Upper GI 23

Abstract

Aims: Endoscopic sphincterotomy (ES) may result in bile duct malignancy in the long term: reflux of pancreatic enzymes into the bile duct may be contributory. To test this hypothesis, we assessed the degree of pancreatico-biliary reflux and associated biliary mucosal inflammation in patients with and without bile duct stones (CBDS) and after sphincterotomy. Methods: Bile was aspirated via cystic duct cannulation in 65 patients undergoing laparoscopic cholecystectomy ± ductal exploration. The quantity of chymotrypsin, lipase and amylase was measured in each sample. Comparisons were made between the following six patient groups: those with no current or previous CBDS (n = 14), patients without pancreatitis who had passed CBDS (n = 7), patients with pancreatitis with previous CBDS (n = 7), patients with current CBDS (n = 23), and patients who had undergone a previous ES, with (n = 7) and without current CBDS (n = 7). The degree of cystic duct inflammation was assessed for each patient by a histopathologist blinded to the clinical history. Results: Patients with no previous CBDS and those without pancreatitis with previous CBDS had negligible biliary concentrations of pancreatic enzymes and no cystic duct mucosal inflammation. Patients with current CBDS had mildly elevated amylase/lipase concentrations (4.1/2.2 activity units mL−1) and negligible cystic duct inflammation. In contrast, patients who had undergone ES (±CBDS) and those with recent pancreatitis had a moderate degree of cystic duct inflammation and higher amylase/lipase concentrations (24/16.2 activity units mL−1: P < 0.05 after ES; 136/61.8 activity units mL−1: P < 0.001 after pancreatitis). Chymotrypsin was only detectable in patients who had pancreatitis (6 activity units mL−1). Conclusions: High concentrations of pancreatic enzymes are only found in bile after a recent attack of acute pancreatitis and subsequent to ES: in both cases, there is associated mucosal inflammation. These changes may contribute to the late sequelae of ES.