Risk stratification for the development of post-ERCP pancreatitis by sphincter of Oddi dysfunction classification.

OBJECTIVES: To explore whether there is a difference in the frequency of postendoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in patients with manometrically confirmed sphincter of Oddi dysfunction (SOD) types I, II, and III. METHODS: A retrospective review of all of the patients who underwent an ERCP with SOD type I or patients with manometrically confirmed SOD type II or type III (mean basal sphincter pressure ≥ 40 mm Hg) from 2006 to 2010 was performed. The primary outcome measure was development of post-ERCP acute pancreatitis in each of the SOD groups. Factors associated with acute pancreatitis in each group were examined by univariate analysis. RESULTS: We identified 147 patients with SOD. Biliary sphincterotomy was performed in all of the patients, and pancreatic sphincterotomy was performed in 68 of the 147 (46%). All of the patients underwent stenting of the pancreatic duct. Post-ERCP pancreatitis occurred in 23% of the study cohort. Patients with SOD type III had a higher frequency of post-ERCP pancreatitis compared with the SOD type I and type II groups (31% vs 20% vs 6%, respectively; P = 0.024). Those with SOD type III had a greater frequency of post-ERCP pancreatitis (odds ratio 6.7; P = 0.05) compared with those with SOD type I. Patients with SOD type III had a two times greater frequency of developing post-ECRP pancreatitis compared with those with SOD type II. CONCLUSIONS: SOD type III is strongly associated with the development of post-ERCP pancreatitis compared with SOD type I.

Prevalence of type III anomalous pancreaticobiliary junction in a tertiary care hospital of North India.

CONTEXT: Anomalous junction of pancreaticobiliary ducts is a condition in which the pancreatic duct and the bile duct join outside the duodenal wall with a long common channel. The most accepted classification of various types of anomalous pancreaticobiliary junction is the new Komi classification. The majority of cases of type III anomalous pancreaticobiliary junction are reported from Japan and very seldom from outside Japan. This study evaluates the prevalence of type III anomalous pancreaticobiliary junction in the Indian population. OBJECTIVE: To retrospectively evaluate the prevalence of type III anomalous pancreaticobiliary junction revealed by endoscopic retrograde cholangiopancreatography (ERCP) examinations carried out between 1985 and 2005. DESIGN: ERCP records of 3,827 patients satisfying inclusion criteria between 1985 and 2005 were retrospectively analyzed. MAIN OUTCOME MEASURE: Patients demonstrating anomalous pancreaticobiliary junction were identified and classified according to the new Komi classification. RESULTS: A total of 101 patients had anomalous pancreaticobiliary junction (2.6% of all ERCP). Only 2 patients (2.0% of all anomalous pancreaticobiliary junction cases and 0.05% of all ERCP examinations) had type III anomalous pancreaticobiliary junction. Both cases were associated with choledochal cysts and chronic pancreatitis. CONCLUSION: Type III anomalous pancreaticobiliary junction is a rare occurrence in Indian patients as compared to Japanese patients in whom the majority of cases are reported. This demographic variation is still unexplained.

The relationship of Mirizzi syndrome and cholecystoenteric fistula: validation of a modified classification.

BACKGROUND: Mirizzi syndrome and cholecystoenteric fistula with or without gallstone ileus are late complications of gallstone disease. We previously suggested that the natural history of Mirizzi syndrome may not end with just a cholecystobiliary fistula and that the continuous inflammation in the triangle of Calot area may result in a complex fistula involving the biliary tract and the adjacent viscera. The purpose of this study was to establish the relationship of Mirizzi syndrome with cholecystoenteric fistulas. METHODS: We retrospectively reviewed the records of all patients older than aged 18 years submitted to emergency or elective cholecystectomy from 1995 to 2006. Of 5,673 cholecystectomies performed during that period, we found 327 (5.7%) patients with Mirizzi syndrome and 105 (1.8%) patients with cholecystoenteric fistula. Ninety-four (89.5%) patients with cholecystoenteric fistula also had an associated Mirizzi syndrome. RESULTS: Cholecystoenteric fistula was associated with Mirizzi syndrome (p < 0.0001), increased age was associated with Mirizzi syndrome and cholecystoenteric fistula (p < 0.0001), and female gender was associated with Mirizzi syndrome (p < 0.0001). CONCLUSION: When during surgery for gallstone disease a cholecystoenteric fistula is encountered, the possibility of an associated Mirizzi syndrome must be considered. The findings of this study confirm the association of Mirizzi syndrome with cholecystoenteric fistula.

Mirizzi syndrome: history, present and future development.

BACKGROUND: Mirizzi syndrome was reported in 0.3-3% of patients undergoing cholecystectomy. The distortion of anatomy and the presence of cholecystocholedochal fistula increase the risk of bile duct injury during cholecystectomy. METHODS: A Medline search was undertaken to identify articles that were published from 1974 to 2004. Additional papers were identified by a manual search of the references from the key articles. RESULTS: A preoperative diagnosis was made in 8-62.5% of cases. Open surgical treatment gave good short-term and long-term results. There was a lack of good data in laparoscopic treatment. Conversion to open surgery rates was high, and bile duct injury rate varied from 0 to 22.2%. CONCLUSION: A high index of clinical suspicion is required to make a preoperative or intraoperative diagnosis, which leads to good surgical planning to treat the condition. Open surgery is the gold standard. Mirizzi syndrome should still be considered as a contraindication for laparoscopic surgery.

Gastrointestinal imaging update: swallowing disorders and sphincter of Oddi dysfunction.

This update focuses on swallowing disorders and sphincter of Oddi dysfunction. Anatomy and physiology of swallowing are described, as are the signs, symptoms, and etiology of swallowing disorders. The imaging of these patients, particularly with videofluoroscopic swallowing study and fiberoptic endoscopic examination of swallowing, is then discussed. Sphincter of Oddi dysfunction as a cause of postcholecystectomy syndrome as well as its classification is described. This is followed by an explanation of the roles of fatty meal sonography and hepatobiliary scintigraphy in patients with sphincter of Oddi dysfunction, particularly type II and type III.

Hybrid classification of sphincter of Oddi dysfunction based on simplified Milwaukee criteria: effect of marginal serum liver and pancreas test elevations.

To date, when using the Milwaukee classification for sphincter of Oddi dysfunction (SOD), one cannot accurately classify patients with marginal elevations in laboratory tests; ie, < 1.5 x the upper limit of normal (ULN). Since subsequent treatment may depend on how they are classified, we sought to determine whether these patients should be considered as type II or type III. Between January 1993 and October 1996, 113 consecutive patients (82 females and 31 males; ages 12-87 years) without prior sphincterotomy were referred to consider a diagnosis of SOD type II or III. SOD II patients had pancreaticobiliary-type pain and laboratory elevations >1.5 x ULN or dilated ducts, while SOD III patients had pain only. Hybrid patients had pain and marginal laboratory elevations <1.5 x ULN, with normal duct diameters. Drainage times, frequency, duration, and propagation were not assessed. Sphincter of Oddi manometry (SOM) was performed in each case, and the frequency of abnormal biliary and/or pancreatic basal sphincter pressure was compared, with respect to type II, III, and hybrid SOD. Successful SOM was obtained in 113/114 patients: Abnormal basal sphincter pressure was found in 65, 89, and 43% of type II, hybrid, and type III SOD, respectively. We found no statistical difference between type II and hybrid patients. In contrast, there was statistical difference between types II and III patients and between type III and hybrid patients. In conclusion, there was no significant difference in the frequency of elevated basal sphincter pressure in SOD type II versus hybrid, and thus they should be considered as one group.

Cystic dilatation of the common bile duct in adults: report of five cases and review of literature

The authors report five cases of cystic dilatation of the common bile duct Type I (TodaniÆs classification) in adults patients, in Division of General Surgery of a University Hospital, treated over a- 25-year- period from 1974 to 1999, among 16.057 operations, and not previously published. Diagnosis was obtained by operative cholangiogram (OC) in the first case, percutaneous transhepatic cholangiogram on the second one (PTHC) and by ultrasonography (US), endoscopic retrograde cholangiopancreatography (ERCP), and operative cholangiogram (OC), respectively, on the last three cases. The second patient had an adenocarcinoma arising in the cystic wall associated with peritoneal metastasis. The first two cases were treated by internal drainage and the last three by excision of the cysts and bilioenteric anastomoses. Classification, incidence, etiology, diagnosis, malignization and surgical treatment of biliary cystic disease (BCD) were revised, with the conclusion that resection must be the preferable method of treatment, when possible, especially due to the concern of malignization.

Abdominal distention and shock in an infant.

Acute abdominal distention in the pediatric patient may be attributable to extraperitoneal fluid, masses, organomegaly, air, an ileus, a functional or mechanical bowel obstruction, or injury and blood secondary to trauma. An infant who presents to the emergency department with acute abdominal distention and shock is a true emergency for which the differential diagnosis is extensive. An unusual case of abdominal distention, ascites, hematochezia, and shock in an infant, subsequently found to have spontaneous perforation of the common bile duct is reported. This uncommon cause of abdominal distention and shock in an infant is many times left out of the differential diagnosis of an acute abdomen. The presentation may be as an uncommon acute form or a classis subacute type. This patient had hematochezia, which had not been previously reported in association with this entity. Failure to recognize and treat an acute abdomen can result in high mortality.

Micro and minilaparotomy surgery in the treatment of Mirizzi's syndrome.

The Mirizzi's syndrome presents a difficult surgical challenge because the dense adhesions and edematous inflammatory tissue cause distorsion of the normal anatomy in Calot's triangle, leading to a great risk of bile duct injury. Therefore, a controversial issue the surgical strategy for treatment of Mirizzi's syndrome since the introduction of laparoscopic cholecystectomy. The present study was undertaken to elucidate the applicability of microlaparotomy cholecystectomy in the management of Mirizzi's syndrome.

Do patients with sphincter of Oddi dysfunction benefit from endoscopic sphincterotomy? A 5-year prospective trial.

OBJECTIVES: To assess the incidence of elevated sphincter of Oddi baseline pressure and the response to endoscopic sphincterotomy in patients with suspected sphincter of Oddi dysfunction. DESIGN: A 5-year prospective clinical trial. METHODS: One-hundred and eight patients with recurrent biliary-type pain after cholecystectomy were enrolled. After thorough investigation, 35 patients with suspected type II sphincter of Oddi dysfunction (SOD) and another 29 type III patients remained for further investigation. Both groups were similar with respect to demographic data and severity of pain. Biliary manometry was performed in all except three patients in either group. Endoscopic sphincterotomy was performed in all patients with abnormal sphincter of Oddi baseline pressure (> 40 mmHg). All patients were clinically re-evaluated after 4-6 weeks, and thereafter the sphincterotomized patients were followed for a median period of 2.5 years. RESULTS: An abnormal sphincter of Oddi baseline pressure was found in 62.5% of the type II patients and in 50% of the patients with suspected type III SOD (P = 0.66). At the 4-6 week follow-up none of those patients without abnormal manometry, but 70% of the patients with type II SOD, and 39% of the type III SOD patients, respectively, reported subjective benefit after sphincterotomy (P = 0.13 type II vs. type III). However, after a median follow-up of 2.5 years, sustained symptomatic improvement after sphincterotomy was found in 60% of the type II patients, but only in 8% of the patients with type III SOD (P < 0.01). CONCLUSION: Disregarding a lack of difference in the incidence of abnormal sphincter of Oddi baseline pressure between type II and type III SOD, the Geenen-Hogan classification helps to predict the clinical outcome after endoscopic sphincterotomy.

Clinical analysis of choledochoduodenal fistula with cholelithiasis in Taiwan: assessment by endoscopic retrograde cholangiopancreatography.

OBJECTIVES: Choledochoduodenal fistula (CDF) is occasionally found during endoscopic retrograde cholangiopancreatography (ERCP). Cholelithiasis is suspected to be the leading cause in some endemic areas. We focus on this cause of CDF to determine which clinical characteristics are relevant to formation of fistulas and to learn whether CDF of various types would imply different clinical significance. METHODS: In 1882 ERCP studies from 1988 to 1993, we found 27 CDF with cholelithiasis in 1066 patients. Their clinical backgrounds and ERCP findings were compared with those of 492 patients who had cholelithiasis but no CDF. RESULTS: The prevalence of CDF was 2.53%. A longer past history of biliary stones, recurrent biliary tract infection (BTI), and the presence of common bile duct stones (CBS) were factors relevant to the formation of fistula. In the case of 24 distal fistulas, including seven of type I and 17 of type II, there was concurrent distal CBS. Three cardinal features of fistula of the distal type were: 1) the length of CDF was less than 1.5 cm, 2) its orifice was just around or on the papillary fold, and 3) all cases of distal type II had prominent pneumobilia, less jaundice, and larger CBS than type I. Aggressive endoscopic or surgical treatment of distal type CDF decreased the recurrence of BTI, as indicated by surveillance for 1 yr. Three fistulas of the proximal type were longer and drained into the duodenum far from the papilla. All of these cases deserved early surgical intervention. CONCLUSIONS: CDF really serves as a chronic sequel of cholelithiasis. Different clinical features of CDF of various types help one to establish diagnosis and treatment. To avoid recurrence of BTI, aggressive therapy to correct CDF is mandatory.

Frequency of abnormal sphincter of Oddi manometry compared with the clinical suspicion of sphincter of Oddi dysfunction.

Patients with pancreaticobiliary pain or idiopathic pancreatitis have been classified as having definitive (type I), presumptive (type II), or possible (type III) sphincter of Oddi dysfunction (SOD) based on clinical, laboratory, and ERCP data. This study was undertaken to determine the frequency of abnormal sphincter of Oddi manometry (SOM) when patients are classified by this system. Two hundred and thirteen patients with pancreaticobiliary pain were evaluated clinically; SOM, ERCP, and ductal contrast drainage time tests were performed. For biliary types I, II, and III, the frequency of abnormal SOM was 85.7%, 55.1%, and 28.1%, respectively. Similarly, for pancreatic types I, II, and III, an elevated basal sphincter pressure occurred in 92.3%, 58.2%, and 35.1%, respectively. When patients with an abnormal basal sphincter pressure were characterized by the magnitude of the elevation, the manometric profiles were similar for types I, II, and III. These data suggest that elevated sphincter pressure occurs more frequently in type III patients than previously reported, and supports consideration of SOM when evaluating and treating type II and type III patients.

[Endoscopic papillosphincterotomy in patients with para-ampullar diverticulosis]. / Endoskopicheskaia papillosfinkterotomiia u bol'nykh s parafateral'nym divertikulom.

It is suggested that the numerous variants of diverticula occurring in the region of the major duodenal papilla should be grouped into four types. Type I--the major duodenal papilla (MDP) is on the floor of the diverticulum; type II--the MDP is in the region of the lower ++semi-circumference of the diverticular orifice while the longitudinal fold runs radially on the wall of the diverticulum; type III--the MDP is in the region of the orifice of the diverticulum while the longitudinal fold does not pass on its wall; type IV--two diverticula located above the MDP to both sides of the longitudinal fold. Endoscopic papillosphincterotomy is considered contraindicated in patients with type I diverticulum. When indicated, the intervention was carried out in patients with types III and IV diverticula. Endoscopic papillosphincterotomy can be conducted in patients with type II diverticulum measuring more than 2 cm.

Choledochocele: case report, literature review, and a proposed classification.

Choledochocele or type III choledochal cyst is a rare abnormality of obscure etiology that consists of cystic or diverticular dilatation of the terminal intramural portion of the common bile duct protruding into the duodenum. It should be considered in the differential diagnosis of otherwise unexplained biliary colic or recurrent pancreatitis--particularly after cholecystectomy. An intraluminal duodenal filling defect on barium study that opacifies during cholangiography or endoscopic retrograde cholangiopancreatography is diagnostic. We present one case of choledochocele in which the first use of the biliary scintigraphic (HIDA) scan for diagnosis is demonstrated. An additional 47 cases found in the literature are reviewed and a new anatomic classification of choledochoceles is proposed as a guide for treatment. Treatment options are partial excision of the cyst, sphincterotomy, or both.

Choledochal cyst.

A 16-year-old girl with recurrent pain in the right upper quadrant and abnormal results of liver function tests was found to have a large choledochal cyst filled with stones. Computerized tomography and endoscopic retrograde cholangiopancreatography showed the large cyst with innumerable primary cyst stones and an anomalous pancreaticobiliary duct junction.