RESUMO
Heterotopic pancreas is a rare congenital abnormality. The most common location is the stomach, duodenum and proximal jejunum. Rare locations are represented by the ampulla of Vater, esophagus, ileum, Meckel diverticulum, biliary tract, mesentery and spleen. We present the case of a 49 year old patient investigated for obstructive jaundice and diagnosed with an ampullar heterotopy of pancreas parenchyma, initially considered to be a malignant tumor. A Whipple pancreatoduodenectomy was performed with good postoperative evolution, the serum levels of bilirubin being normal after the first postoperative week.
Assuntos
Ampola Hepatopancreática , Coristoma , Icterícia Obstrutiva , Pâncreas , Pancreaticoduodenectomia , Humanos , Ampola Hepatopancreática/cirurgia , Icterícia Obstrutiva/etiologia , Icterícia Obstrutiva/cirurgia , Icterícia Obstrutiva/diagnóstico , Coristoma/complicações , Coristoma/cirurgia , Coristoma/diagnóstico , Pancreaticoduodenectomia/métodos , Pessoa de Meia-Idade , Resultado do Tratamento , Diagnóstico Diferencial , Masculino , Doenças do Ducto Colédoco/cirurgia , Doenças do Ducto Colédoco/diagnóstico , Doenças do Ducto Colédoco/complicaçõesRESUMO
BACKGROUND: Chronic cough is characterized by cough as the only or main symptom, with a duration of more than 8 weeks and no obvious abnormality in chest X-ray examination. Its etiology is complex, including respiratory disease, digestive system disease, circulation system disease, and psychological disease. Although a set of etiological diagnosis procedures for chronic cough have been established, it is still difficult to diagnose chronic cough and there are still some patients with misdiagnosis. CASE PRESENTATION: We present a case of a 54-year-old female patient who had chronic cough for 28 years. Physical examination had no positive signs and she denied any illness causing cough like tuberculosis, rhinitis. Recurrent clinic visits and symptomatic treatment didn't improve the condition. Finally, gastroscopy identified the possible etiology of choledochoduodenal fistula that was proved by surgery. And after surgery, the patient's cough symptoms were significantly improved. CONCLUSION: We report a rare case of chronic cough caused by choledochoduodenal fistula which demonstrates our as yet inadequate recognition of the etiology and pathogenesis. Written informed consent was obtained from the patient.
Assuntos
Fístula Biliar/diagnóstico , Doenças do Ducto Colédoco/diagnóstico , Tosse/etiologia , Duodenopatias/diagnóstico , Fístula Intestinal/diagnóstico , Fístula Biliar/cirurgia , Colangiopancreatografia por Ressonância Magnética , Doença Crônica , Doenças do Ducto Colédoco/cirurgia , Duodenopatias/cirurgia , Feminino , Gastroscopia , Humanos , Fístula Intestinal/cirurgia , Pessoa de Meia-Idade , Resultado do TratamentoAssuntos
Ampola Hepatopancreática/cirurgia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Doenças do Ducto Colédoco/cirurgia , Divertículo/cirurgia , Duodenopatias/cirurgia , Icterícia Obstrutiva/cirurgia , Esfinterotomia Endoscópica/métodos , Idoso de 80 Anos ou mais , Colangite/etiologia , Doenças do Ducto Colédoco/complicações , Divertículo/complicações , Duodenopatias/complicações , Feminino , Humanos , Icterícia Obstrutiva/etiologia , TraçãoRESUMO
INTRODUCTION: Endoscopic and open surgical interventions are widely implemented as the standard practice in common bile duct exploration. However, the laparoscopic approach has been also reported to have comparative/superior outcomes in this concept. This has created an ongoing debate about the ideal approach to adopt in practice. METHODS: A systematic review of the published evidence over the last decade that has looked into the outcomes of laparoscopic exploration of the common bile duct through transductal and transcystic approaches. RESULTS: Our systematic review included 36 relevant papers. The majority were based on nonrandomized protocols conducted in single centers with high expertise. The data analysis showed that laparoscopic common bile duct exploration through both approaches was successful in more than 84% of the patients, with an average length of hospital stay of 5.6 days. Conversion to open surgery was reported in 5%-8% of the patients, and the bile leak rates from the more recent studies was 0%-12%, with mortality figures of 0%-1.3%. The outcomes were statistically in favor of the transcystic route when compared to the transductal route from the viewpoints of bile leak rates, mean operative time, duration of hospital stay and morbidity. CONCLUSION: In experienced hands, both laparoscopic approaches in common bile duct exploration are safe in patients who are clinically fit to have this intervention. It is associated with a statistically significant lower overall morbidity and shorter duration of hospital stay when compared to open surgery. Relevant up-to-date high-quality randomized trials are unavailable.
Assuntos
Doenças do Ducto Colédoco/diagnóstico por imagem , Doenças do Ducto Colédoco/cirurgia , Ducto Colédoco/diagnóstico por imagem , Ducto Colédoco/cirurgia , Laparoscopia/métodos , Humanos , Resultado do TratamentoRESUMO
OBJECTIVE: Common bile duct stone (CBDS) recurrence is associated with bile microbial structure. This study explored the structure of bile microbiome in patients with recurrent CBDS, and its relationship with the recurrence of CBDS. METHODS: Patients with recurrent CBDS (recurrence group) and controls without CBDS (control group) requiring endoscopic retrograde cholangiopancreatography (ERCP) were prospectively included. The control group was noncholelithiasis patients, mainly including benign and malignant biliary stenosis. Bile samples were collected, and bile microbiome structure was analyzed by the 16S rRNA encoding gene (V3-V4). RESULTS: A total of 27 patients in the recurrence group and 19 patients in the control group were included. The diversity of bile microbiome in the recurrence group was significantly lower than that in the control group (Shannon index: 2.285 vs. 5.612, P = 0.001). In terms of bile microbial distribution, patients with recurrent CBDS had significantly higher Proteobacteria (86.72% vs. 64.92%, P = 0.037), while Bacteroidetes (3.16% vs. 8.53%, P = 0.001) and Actinobacteria (0.29% vs. 6.74%, P = 0.001) are significantly lower compared with the control group at the phylum level. At the genus level, the recurrence group was mainly the Escherichia, and there was a variety of more evenly distributed microbiome in the control group, with significant differences between the two groups. CONCLUSION: The diversity of bile microbiome in patients with recurrent CBDS is lower. Patients with recurrent CBDS may have bile microbial imbalance, which may be related to the repeated formation of CBDS.
Assuntos
Bile/microbiologia , Doenças do Ducto Colédoco/epidemiologia , Cálculos Biliares/epidemiologia , Microbiota/genética , Adulto , Idoso , Idoso de 80 Anos ou mais , Colangiopancreatografia Retrógrada Endoscópica , Doenças do Ducto Colédoco/patologia , Doenças do Ducto Colédoco/cirurgia , DNA Bacteriano/genética , Disbiose/microbiologia , Feminino , Cálculos Biliares/patologia , Cálculos Biliares/cirurgia , Variação Genética/genética , Humanos , Masculino , Pessoa de Meia-Idade , RNA Ribossômico 16S/genética , RecidivaRESUMO
The review is withdrawn as it has not been maintained since its first publication in 2001 (searches date back to the year 2000). Since then, new trials have been published that may or may not change the conclusions of the review. A new team of authors overtook the review on 26.10.2020, and the new review is expected to be published by the beginning of 2022. The review will be prepared based on most recent Cochrane methods. Readers may still find the outdated review on the CDSR (the Cochrane Library).
Assuntos
Doenças do Ducto Colédoco/cirurgia , Esfíncter da Ampola Hepatopancreática/cirurgia , Esfincterotomia/métodos , Intervalos de Confiança , Humanos , Razão de Chances , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
Fasciolopsis buski, also called the giant intestinal fluke, is the largest intestinal fluke of the zoonotic trematode parasites and found mainly in Southeast Asian countries, including China. Fasciolopsis buski infection was formerly a common health problem in many countries, but it is now rare. Typically, it can be cured by oral drugs, but some infected patients need surgical intervention because of the severity of their condition or because of an unclear diagnosis or even misdiagnosis. Here, we report a case of a 15-year-old girl from Guizhou Province, China, presenting with recurrent upper-middle abdominal pain that was misdiagnosed as a choledochal cyst. Through laparotomy combined with postoperative histopathological examination, the source of the pain was proven to be mechanical biliary obstruction caused by F. buski infection. In the past, mechanical obstruction, especially biliary obstruction, caused by F. buski infection leading to surgery was not uncommon, but it is very rare in modern society. Moreover, delayed treatment and misdiagnosis of parasitic infection can lead to severe consequences. Therefore, we reviewed the previous literature on F. buski infection treated by surgical operation and summarized the characteristics and therapeutic strategies of these cases to raise clinicians' awareness of this rare infection.
Assuntos
Colestase/cirurgia , Doenças do Ducto Colédoco/cirurgia , Infecções por Trematódeos/cirurgia , Dor Abdominal , Adolescente , Animais , Anti-Helmínticos/uso terapêutico , Colangiopancreatografia por Ressonância Magnética , Colangite/diagnóstico , Cisto do Colédoco/diagnóstico , Colestase/diagnóstico , Colestase/etiologia , Doenças do Ducto Colédoco/diagnóstico , Doenças do Ducto Colédoco/etiologia , Diagnóstico Diferencial , Fasciolidae , Feminino , Humanos , Laparotomia , Praziquantel/uso terapêutico , Infecções por Trematódeos/diagnóstico , Infecções por Trematódeos/tratamento farmacológico , UltrassonografiaRESUMO
The ampulla of Vater gives rise to a versatile group of cancers of mixed/hybrid histologic phenotype. Ampullary carcinomas (ACs) are most frequently intestinal or pancreatobiliary adenocarcinomas but other subtypes, such as medullary, mucinous, or signet ring/poorly cohesive cell carcinoma, may be encountered. Ampullary cancer can also be subclassified based on immunohistochemical features, however these classification systems fail to show robust prognostic reliability. More recently, the molecular landscape of AC has been uncovered, and has been shown to have prognostic and predictive significance. In this article, the site-specific, histologic, and genetic characteristics of ampullary carcinoma and its precursor lesions are discussed.
Assuntos
Ampola Hepatopancreática/patologia , Ampola Hepatopancreática/cirurgia , Biópsia , Doenças do Ducto Colédoco/diagnóstico , Doenças do Ducto Colédoco/patologia , Doenças do Ducto Colédoco/cirurgia , Neoplasias do Ducto Colédoco/diagnóstico , Neoplasias do Ducto Colédoco/patologia , Neoplasias do Ducto Colédoco/cirurgia , Diagnóstico Diferencial , Humanos , Estadiamento de NeoplasiasAssuntos
Fístula Biliar/cirurgia , Colangite/etiologia , Doenças do Ducto Colédoco/cirurgia , Duodenopatias/cirurgia , Fístula Intestinal/cirurgia , Fístula Biliar/diagnóstico , Colangiopancreatografia Retrógrada Endoscópica , Doenças do Ducto Colédoco/diagnóstico , Duodenopatias/diagnóstico , Humanos , Fístula Intestinal/diagnóstico , Masculino , Pessoa de Meia-IdadeRESUMO
Research conclusions differ on the impact of periampullary diverticulum (PAD) on endoscopic retrograde cholangiopancreatography (ERCP). An up-to-date meta-analysis evaluated the role of PAD in ERCP, especially in terms of cannulation failure and early complications. A comprehensive literature search was performed. All statistical analyses were carried out with the Review Manager 5.3 software. Horizontal lines represented a 95% confidence interval (CI) and the area of each square in forest plots. Twenty-six studies including 23 826 patients with or without PAD who underwent ERCP were evaluated. PAD was associated with an increase in the overall cannulation failure rate (RR=1.46, 95% CI: 1.27-1.67; p<.00001), but in the subgroup of studies performed post-2000, PAD was irrelevant to cannulation failure (RR=1.16, 95% CI: 0.96-1.41; p=0.12). In overall analyses, PAD was also associated with a high risk of ERCP-related pancreatitis (RR=1.32, 95% CI: 1.10-1.59; p=0.003), perforation (RR=1.73, 95% CI: 1.06-2.82; p=0.030), and bleeding (RR=1.48, 95% CI: 1.13-1.93; p=0.005). The presence of PAD increased the overall cannulation failure rate, but not the rate post-2000. PAD also affected the occurrence of early pancreatitis, perforation, and bleeding.
Assuntos
Ampola Hepatopancreática/cirurgia , Cateterismo/efeitos adversos , Colangiopancreatografia Retrógrada Endoscópica/efeitos adversos , Doenças do Ducto Colédoco/complicações , Divertículo/complicações , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Ampola Hepatopancreática/patologia , Doenças do Ducto Colédoco/patologia , Doenças do Ducto Colédoco/cirurgia , Divertículo/patologia , Divertículo/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
INTRODUCTION: Spontaneous perforation of the common bile duct is rare. The cause is usually unknown, although it is sometimes related to the malformation of the bile duct. CLINICAL CASE: Female of 1 year, with abdominal distention, hyporexia and fever, tomography with ascites, surgical findings included retroperitoneal bilioma, peritonitis and perforation of common bile duct. Block resection and primary hepato-duodenal anastomosis were performed. DISCUSSION: Spontaneous perforation of the common bile duct tend to evolve insidiously and delay in diagnosis is frequent. Surgical management is decisive, and there are different techniques described. CONCLUSION: A high index of suspicion is important, treatment must be individualized according to each patient.
INTRODUCCIÓN: La perforación espontánea del colédoco es rara. La causa generalmente se desconoce, aunque en ocasiones guarda relación con una malformación de la vía biliar. CASO CLÍNICO: Niña de 1 año, con distensión abdominal, hiporexia y fiebre, tomografía con ascitis, se interviene y se encuentra bilioma retroperitoneal, peritonitis y perforación de colédoco. Se realiza resección en bloque y anastomosis hepatoduodenal primaria. DISCUSIÓN: La perforación espontánea del colédoco tiende a evolucionar insidiosamente y el retraso en el diagnóstico es frecuente. El manejo quirúrgico es resolutivo; existen distintas técnicas descritas. CONCLUSIÓN: Es importante un alto índice de sospecha. El tratamiento se debe individualizar en cada paciente.
Assuntos
Doenças do Ducto Colédoco/cirurgia , Perfuração Espontânea/cirurgia , Feminino , Humanos , LactenteRESUMO
OBJECTIVE: The aim of the study was to define histopathologic characteristics that independently predict overall survival (OS) and disease-free survival (DFS), in patients who underwent resection of an ampullary adenocarcinoma with curative intent. SUMMARY BACKGROUND DATA: A broad range of survival rates have been described for adenocarcinoma of the ampulla of Vater, presumably due to morphological heterogeneity which is a result of the different epitheliums ampullary adenocarcinoma can arise from (intestinal or pancreaticobiliary). Large series with homogenous patient selection are scarce. METHODS: A retrospective multicenter cohort analysis of patients who underwent pancreatoduodenectomy for ampullary adenocarcinoma in 9 European tertiary referral centers between February 2006 and December 2017 was performed. Collected data included demographics, histopathologic details, survival, and recurrence. OS and DFS analyses were performed using Kaplan-Meier curves and Cox proportional hazard models. RESULTS: Overall, 887 patients were included, with a mean age of 66â±â10 years. The median OS was 64 months with 1-, 3-, 5-, and 10-year OS rates of 89%, 63%, 52%, and 37%, respectively. Histopathologic subtype, differentiation grade, lymphovascular invasion, perineural invasion, T-stage, N-stage, resection margin, and adjuvant chemotherapy were correlated with OS and DFS. N-stage (HR = 3.30 [2.09-5.21]), perineural invasion (HR = 1.50 [1.01-2.23]), and adjuvant chemotherapy (HR = 0.69 [0.48-0.97]) were independent predictors of OS in multivariable analysis, whereas DFS was only adversely predicted by N-stage (HR = 2.65 [1.65-4.27]). CONCLUSIONS: Independent predictors of OS in resected ampullary cancer were N-stage, perineural invasion, and adjuvant chemotherapy. N-stage was the only predictor of DFS. These findings improve predicting survival and recurrence after resection of ampullary adenocarcinoma.
Assuntos
Adenocarcinoma/mortalidade , Adenocarcinoma/patologia , Ampola Hepatopancreática , Doenças do Ducto Colédoco/mortalidade , Doenças do Ducto Colédoco/patologia , Recidiva Local de Neoplasia/epidemiologia , Adenocarcinoma/cirurgia , Idoso , Estudos de Coortes , Doenças do Ducto Colédoco/cirurgia , Intervalo Livre de Doença , Feminino , Humanos , Cooperação Internacional , Masculino , Pessoa de Meia-Idade , Pancreaticoduodenectomia , Valor Preditivo dos Testes , Estudos Retrospectivos , Taxa de SobrevidaRESUMO
Mirizzi Syndrome (MS) is an uncommon complication of chronic gallstone disease defined as a common bile duct (CBD) obstruction secondary to gallstone impaction in the cystic duct or gallbladder neck. MS is still a challenging clinical situation: preoperative diagnosis of MS is complex and can be made in 18-62.5% of patients. Over 50% of patients with MS is diagnosed during surgery. In most of cases, laparotomy is the preferred surgical approach. We report the case of a 70-year-old woman with a history of asthenia, jaundice, abdominal pain and preoperative imaging that suggest the presence of biliary stones with a choledocal stenosis. Intraoperatively, a MS with cholecysto-biliary fistula involving less than two-thirds of the circumference of the bile duct was diagnosed and successfully treated.
Assuntos
Fístula Biliar/diagnóstico , Doenças do Ducto Colédoco/diagnóstico , Síndrome de Mirizzi/diagnóstico , Dor Abdominal/diagnóstico , Idoso , Astenia/etiologia , Fístula Biliar/cirurgia , Doenças do Ducto Colédoco/cirurgia , Feminino , Cálculos Biliares/diagnóstico por imagem , Humanos , Período Intraoperatório , Icterícia/diagnóstico , Imageamento por Ressonância Magnética , Síndrome de Mirizzi/cirurgiaAssuntos
Doenças do Ducto Colédoco/etiologia , Ducto Colédoco/patologia , Corpos Estranhos/complicações , Idoso de 80 Anos ou mais , Colangiopancreatografia Retrógrada Endoscópica , Ducto Colédoco/diagnóstico por imagem , Ducto Colédoco/cirurgia , Doenças do Ducto Colédoco/diagnóstico por imagem , Doenças do Ducto Colédoco/patologia , Doenças do Ducto Colédoco/cirurgia , Dilatação Patológica , Endossonografia , Feminino , Corpos Estranhos/diagnóstico por imagem , Corpos Estranhos/cirurgia , Humanos , Esfinterotomia Endoscópica , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
Background: Laparoscopic pancreatectomy (LP) is increasingly performed with several institutional series and comparative studies reported. We have applied LP to a variety of pancreatic resections since 2004. This article is to report results of 15-year practice of 605 LPs for pancreatic and periampullary diseases. Methods: Patients with benign or malignant diseases in the pancreas and periampullary region, who underwent LP from June 2004 to June 2018, were retrospectively reviewed. The demographics and indications, and intraoperative and perioperative outcomes were evaluated. Results: A total of 605 consecutive LPs were analyzed, including 237 (39.2%) distal pancreatectomy with splenectomy (DPS), 116 (19.2%) spleen-preserving distal pancreatectomy (SPDP), 30 (5.0%) enucleation (EN), 30 (5.0%) central pancreatectomy (CP), 186 (30.7%) pancreatoduodenectomy (PD), and 6 (1.0%) pancreatoduodenectomy with total pancreatectomy (PDTP). The most common pathologic finding was pancreatic ductal adenocarcinomas (146, 24.1%). Conversion to open procedure was required in 22 patients (3.6%) (12 with PD, 8 with DPS, 1 with CP, and 1 with PDTP). The mean operative time was 241.5 ± 105.5 minutes (range 50-550 minutes) for the entire population and 367.1 ± 61.8 minutes (range 230-550 minutes) for PD. Clinically significant pancreatic fistula (ISGPF grade B and C) rate was 12.4% for the entire cohort and 16.1% for PD. Rate of Clavien-Dindo III-V complications was 17.4% for the entire cohort and 23.7% for PD. Ninety-day mortality was observed only in the cohort of patients undergoing PD (n = 4). Conclusions: The LP procedure appears to be technically safe and feasible, with an acceptable rate of morbidity when performed at our experienced, high-volume center. However, PD has less favorable outcomes and needs further evaluation.
Assuntos
Doenças do Ducto Colédoco/cirurgia , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Laparoscopia/métodos , Pâncreas/cirurgia , Pancreatectomia/métodos , Pancreatopatias/cirurgia , Complicações Pós-Operatórias/epidemiologia , China/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade/tendências , Duração da Cirurgia , Estudos Retrospectivos , Esplenectomia/efeitos adversosRESUMO
Benign bile duct stricture poses a significant challenge for gastroenterologists and general surgeons due to the inherent nature of the disease, difficulty in sustaining long-term solutions and fear of pitfalls in performing biliary tract operations. Operative management with an open biliary bypass is mainly reserved for patients who have failed multiple attempts of endoscopic and percutaneous treatments. However, recent advances in minimally invasive technology, notably in the form of the robotics, have provided a new approach to tackling biliary disease. In this technical report, we describe our standardized method of robotic choledochoduodenostomy in a 59-year-old woman with history of Roux-en-Y gastric bypass who presents with benign distal common bile duct stricture following failure of non-operative management. Key steps in this approach involved adequate duodenal Kocherization, robotic portal dissection and creation of a side-to-side choledochoduodenal anastomosis. The operative time was 200 min with no intraoperative complications and estimated blood loss was less than 50 mL. No abdominal drains were placed. The patient was discharged home on postoperative day 1 tolerating regular diet and able to resume her usual activities within 1 week of her operation. A video is attached to this report.
Assuntos
Coledocostomia , Doenças do Ducto Colédoco/cirurgia , Duodenostomia , Procedimentos Cirúrgicos Robóticos , Anastomose em-Y de Roux , Coledocostomia/efeitos adversos , Coledocostomia/métodos , Constrição Patológica , Duodenostomia/efeitos adversos , Duodenostomia/métodos , Feminino , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Procedimentos Cirúrgicos Robóticos/métodosRESUMO
Consensus guidelines recommend patients with symptomatic cholelithiasis and suspected choledocholithiasis have common bile duct exploration (CBDE) at the time of cholecystectomy to prevent downstream problems. Despite superiority of single-stage cholecystectomy with CBDE, 2-stage precholecystectomy/postcholecystectomy with endoscopic clearance of the duct is commonly practiced. This is related to inadequate training in minimally invasive techniques, lack of technical support for efficient and safe CBDE, and surgeons' inexperience with complex biliary pathologic condition. This article provides a framework for evaluating and treating patients with CBD pathologic condition with an emphasis on technical aspects of CBDE and preoperative planning and preparation.
Assuntos
Procedimentos Cirúrgicos do Sistema Biliar/métodos , Doenças do Ducto Colédoco/diagnóstico , Doenças do Ducto Colédoco/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Colangiografia , HumanosRESUMO
The major papilla of Vater can be ectopically present in the stomach, pyloric canal, duodenal bulb, and third or fourth portion of the duodenum. In this study, we determined the clinical significance of ectopic papilla of Vater by endoscopic retrograde cholangiopancreatogram (ERCP).A retrospective study was conducted by reviewing the medical records of 6133 patients receiving ERCP from 1988 to 2011. The diagnosis was confirmed if both the common bile duct (CBD) and the main pancreatic duct (PD) drained into the same opening, either by ERCP or magnetic resonance cholangiopancreatography.Eight patients with major papilla of Vater in the duodenal bulb were identified among 6133 patients receiving ERCP from 1988 to 2011, with an incidence rate of 0.13%. The mean age was 67 years and patients were predominantly male. Duodenal bulb deformity was noted in all patients and three of them had shallow gastric and/or duodenal ulcers. Hook-shaped CBD configuration was seen only in half of our cases. Three patients with CBD stones were treated successfully after endoscopic sphincterotomy or papillary balloon dilation.Ectopic orifice of papilla is a rare finding of ERCP. Opacification of both the CBD and main PD from the same opening is an essential criterion for diagnosing an ectopic papilla of Vater in the duodenal bulb.