Choledochocele, an overlooked diagnosis: report of 15 cases and review of 56 published reports from 1984 to 1992.

BACKGROUND AND STUDY AIMS: Choledochocele (CDCL) is still regarded as being a rare abnormality, despite the increasing number of case reports published in the last ten years. The aim of this prospective study was to investigate the prevalence rate of CDCL in patients referred for endoscopic retrograde cholangiopancreatography (ERCP), as well as the short-term and long-term complications of endoscopic treatment. PATIENTS AND METHODS: Over a seven-year period, fifteen symptomatic patients (ten male, five female, age range 47-93 years) were identified as having CDCL out of a total of 1019 ERCP referrals to our unit. The diagnosis of CDCL was made by both duodenoscopy and ERCP. RESULTS: All 15 patients had small (4-25 mm) CDCLs associated with pancreatic (n = 1) or biliary (n = 14) disorders. Ten of the 15 patients (67%) had choledocholithiasis as well. Twelve patients were treated by endoscopic sphincterotomy (ES), and three by surgery. The immediate post-ES complications (2 of 12, 16.7%) were acute cholangitis (n = 1) and acute pancreatitis (n = 1). Eleven (76%) of the 14 patients who had a complete follow-up were symptom-free, with normal liver function tests at a median of 18 months (range 12-97). Two patients reported episodes of acute cholangitis, and one patient died of a misdiagnosed ampullary carcinoma arising in the CDCL. CONCLUSIONS: These results suggest that CDCL is probably an overlooked diagnosis in patients with pancreaticobiliary symptoms. It should be readily recognized and treated, preferably by endoscopic sphincterotomy. The endoscopist must be aware that an ampullary carcinoma may develop in a CDCL.

The clinical need for sphincter of Oddi manometry in gastrointestinal endoscopy units.

The clinical need for sphincter of Oddi manometry (SOM) was investigated by retrospective analysis of 736 consecutive endoscopic retrograde cholangiopancreatography (ERCP) referrals (1985-89). During this period SOM was not performed in any unit in Greece including our own. Assuming a conservative or a more liberal policy in the utilization of SOM, a biliary and a pancreatic group of patients were established respectively, depending on the clinical presentation. ERCP was diagnostic in 168/194 (86.6%) of patients referred for post-cholecystectomy symptoms, but SOM was considered to be necessary to establish a diagnosis in the remaining 26 (13.4%) patients (biliary group). ERCP revealed pancreatic and/or biliary pathology in 46/69 (66.7%) patients, referred for symptoms attributed to pancreatitis, but 11/69 (15.9%) patients with pancreas divisum and 12/69 (17.4%) with acute recurrent idiopathic pancreatitis may have benefitted from SOM for planning endoscopic therapy (pancreatic group). Thus, only 5 patients from each group per 147 ERCP annual referrals were candidates for SOM. When taking into account that to run a SOM service the minimum annual number of investigations should be 50 and that the provision of ERCP in the UK is 50 per 100,000 of population per year, it is extrapolated that such a Gastrointestinal Endoscopy Unit should serve a population of 1.5 to 3 million.