Patients with Ectopic Papilla of Vater, Bulbar Stenosis and Choledocholithiasis: A New Syndrome?

Abstract

Introduction: Ectopic localization of papilla of Vater and/or stenosis at duodenal bulb may cause challenges in the cannulation of papilla and the endoscopic treatment of the biliary diseases. Twelve patients with biliary stones, stenosis and deformity at the duodenal bulb, and papilla ectopically located at duodenal bulb or junction of the first and second parts of the duodenum; and their endoscopic management are presented here. Patients All of the patients were male, median age was 46 (35-52). In eight (%67) of the patients, there were accompanying stones in the gall bladder. One of the patients was diagnosed as secondary biliary cirrhosis. In none of the patients, there were symptoms related to duodenal stenosis. In 9 (%75) of the 12 patients the duodenoscope could not be advanced beyond the bulbus into descending duodenum because of the mechanical obstruction and deformity. The stenotic parts in the bulbus were dilated with TTS balloons with diameters ranging from12 to18 mm. Thus, ectopic papillae could be reached in all of the cases. Papilla could not be cannulated in one patient (%8) and in the remaining 11 cases, biliary stones ranging from 6 to 14 mm were detected with cholangiography. Since the site of the sphincterotomy and distal common bile duct (CBD) indentation could not be evaluated, papillary orifice and distal CBD were dilated with balloons starting from a 4 mm diameter and increasing the diameter of the balloons stepwise to 4 to 15 mm. In 6 (%50) of the patients, the stones could be extracted in the same endoscopy session with the cholangiography. In 3 (%25) of the patients, stones could be extracted in a second session and in the remaining 3 (%25), the endoscopic treatment for the biliary stones had failed. In one of the patients, after dilatation of CBD with a 12 mm balloon, retroperitoneal perforation in the intrapancreatic segment of the CBD occured and he was operated. No other major complication occured. Conclusion The shared features which may constitute a new syndrome of the presented cases are 1) male gender 2) ectopic location of the papilla 3) deformity and stenosis in the bulbus 4) presence of stones in the CBD. Bile duct stones can be treated with endoscopic balloon dilatation of distal CBD and papilla, bearing in mind that a serious complication such as perforation might be encountered. Introduction: Ectopic localization of papilla of Vater and/or stenosis at duodenal bulb may cause challenges in the cannulation of papilla and the endoscopic treatment of the biliary diseases. Twelve patients with biliary stones, stenosis and deformity at the duodenal bulb, and papilla ectopically located at duodenal bulb or junction of the first and second parts of the duodenum; and their endoscopic management are presented here. Patients All of the patients were male, median age was 46 (35-52). In eight (%67) of the patients, there were accompanying stones in the gall bladder. One of the patients was diagnosed as secondary biliary cirrhosis. In none of the patients, there were symptoms related to duodenal stenosis. In 9 (%75) of the 12 patients the duodenoscope could not be advanced beyond the bulbus into descending duodenum because of the mechanical obstruction and deformity. The stenotic parts in the bulbus were dilated with TTS balloons with diameters ranging from12 to18 mm. Thus, ectopic papillae could be reached in all of the cases. Papilla could not be cannulated in one patient (%8) and in the remaining 11 cases, biliary stones ranging from 6 to 14 mm were detected with cholangiography. Since the site of the sphincterotomy and distal common bile duct (CBD) indentation could not be evaluated, papillary orifice and distal CBD were dilated with balloons starting from a 4 mm diameter and increasing the diameter of the balloons stepwise to 4 to 15 mm. In 6 (%50) of the patients, the stones could be extracted in the same endoscopy session with the cholangiography. In 3 (%25) of the patients, stones could be extracted in a second session and in the remaining 3 (%25), the endoscopic treatment for the biliary stones had failed. In one of the patients, after dilatation of CBD with a 12 mm balloon, retroperitoneal perforation in the intrapancreatic segment of the CBD occured and he was operated. No other major complication occured. Conclusion The shared features which may constitute a new syndrome of the presented cases are 1) male gender 2) ectopic location of the papilla 3) deformity and stenosis in the bulbus 4) presence of stones in the CBD. Bile duct stones can be treated with endoscopic balloon dilatation of distal CBD and papilla, bearing in mind that a serious complication such as perforation might be encountered.