Extending the sphincterotomy

Abstract

Brand et al. prospectively studied the outcome of endoscopic sphincterotomy in 29 consecutive patients with biliary-type pain (two or more out of eight criteria), elevated liver enzyme levels (AST, ALP, or γ-glutamyltransferase), and no clear evidence of biliary pathology on transabdominal ultrasound and diagnostic endoscopic retrograde cholangiography. Elevated bilirubin levels (range = 1.3–7.2 mg/dl) were found in 18 patients. The majority of patients (n = 21) had gallbladders in situ. The findings from bile duct exploration after sphincterotomy were recorded, and pain (as measured by a visual analogue scale) and laboratory findings were assessed. The inclusion criteria for endoscopic sphincterotomy were 1) the presence of at least two of any eight characteristics associated with typical biliary-related pain (coliclike, located at the right upper abdomen, radiation to back or right shoulder, pain intensity > 4 on the visual analogue scale [possible range = 0–10], duration of pain > 30 min, postprandial pain, symptoms occurring at night, precise definition of onset and relief of pain), 2) elevated liver enzyme levels (AST, ALP, or γ-glutamyltransferase elevated more than 2-fold) in patients without histories of alcohol abuse or liver disease, and 3) absence of clear pathology on diagnostic endoscopic retrograde cholangiography—that is, no or only mild dilation of the biliary duct system (common bile duct ≤ 12 mm in patients who had undergone cholecystectomies, and ≤ 8 mm in patients with gallbladders in situ) as measured in relation to the diameter of the duodenoscope. Wire-guided sphincterotomy was successful in all patients, whereas uncomplicated pancreatitis occurred in one instance. In 16 patients (55%) there was macroscopic evidence of small stones (n = 2), sludge (n = 12), or both (n = 2) after bile duct exploration with a Dormia basket. In addition, microscopy revealed cholesterol crystals in four patients who had no macroscopic findings. All four patients with elevations of pancreatic enzymes before treatment and four of those eight patients with previous cholecystectomies demonstrated evidence of biliary pathology. The initial median pain intensity was 8 (range = 1–10); 26 patients became pain free within 3 months after endoscopic sphincterotomy. Twenty-six of 28 patients (93%) remained asymptomatic over a median follow-up period of 19 months (range = 12–26); one died of an unrelated malignancy 6 months after therapy. The authors concluded that endoscopic sphincterotomy may be acceptable therapy in patients with clinical presentations suggesting papillary or biliary origins of pain without further diagnostic workup.