of SO has not been elucidated. The aim of this study was to determine the clinical significance of SO. Methods: Patients with SO that underwent endoscopic retrograde cholangiopancreatography (ERCP) as well as endoscopic biopsies of duodenal papillae were studied. Both the endoscopic features and the histopathological findings using COX-2 and ki-67 immunostaining were reviewed retrospectively. The findings of cases with SO (n=8) were compared to those without SO (n=22). Results: The features of duodenal papilla in SO cases were classified endoscopically into 3 types. Type IA: the incomplete type, in which both orifices were found within one major papilla (interposed septum); type IB: incomplete type, in which the major papilla was divided into two orifices; type II: complete type, in which a hooding fold was interposed between the two orifices. The distribution of the types was as follows: of the 8 cases with SO, 2 were type 1A, 3 were type 1B, and 3 were type II. In 1 of type IB cases and all of type II cases, papillae were located in the vicinity of the diverticula. One type IB and 2 type II cases with choledochlithiasis had a long protrusion over the orifice for the bile duct. Two type IB cases and 2 type II cases were complicated with choledochlithiasis. One type IB case was complicated with a Klaskin tumor. The endoscopic biopsy specimens showed that 4 of the 6 SO cases had papillitis in the background of plasma cell infiltration as well as epithelial hyperplasia; cases without SO had no epithelial hyperplasia. There were no significant differences between the SO cases and those without SO with respect to the intensities of the COX-2 and ki-67 labeling index. The intensities of the COX-2 staining of the SO cases tended to be stronger than those of cases without SO. The protrusions of 3 SO cases with choledochlithiasis were long and exposed over the orifice for the bile ducts. Conclusion: Patients with SO tended to have chronic papillitis in the background of epithelial hyperplasia and also the orifice for bile duct was covered with a long protrusion, both of which suggested impairment of bile duct out-flow. Our results strongly suggested that SO is a risk factor for choledochlithiasis.