Juxtapapillary Duodenal Diverticula Research Articles

Multi-slice spiral computed tomography diagnosis of juxta-papillary duodenal diverticulum and its relationship with biliopancreatic diseases.

Juxta-papillary duodenal diverticula (JPDD) are common but are usually asymptomatic, and they are often diagnosed by coincidence. To analyse the anatomy and classification of JPDD and its relationship with biliary and pancreatic disorders, and to explore the diagnostic value of multi-slice spiral computed tomography (MSCT) in patients with JPDD. The imaging data of patients with JPDD, which was obtained via abdominal computed tomography examination and confirmed via gastroscopy and/or upper gastrointestinal barium enema, in our hospital from 1 January 2019 to 31 December 2020 were retrospectively analysed. All patients were scanned using MSCT, and the imaging findings, classification and grading were analysed. A total of 119 duodenal diverticula were detected in 96 patients, including 73 single diverticula and 23 multiple diverticula. The imaging findings were mainly cystic lesions of the inner wall of the duodenum protruding to the outside of the cavity. The thin layer showed a narrow neck connected with the duodenal cavity, and the shape and size of the diverticula were different: 67 central-type cases and 29 peripheral-type cases. There were 50 cases of type I, 33 cases of type II, 19 cases of type III and six cases of type IV. Furthermore, there were seven small, 87 medium and 14 large diverticula. The differences in the location and size of the JPDD in MSCT grading were statistically significant (P< 0.05). The MSCT method has an important diagnostic value for the classification of JPDD, and MSCT images are helpful in the clinical evaluation of patients with JPDD and the selection of treatment options.

Risk factors of pancreatitis after endoscopic retrograde cholangiopancreatography in patients with biliary tract diseases

BackgroundTo investigate the risk factors of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in patients with biliary tract diseases.MethodsWe retrospectively analyzed the clinical data of 480 patients who underwent ERCP for biliary tract diseases at the Affiliated Zhongshan Hospital of Dalian University from October 2011 to October 2016. The patients were divided into a study group (n = 75, with PEP) and a control group (n = 405, without PEP) based on whether they developed post-ERCP pancreatitis (PEP), and their clinical baseline data and intraoperative conditions were retrieved and compared. Then, factors associated with PEP were analyzed using logistic regression model, based on which a nomogram prediction model was constructed. The receiver operating characteristic (ROC) curve and calibration curve were used to evaluate the performance of the prediction model.ResultsSignificant differences in age, sex, history of pancreatitis, history of choledocholithiasis, pancreatic duct imaging, pancreatic sphincterotomy, difficult cannulation, multiple cannulation attempts and juxtapapillary duodenal diverticula were observed between the two groups. Multivariate logistic regression analysis showed that age less than 60 years (OR, 0.477; 95% CI, 0.26–0.855), female sex (OR, 2.162; 95% CI, 1.220–3.831), history of pancreatitis (OR, 2.567; 95% CI, 1.218–5.410), history of choledocholithiasis (OR, 2.062; 95% CI, 1.162–3.658), pancreatic sphincterotomy (OR, 2.387; 95% CI, 1.298–4.390), pancreatic duct imaging (OR, 4.429; 95% CI, 1.481–13.242), multiple cannulation attempts (OR, 2.327; 95% CI, 1.205–4.493), difficult cannulation (OR, 2.421; 95% CI, 1.143–5.128), and JPD (OR, 2.002; 95% CI, 1.125–3.564) were independent risk factors for PEP. The nomogram for predicting the occurrence of PEP demonstrated an area under the ROC curve (AUC) of 0.787, and the calibration curves of the model showed good consistency between the predicted and actual probability of PEP.ConclusionOur results showed that age less than 60 years, female sex, history of pancreatitis, history of choledocholithiasis, pancreatic sphincterotomy, pancreatic duct imaging, multiple cannulation attempts, difficult cannulation and juxtapapillary duodenal diverticula were independent risk factors for PEP. In addition, the established nomogram demonstrated promising clinical efficacy in predicting PEP risk in patients who underwent ERCP for biliary tract diseases.

Clinical Impacts of Juxtapapillary Duodenal Diverticulum Detected on Computed Tomography.

Diverticula are commonly observed in the duodenum. Duodenal Diverticulum (DD) usually does not give symptoms throughout life and is diagnosed by coincidence. However, it may present with different symptoms in patients. This study aims to evaluate the prevalence of DD and Juxtapapillary Duodenal Diverticulum (JDD) and its association with other possible pathologies and to determine its clinical impact by using Computed Tomography (CT). This retrospective observational study, which was taken consecutively between the years of 2013-2020, was evaluated in the Radiology Department. The total number of cases was 4850 (male-2440; female-2410). CT images were evaluated by two experienced radiologists at the workstation. DD and JDD prevalence and clinical findings in the hospital registry system were examined. The age of the patients included in the study ranged from 17 to 92 years (mean age 46.94±16.42). In patients with DD (female-130; male-101), mean age was 62.24 ± 12.69 (21-92). The prevalence of DD was 4.76% (n=231). The prevalence of JDD was 4.02% (n=195) and increased with age (p<0.01). The average diameter of the JDD was measured as 23.29±8.22 (9.5-55.3) mm. A significant positive correlation was found between age and DD diameter (p=0.039). DDs were found most commonly 84.42% (n=195) in the second segment of the duodenum as JDD. In patients with JDD, the mean diameter of choledochus and wirsung canal were 6.7 ± 2.4 (3-15.3) mm and 0.31 ± 0.1 (0.1-6.5) mm respectively. The choledochal diameter was correlated with the JDD size (p = 0.004). Cholelithiasis (n=56), choledocholithiasis (n=20), cholecystitis (n=52), diverticulitis (n=15), duodenitis (n=37), pancreatitis (n=5) and hiatal hernia (n=60) with JDD were observed. Periampullary carcinoma was detected in one patient. Our study shows that cholelithiasis, choledocholithiasis, cholecystitis, diverticulitis, duodenitis, pancreatitis may be associated with JDD. Therefore, in contrast-enhanced abdominal CT scans taken for various reasons, investigation of the presence and characteristics of JDD and detection of pathologies that may be associated with JDD are important for patients to benefit from early diagnosis and treatment opportunities and to take precautions against possible complications.

Juxta-papillary duodenal diverticula are associated with pyogenic liver abscesses: a case control study

BackgroundJuxta-papillary duodenal diverticulum (JPDD) has been associated with obstructive jaundice and ascending cholangitis. Potential mechanisms include periampullary colonization of pathogenic bacteria and mechanical obstruction. However, the relation of JPDD with pyogenic liver abscess (PLA) has not been reported. Moreover, approximately one third of patients with PLA have no identifiable risk factors and are labelled as “cryptogenic”. We hypothesized that JPDD is an unidentified risk factor for cryptogenic PLA and the aim of this study was to examine this association.MethodsWe conducted a retrospective chart review to identify cases of PLA (n = 66) and compare those to matched controls (n = 66). 66 patients met the study inclusion criteria of a diagnosis of PLA using computerized tomography (CT) imaging and either positive culture or confirmed resolution after antibiotic therapy. Patients with diagnoses of amebic liver abscess, traumatic liver abscess, post cholecystectomy liver abscess, concurrent acute cholecystitis, and hepatobiliary malignancy were excluded. Controls were identified from a radiology database and matched one-to-one with the cases by age and sex. Demographic and clinical data was extracted from electronic medical records. CT scan images of all cases and controls were reviewed by a single expert radiologist to identify the presence of JPDD. Statistical tests including Chi-square and t-test with multiple logistic regression were used to examine the group differences in JPDD and other factors.ResultsAmong 132 study samples, 13.6% (9/66) of the cases were found to have JPDD, compared to 3.0% (2/66) among controls (p = 0.03). This corresponded to an odds ratio (OR) of 5.05 [OR 5.05; CI 1.05–24.4] on multiple logistic regression analysis. In addition, 1/3rd of PLA cases with JPDD had no other traditional risk factors (cryptogenic PLA). However, a statistically significant association of JPDD with cryptogenic PLA could not be established possibly because of a small number of cases. We found significantly high rate of diabetes mellitus (DM) (42.4%; n = 28/66) among cases compared to controls (21.2%; n = 14/66; p = 0.01).ConclusionWe found a significant association between JPDD and PLA. We need studies with larger sample sizes to confirm this relationship and to explore if JPDD could be related to cryptogenic liver abscesses.

Treatment of Dieulafoy Lesion in Juxtapapillary Duodenal Diverticula by Monopolar Hemostatic Forceps with Soft Coagulation

Dieulafoy lesion (DL) is an uncommon cause of nonvariceal upper gastrointestinal bleeding. It is usually seen in the stomach; however, some cases have been reported within juxtapapillary duodenal diverticula (JPDD). DL in JPDD was observed in the endoscopic examination of an 85-year-old male patient who attended the hospital because of melena. The lesion was successfully treated by applying monopolar hemostatic forceps with soft coagulation (MHFSC). Despite being rare, DL can be seen in JPDD. MHFSC is effective and reliable in treating DL.

Precautionary Measures: Performing ERCP on a Patient With Juxtapapillary Duodenal Diverticula (JPDD)-Related Biliary Stone After COVID-19 Lockdown Restriction Lifted in Wuhan, China

On April 8, 2020, after nearly 3 months of battling against the outbreak of COVID-19, Wuhan, where the pandemic began, began easing lockdown restrictions. However, given that asymptomatic carriers could continue to lead to transmission of COVID-19 during the very early stages, the endoscopists have taken precautions and conduct risk assessments to perform endoscopic intervention in this transition stage. Here, we have reported an urgent ERCP in a patient with acute pancreatitis secondary to JPDD-related biliary stone. Based on our experiences, the objective is to provide practical suggestions for the safe resumption of ERCP procedures in the setting of the COVID-19 pandemic with specific focus on patient risk assessment, personal protection equipment (PPE), and dress code modalities, all of which have been implemented in our hospital to reduce the risk of viral transmission.

Evaluation of juxtapapillary duodenal diverticula using multiplanar reformation in MDCT: correlation with ERCP findings.

To determine the ability of multidetector computed tomography (MPR-MDCT) to identify and classify the juxtapapillary duodenal diverticulum (JPDD), with ERCP findings as the gold standard. We retrospectively reviewed all ERCP examinations (n: 455) performed between January 2010 to December 2018 and selected 105 patients with JPDD as the inclusion criteria. Of those, 28 patients were excluded because of advanced pancreatic carcinoma, incomplete MDCT examinations and biliary catheter insertion. Finally, MDCT examinations of 77 patients with JPDD were assessed for the presence and type of JPDD. MPR-MDCT was able to identify 71 (92.2%) JPDD in 77 cases with 88.9% accuracy, 83.3% sensitivity, and 91.6% specificity in classifying the type of JPDD. MPR-MDCT performed best in determining type 1 JPDD, with accuracy of 95.4% compared with type 2 (83.3%) and type 3 (87.8%). There was no significant difference between age, gender, incidence of biliary stones and pancreatitis between each type of JPDD. No correlation of sizes with types of JPDD was found. MPR-MDCT can accurately identify and classify JPDD. This information will be useful in determining the difficulty of ERCP.

2968 Juxta-Papillary Duodenal Diverticulum (JPDD) Are Associated With Pyogenic Liver Abscesses

INTRODUCTION: Juxta-papillary duodenal diverticulum (JPDD) has been implicated by association as a potential risk factor for ascending cholangitis. Putative mechanisms include periampullary colonization of pathogenic bacteria and mechanical obstruction. The relationship of JPDD to liver abscess has not been described. We hypothesize that JPDD is associated with pyogenic liver abscess (PLA). METHODS: We conducted an IRB approved retrospective chart review from 2008 to 2018 to identify 66 cases of pyogenic liver abscess. Inclusion criteria for the diagnosis of liver abscess included CT imaging and either culture or confirmed resolution after antibiotic therapy. A similar number of age and sex matched controls were identified who had abdominal CT scan performed for another reason. All cases and controls were reviewed by a single expert radiologist to identify the presence of JPDD. Chi square statistic was used to test our hypothesis. RESULTS: 8 out of 66 cases of PLA had JPDD compared to only 2 out of 66 controls. Chi square testing was statistically significant for association between JPDD and PLA (Chi Square statistic = 3.89; P = 0.048). CONCLUSION: JPDD has statistically significant association with PLA. This may suggest a role of JPDD in etiology of “idiopathic” liver abscesses by either mechanical effect or by increased colonization by the pathogenic bacteria.

Association of juxtapapillary duodenal diverticulum with pancreaticobiliary diseases and with diagnosis and treatment of endoscopy

Objective To study the relationship between juxtapapillary duodenal diverticulum (JPDD) and pancreaticobiliary diseases, and the effect of JPDD on the diagnosis and treatment of ERCP. Methods A retrospective analysis was performed on data of 1 230 patients who had received ERCP in general surgery departments of Shengjing Hospital of China Medical University from January 2012 to January 2017. The patients were divided into JPDD group (n=360) and non-JPDD group (n=870) according to whether JPDD was found. Patients with JPDD were divided into intradiverticular papilla group (n=41) and non-intradiverticular papilla group (n=319) according to whether the papilla located in diverticulum. The incidence of pancreaticobiliary diseases, success rate of cannulation, success rate of stones removal, and incidence of postoperative complications among each group were compared by using chi-square test or Fisher′s exact probability. P<0.05 was statistically significant. Results The incidence of choledocholithiasis, primary choledocholithiasis and recurrent choledocholithiasis were 87.78% (316/360) , 31.11% (112/360) , and 6.67% (24/360) , respectively, in the JPDD group, and 75.52% (657/870) , 19.08% (166/870) , and 4.02% (35/870) , respectively, in the non-JPDD group. There were significant differences between the two groups (χ2=23.158, P 0.05) . The incidence of recurrent choledocholithiasis in the intradiverticular papilla group and the non-intradiverticular papilla group were 14.63% (6/41) and 5.64% (18/319) , respectively, with significant difference (χ2=4.721, P=0.030) . There were no significant differences between the two groups in the incidence of choledocholithiasis and primary choledocholithiasis, the success rate of cannulation and complete stones removal during the first ERCP session, as well as the incidence of postoperative hemorrhage, pancreatitis and hyperamylasemia (all P>0.05) . Conclusion JPDD is associated with the occurrence of primary choledocholithiasis. JPDD patients, especially the patients with intradiverticular papilla, are more likely to have recurrent choledocholithiasis after ERCP treatment. Key words: Cholangiopancreatography, endoscopic retrograde; Juxtapapillary duodenal diverticulum; Intradiverticular papilla

Association Between Juxtapapillary Duodenal Diverticula and Risk of Choledocholithiasis: A Systematic Review and Meta-Analysis

1149_A Figure 1. Forest plot of this meta-analysisIntroduction:Background/Objectives: Studies have suggested that the presence of juxtapapillary duodenal diverticula (JDD) could be a predisposing factor for choledocholithiasis. JDD may interfere with biliary drainage by externally compressing the common bile duct which could predispose to bile stasis and stone formation. This systematic review and meta-analysis was conducted with the aims to summarize all available evidence to better characterize the risk. Methods: A literature search was performed using MEDLINE and EMBASE database from inception to January 2018. Cross-sectional studies that reported odd ratios (OR) comparing the risk of choledocholithiasis among individuals with JDD versus individuals without JDD were included. Pooled OR and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method. Results: Of 527 retrieved articles, 11 studies met our eligibility criteria and were included in analysis. We found a significant association between the presence of JDD and choledocholithiasis with the pooled OR of 2.30 (95% CI, 1.84-2.86). The statistical heterogeneity was moderate with an I2 of 60%. Conclusion:Conclusions: A significantly increased risk of choledocholithiasis among individuals with JDD was observed in this study.1149_B Figure 2. Funnel plot of this meta-analysis

Association Between Juxtapapillary Duodenal Diverticula and Risk of Choledocholithiasis: a Systematic Review and Meta-analysis

Background/ObjectivesStudies have suggested that the presence of juxtapapillary duodenal diverticula (JDD) could be a predisposing factor for choledocholithiasis. This systematic review and meta-analysis was conducted with the aims to summarize all available evidence to better characterize the risk. MethodsA literature search was performed using MEDLINE and EMBASE database from inception to January 2018. Cross-sectional studies that reported odd ratios (OR) comparing the risk of choledocholithiasis among individuals with JDD versus individuals without JDD were included. Pooled OR and 95% confidence interval (CI) were calculated using a random-effect, generic inverse variance method. ResultsOf 527 retrieved articles, 11 studies met our eligibility criteria and were included in analysis. We found a significant association between the presence of JDD and choledocholithiasis with the pooled OR of 2.30 (95% CI, 1.84–2.86). The statistical heterogeneity was moderate with an I2 of 60%. ConclusionsA significantly increased risk of choledocholithiasis among individuals with JDD was observed in this study.

Influence of juxtapapillary duodenal diverticulum on diagnostic and therapeutic performance of endoscopic retrograde cholangiopancreatography

Influence of juxtapapillary duodenal diverticulum on diagnostic and therapeutic performance of endoscopic retrograde cholangiopancreatography

Value of endoscopic sphincterotomy with small incision combined with balloon dilatation in the treatment of choledocholithiasis with juxtapapillary duodenal diverticula

Objective To explore the efficacy of endoscopic sphincterotomy with small incision combined with balloon dilatation (sEST+ EPBD) in the treatment of patients with choledocholithiasis and juxtapapillary duodenal diverticula (JPDD). Methods From January 2011 to January 2015, 149 patients with choledocholithiasis and JPDD who underwent endoscopic retrograde cholangio-pancreatography (ERCP) were enrolled.Among them, 60 patients were in sEST+ EPBD group and 89 were in endoscopic sphincterotomy (EST) group. Success rate of ERCP and first-time stone removal, changes of total bilirubin (TBil) and direct bilirubin (DBil) levels, as well as the incidence of postoperative complications between the two groups were compared. Chi-square test or t-test was performed for statistical analysis. Results The ERCP success rate sEST+ EPBD group was 100.0%(60/60), and the first-time success rate of stone removal was 91.7%(55/60); correspondingly, ERCP success rate of EST group was 98.9%(88/89), and the success rate of first-time stone removal was 77.5%(69/89). There was no statistically significant difference in success rate of ERCP between the two groups (χ2=0.19, P=0.410). The first-time success rate of stone removal of sEST + EPBD group was higher than that of EST group, and the difference was statistically significant (χ2=5.53, P=0.020). After operation, the TBil level of sEST+ EPBD group was (152.62±109.04) μmol/L, which was lower than that before operation ((266.02±143.31) μmol/L), and the difference was statistically significant (t=4.88, P<0.01). After operation, the DBil level of sEST + EPBD group was (87.13±65.90) μmol/L, which was lower than that before operation ((175.70±100.53) μmol/L), and the difference was statistically significant (t=5.71, P<0.01). After operation, the TBil level of EST group was (251.90±247.90) μmol/L, which was lower than that before operation ((340.20±176.20) μmol/L), and the difference was statistically significant (t=2.74, P<0.05). After operation, the DBil level of EST group was (168.10±140.60) μmol/L, which was lower than that before operation ((228.40±139.60) μmol/L), and the difference was statistically significant (t=2.87, P=0.005). The complication rate of sEST+ EPBD group after operation was 8.3%(5/60), which was lower than that of EST group (20.2%, 18/89), and the difference was statistically significant (χ2=3.88, P=0.049). Conclusion sEST+ EPBD could increase the first-time success rate of stone removal in patients with choledocholithiasis and JPDD, and it is a safe and effective treatment. Key words: Choledocholithiasis; Juxtapapillary duodenal diverticula; Endoscopic sphincterotomies; Balloon dilatation

Perforation of the Papilla of Vater in Wire-Guided Cannulation.

Background. WGC in ERCP is considered a safe technique, although rare complications can occur. One unique complication of WGC is the perforation of the papilla of Vater by the guidewire. Subjects and Methods. Of 2032 patients who underwent ERCP at our department between January 2010 and December 2014, we selected 208 patients who underwent WGC for naïve papilla as subjects. A detailed examination of patients in whom a perforation occurred was conducted, and risk factors for perforations were investigated. Results. The perforation was observed in 7 of 208 patients (3.4%). All patients recovered with conservative treatment without the need for surgery. The perforation rate was significantly higher in the patients with juxtapapillary duodenal diverticula than those without diverticula (12.5% versus 0.6%, p < 0.001). Cannulation of the bile duct was ultimately achieved in 5 of 7 patients; PSP was performed for 4 of these patients. Conclusion. Caution must be exercised when dealing with patients who have a juxtapapillary duodenal diverticula because they are at higher risk of perforations. Because these are small perforations made by a wire, most of them heal with conservative treatment. However, perforations can make cannulation difficult, and PSP may be useful for deep cannulation.

Differences in Clinical Characteristics between Juxtapapillary Duodenal Diverticulum and Intradiverticular Papillae

Differences in Clinical Characteristics between Juxtapapillary Duodenal Diverticulum and Intradiverticular Papillae

傍乳頭憩室内結石の小腸への落下によりイレウスを来した1例

傍乳頭憩室内結石の小腸への落下によりイレウスを来した1例

Analysis on the risk factors of multiple recurrent common bile duct stones after endoscopic treatment

Objective To investigate the risk factors of multiple recurrent bile duct stones in patients with common bile duct (CBD) stones and received endoscopic sphincterotomy (EST) treatment. Methods From June 1st, 2007 to June 1st, 2011, the patients received EST treatment were followed up, the follow-up time was three to seven years. A total of 2 738 patients were successfully followed up, including 24 patients with two or more than two times of recurrent bile stone after EST who were enrolled in multiple recurrence group. One hundred patients without recurrence were randomly selected by table of random number as control group. The clinical data of two groups were compared by t test or Chi-square test. The factors were analyzed with multivariate Logistic regression analysis and try to find out the risk factors of multiple recurrence. Results The comparative analysis between two groups showed that the three factors of juxtapapillary duodenal diverticula [17.0%(17/100) vs 41.7%(10/24)], history of biliary tract surgery [13.0%(13/100) vs 45.8%(11/24)] and the angle enclosed between the horizontal portion of the CBD and the horizontal plane (angleofbile duct) less than 45° [2.0%(2/100) vs 20.8%(5/24)] were statistically significant (χ2=6.914、13.37、9.595, all P<0.01). Furthermore, logistic regression analysis indicated that juxtapapillary duodenal diverticula (B=1.421, OR=4.142, P=0.01), history of biliary tract surgery (B=1.612, OR=5.011, P=0.004) and the angle of bile ductless than 45°(B=2.661, OR=14.31, P=0.005) were risk factors of multiple recurrence. Conclusion Juxtapapillary duodenal diverticula, history of biliary tract surgery, and the angle of bile duct less than 45° are independent risk factors of multiple recurrence of CBD stones. Key words: Cholangiopancreatography, endoscopic retrograde; Sphincterotomy, endoscopic; Choledocholithiasis; Multiple recurrence; Risk factors

Carcinoma of the ampulla of Vater diagnosed after surgical treatment for Lemmel’s syndrome

Lemmel's syndrome encompasses a range of conditions in which a juxtapapillary duodenal diverticulum exerts mechanical and functional effects on the common bile and pancreatic ducts, leading to jaundice and pancreatitis. In this report, we describe a very rare case of carcinoma of the ampulla of Vater that was detected during postoperative follow-up in a patient who had undergone choledochojejunostomy following a diagnosis of Lemmel's syndrome. We present our clinical and pathological experiences with the diagnosis and treatment of this case as well as a review of the present literature concerning Lemmel's syndrome.

The therapeutic effect of endoscopic papillary large–balloon dilation for juxtapapillary duodenal diverticulim combined with large common bile duct stones

Objective To investigate the effectiveness and safety of endoscopic papillary large–balloon dilation(EPLBD) for juxtapapillary duodenal diverticulum(JPD)combined with large common bile duct stones. Methods A total of 87 patients with juxtapapillary duodenal diverticulum and large common bile duct stones were randomly divided to 2 groups. Forty–five cases received endoscopic papillary large–balloon dilation(EPLBD group) as the treatment group, and 42 cases were treated by conventional endoscopic sphincterotomy(EST group) as the control group. The success rate of stone clearance in a single session, operation time, the rate of mechanical lithotripsy and complications were observed. Results Stone clearance in a single session of 2 groups were 91.1%(EPLBD group)and 92.9%(EST group) respectively with no significant difference(P>0.05). The stone removal time were(25.48±7.92)min in EPLBD group and(35.56±9.23)min in EST group(P 0.05). No death happened in any group. Conclusion EPLBD is a safe and effective method for clearance of large common bile duct stones combined with juxtapapillary duodenal diverticulum which can reduce the occurrence of mechanically breaking stone and operation time. Key words: Choledocholithiasis; Juxtapapillary duodenal diverticulim; Sphincterotomy; Ballon dilatation

The clinical importance of different localizations of the papilla associated with juxtapapillary duodenal diverticula.

Previous studies have evaluated the presence of juxtapapillary duodenal diverticula (JPDD) and the association with pancreatobiliary disease, but not the association of the papilla with an existing JPDD. We investigated the association of different localizations of the papilla with JPDD. We studied patients in whom JPDD was detected during endoscopic retrograde cholangiopancreatography. Patients were classified into 3 groups: 1) papilla located inside the diverticulum, 2) papilla located at the edge of the diverticulum and 3) papilla located closer than 3 cm to the diverticulum. The patients were examined with respect to localization of papilla-diverticula and to the association of the localization with pancreaticobiliary disease. We enrolled 274 patients in our study. Biliary stone disease more frequently existed in group 3. The number of patients presenting with obstructive jaundice was higher in groups 2 (83.6%) and 3 (83.3%) than group 1 (66%). Cholangitis was more common in group 1 (21.3%) than in groups 2 (6.7%) and 3 (2.3%). The presence of biliary stone disease among patients presenting with pancreatitis was significantly different between groups 1 and 3 (p = 0.013) and between groups 2 and 3 (p = 0.017). The common bile duct more frequently contained stones or sludge in group 3 than in groups 1 and 2. When the papilla is located close to the JPDD, the incidence of biliary stone disease decreases, and pancreatobiliary diseases are caused mostly in the absence of biliary stone disease.