Double major papilla: diagnostic challenge of an unusual anatomical variant.

We report the endoscopic finding of a double papilla of Vater in a patient presenting choledocholithiasis who underwent endoscopic retrograde cholangiopancreatography (ERCP). The images showed the presence of two perfectly delimited papillary orifices, 1cm apart from each other. After cannulation of each orifice, we observed the Wirsung and the common bile duct (CBD) as completely independent ducts. Given the diagnostic challenge posed by this entity and the importance of differentiating it from a bilioenteric fistula, we believe it is worth knowing about it in order to manage it properly and to minimize secondary risks during the exploration.

Safety and efficacy of large balloon sphincteroplasty in a third care hospital.

BACKGROUND AND AIMS: large balloon sphincteroplasty (LBS) associated with sphincterotomy (ES) has gained acceptance as a useful tool in extracting difficult bile duct stones. Our purpose was to evaluate the efficacy and safety of LBS with balloons > or = 10 mm in clinical practice setting. PATIENTS AND METHODS: unicentre prospective study in a tertiary care hospital. All patients who underwent LBS associated with ES between July 2007 and March 2011 were included prospectively in a database recording clinical aspects, procedure data, outcome and complications.Success is the main outcome defined as complete stone removal documented by absence of any filling defect during a final occlusion cholangiogram and absence of clinical or radiological findings after the ERCP consistent with remaining stones. Complications as pancreatitis, cholangitis, post-ERCP bleeding, perforation and others were also measured. RESULTS: one hundred twenty procedures were made in 109 patients with balloons ranging from 10 to 20 mm. Success rate was 91% in the first attempt and 96.7% after two procedures. Mechanical lithotripsy was only needed in one case (0.8%). Complication rate was 4.2% due to five cases of post-ERCP bleeding in high risk patients. CONCLUSION: large balloon sphincteroplasty associated to sphincterotomy in clinical practice is a very effective and safe technique.

Dilatación con balón asociada a esfinterotomía, evaluación de eficacia y seguridad en un hospital terciario / Safety and efficacy of large balloon sphincteroplasty in a third care hospital

Introducción y objetivos: la dilatación con balón de gran tamaño asociada a esfinterotomía es un recurso cada vez más utilizado en la extracción de coledocolitiasis de gran tamaño. El objetivo de este estudio es evaluar la eficacia y seguridad de la dilatación con balones mayores de 10 mm en un entorno de práctica clínica habitual. Pacientes y métodos: estudio prospectivo en un hospital terciario. Todos los pacientes en los que se realizó dilatación con balón mayor de 10 mm asociado a esfinterotomía entre julio de 2007 y marzo de 2011 se incluyeron prospectivamente en una base de datos incluyendo aspectos clínicos, del procedimiento, resultados y complicaciones. El éxito del procedimiento se definió como la extracción de todos los cálculos presentes documentada como ausencia de defectos de repleción en la colangiografía final y la ausencia de signos clínicos y/o radiológicos tras la CPRE sugestivos de persistencia de litiasis. La presencia de pancreatitis, colangitis, perforación y hemorragia post-CPRE también se documentó. Resultados: se realizaron 120 procedimientos en 109 pacientes diferentes, con balones entre 10 y 20 mm de diámetro. La tasa de éxito fue del 91% en el primer intento y del 96,7% tras dos procedimientos. La litotricia mecánica solo se necesitó en un caso (0,8%). La tasa de complicaciones fue del 4,2% debido a cinco casos de hemorragia post-CPRE en pacientes de alto riesgo de sangrado. Conclusión: la dilatación con balón asociada a esfinterotomía en condiciones de práctica clínica habitual muestra una tasa de éxito excelente con un índice de complicaciones reducido(AU)

Background and aims: large balloon sphincteroplasty (LBS) associated with sphincterotomy (ES) has gained acceptance as a useful tool in extracting difficult bile duct stones. Our purpose was to evaluate the efficacy and safety of LBS with balloons >=10 mm in clinical practice setting. Patients and methods: unicentre prospective study in a tertiary care hospital. All patients who underwent LBS associated with ES between July 2007 and March 2011 were included prospectively in a database recording clinical aspects, procedure data, outcome and complications. Success is the main outcome defined as complete stone removal documented by absence of any filling defect during a final occlusion cholangiogram and absence of clinical or radiological findings after the ERCP consistent with remaining stones. Complications as pancreatitis, cholangitis, post-ERCP bleeding, perforation and others were also measured. Results: one hundred twenty procedures were made in 109 patients with balloons ranging from 10 to 20 mm. Success rate was 91% in the first attempt and 96.7% after two procedures. Mechanical lithotripsy was only needed in one case (0.8%). Complication rate was 4.2% due to five cases of post-ERCP bleeding in high risk patients. Conclusion: large balloon sphincteroplasty associated to sphincterotomy in clinical practice is a very effective and safe technique(AU)

Uso de gadolinio como contraste en CPRE en pacientes con reacciones adversas a contrastes yodados / Use of gadolinium as contrast agent in endoscopic retrograde cholangiopancreatography in patients with iodine allergy

Introducción Para la realización de colangiopancreatografía retrógrada endoscópica (CPRE) es necesario el uso de contrastes radiológicos, utilizándose habitualmente contrastes yodados. La pauta de actuación ante pacientes que han sufrido reacciones adversas a contrastes yodados y que van a recibir una CPRE es controvertida. Objetivo Evaluar la seguridad y eficacia de un contraste basado en gadolinio en pacientes con reacciones alérgicas previas a contrastes yodados durante la realización de CPRE. Material y métodos Se utilizó gadobutrol como agente de contraste, un compuesto basado en el gadolinio, sin utilizar profilaxis previa. Se realizaron 13 procedimientos en 11 pacientes con antecedentes de reacciones adversas previas a contrastes yodados. Resultados Las CPRE fueron completadas satisfactoriamente en todos los casos, obteniéndose 13 colangiogramas y un pancreatograma. La calidad de imagen obtenida fue buena, equiparable a la obtenida con los contrastes yodados utilizados habitualmente, y permitiendo realizar el diagnóstico y la terapéutica endoscópica sin suponer una limitación. No se encontraron efectos adversos relacionados con el contraste y tampoco complicaciones post-CPRE. Conclusiones El gadobutrol, un contraste basado en gadolinio, es una alternativa segura y eficaz en pacientes alérgicos a contrastes yodados(AU)

Introduction Radiologic contrasts are required during endoscopic retrograde cholangiopancreatography (ERCP). The most frequently used are iodine-based contrast media. Controversy still surrounds the optimal strategy in patients with previous adverse reactions to iodine contrasts that need to undergo an ERCP. Objective To evaluate the safety and efficacy of a gadolinium-derived contrast medium in patients with previous reactions to iodine-derived agents during ERCP. Material and methods Thirteen ERCP were performed in 11 patients with well-established adverse reactions to iodine compounds. ERCP was carried out with gadobutrol, a non-ionic gadolinium compound and without prophylaxis. Results In all patients, ERCP were satisfactorily completed. Thirteen cholangiograms and one pancreatogram were obtained. All procedures were technically successful, allowing diagnosis and endotherapy. The quality of the images was good, similar to those obtained with standard contrast media, and did not represent a limitation. No contrast-related adverse events were observed, and there were no post-ERCP complications. Conclusions Gadolinium-derived agents are a safe and effective alternative in iodine-allergic patients (AU)

[Use of gadolinium as contrast agent in endoscopic retrograde cholangiopancreatography in patients with iodine allergy]. / Uso de gadolinio como contraste en CPRE en pacientes con reacciones adversas a contrastes yodados.

INTRODUCTION: Radiologic contrasts are required during endoscopic retrograde cholangiopancreatography (ERCP). The most frequently used are iodine-based contrast media. Controversy still surrounds the optimal strategy in patients with previous adverse reactions to iodine contrasts that need to undergo an ERCP. OBJECTIVE: To evaluate the safety and efficacy of a gadolinium-derived contrast medium in patients with previous reactions to iodine-derived agents during ERCP. MATERIAL AND METHODS: Thirteen ERCP were performed in 11 patients with well-established adverse reactions to iodine compounds. ERCP was carried out with gadobutrol, a non-ionic gadolinium compound and without prophylaxis. RESULTS: In all patients, ERCP were satisfactorily completed. Thirteen cholangiograms and one pancreatogram were obtained. All procedures were technically successful, allowing diagnosis and endotherapy. The quality of the images was good, similar to those obtained with standard contrast media, and did not represent a limitation. No contrast-related adverse events were observed, and there were no post-ERCP complications. CONCLUSIONS: Gadolinium-derived agents are a safe and effective alternative in iodine-allergic patients.

Carcinoma de células en anillo de sello de la ampolla de Vater / Signet ring cell carcinoma of the ampulla of Vater

Introducción El carcinoma de células en anillo de sello de la ampolla de Vater es una entidad infrecuente, con menos de 20 casos descritos en la literatura. El objetivo de este artículo es presentar dos pacientes con esta patología y realizar una revisión de los estudios previos. Observación clínica Los dos pacientes ingresaron por ictericia obstructiva. En la ecografía y la tomografía computarizada abdominales se apreció una dilatación de la vía biliar intra y extrahepática. En la duodenoscopia, se visualizó una masa excrecente de la ampolla de Vater que, histológicamente, presentaba células con características típicas de células en anillo de sello. Se realizaron una duodenopancreatectomía cefálica con linfadenectomía y una pancreatectomía total respectivamente. Discusión El carcinoma de células en anillo de sello de la ampolla de Vater ha sido descrito únicamente en casos aislados en la literatura. Por este motivo, sus características clínicopatológicas y su pronóstico aún no están bien definidos (AU)

Introduction: Signet ring cell carcinoma of the ampulla of Vater is a rare entity and less than20 cases have been described in the literature. We report the cases of two patients with thisdisease and provide a literature review of previous studies. Case report: We describe two patients with obstructive jaundice. Abdominal ultrasonographyand abdominal computed tomography showed dilatation of the intrahepatic and common bileduct. Duodenoscopy indicated a protruding mass on the ampulla of Vater. Histopathologicalexamination showed round cells and their nuclei were located on one side with prominentsignet-ring features. One patient underwent a cephalic pancreatoduodenectomy with lymphadenectomyand the other a total pancreatectomy. Discussion: Signet ring cell carcinoma of the ampulla of Vater has only been described in isolatedcases in the literature. Therefore, the clinicopathological features and prognosis of this diseasehave not yet been well defined (AU)