Association of Periampullary Duodenal Diverticula with Bile Duct Stones and with Technical Success of Endoscopic Retrograde Cholangiopancreatography
Submitted 22 September 2003
Accepted after Revision 3 August 2004
01. Dezember 2004 (online)
Background and Study Aims: Periampullary diverticula are thought to be associated with bile duct stones. However, studies to date have been inconclusive as they have not taken into account the influence of age. Our study analysed the association of diverticula with bile duct stones and with the technical success of endoscopic retrograde cholangiopancreatography (ERCP).
Patients and Methods: A total of 415 consecutive patients who were undergoing ERCP were prospectively entered into a database. Of these patients, 83 (20 %; mean age 73 years; 34 men, 49 women) were found to have diverticula. The age-matched control group comprised 261 patients (mean age 72 years; 106 men, 155 women). The chi-squared test was used to analyse the results.
Results: In the diverticula group, 53 (64 %) had bile duct stones, compared with 86 (33 %) of the controls (P < 0.0001), with an odds ratio of 3.6. Significantly more patients in the diverticula group had primary bile duct stones; also significantly more of them had stones in both the bile duct and gallbladder. There was no difference between the two groups with regard to previous history of pancreatitis (10 % in the diverticula group vs. 11 % in the control group). There were no significant differences found between the diverticula group and the control group in terms of successful duct cannulation (94 % in both groups), sphincterotomies (96 % vs. 98 %) or stone extraction (94 % vs. 88 %). The incidence of complications was similar in the two groups (diverticula group 5 % vs. control group 3.3 %).
Conclusions: Periampullary diverticula are associated with an increased incidence of bile duct stones but not with pancreatitis. Diverticula did not cause any technical difficulties at ERCP or increase the risk of complications.
- 1 Lobo D N, Balfour T W, Iftikhar S Y, Rowlands B J. Periampullary diverticula and pancreaticobiliary disease. Br J Surg. 1999; 86 588-597
- 2 Kim M-H, Myung S J, Seo D W. et al . Association of periampullary diverticula with primary choledocholithiasis but not with secondary choledocholithiasis. Endoscopy. 1998; 30 601-604
- 3 Novacek G, Walgram M, Bauer P. et al . The relationship between juxtapapillary duodenal diverticula and biliary stone disease. Eur J Gastroenterol Hepatol. 1997; 9 375-379
- 4 Kennedy R H, Thompson M H. Are duodenal diverticula associated with choledocholithiasis?. Gut. 1988; 29 1003-1006
- 5 Psathakis D, Utschakowski A, Muller G. et al . Clinical significance of duodenal diverticula. J Am Coll Surg. 1994; 178 257-260
- 6 Uomo G, Manes G, Ragozzino A. et al . Periampullary extraluminal duodenal diverticula and acute pancreatitis: an underestimated etiological association. Am J Gastroenterol. 1996; 91 186-1188
- 7 Shemesh E, Klein E, Czerniak A. et al . Endscopic sphincterotomy in patients with gallbladder in situ: the influence of periampullary duodenal diverticula. Surgery. 1990; 107 163-166
- 8 Vaira D, Dowsett J F, Hatfield A RW. et al . Is duodenal diverticulum a risk factor for sphincterotomy?. Gut. 1989; 30 939-942
- 9 Leung J WC, Chan F KL, Sung J JY, Chung S CS. Endoscopoc sphincterotomy-induced hemorrhage: a study of risk factors and the role of epinephrine injection. Gastrointest Endosc. 1995; 42 550-554
- 10 Miyazawa Y, Okinaga K, Nishida K, Okano T. Recurrent common bile duct stones associated with periampullary duodenal diverticula and calcium bilirubinate stones. Int Surg. 1995; 80 120-124
- 11 Hall R I, Ingoldby C JH, Denyer M E. Periampullary diverticula predispose to primary rather than secondary stones in the common bile duct. Endoscopy. 1990; 22 127-128
- 12 MacKenzie M E, Davies W T, Farnell M B. et al . Risk of recurrent biliary tract disease after cholecystectomy in patients with duodenal diverticula. Arch Surg. 1996; 131 1083-1085
- 13 Sandstad O, Osnes T, Skar V. et al . Common bile duct stones are mainly brown and associated with duodenal diverticula. Gut. 1994; 35 1464-1467
- 14 Leinkram C, Roberts-Thomson I C, Kune G A. Juxtapapillary duodenal diverticula: association with gallstones and pancreatitis. Med J Aust. 1980; 1 209-210
- 15 Psathakis D, Utschakowski A, Muller G. et al . Clinical significance of duodenal diverticula. J Am Coll Surg. 1994; 178 257-260
- 16 Kirk A P, Summerfield J A. Incidence and significance of juxtapapillary diverticula at endoscopic regrograde cholangiopancreatography. Digestion. 1980; 20 31-35
- 17 Shemesh E, Fredman E, Czerniak A, Bat L. The association of biliary and pancreatic anomalies with periampullary duodenal diverticula: correlation with clinical presentations. Arch Surg. 1987; 122 1055-1057
- 18 Lintott D J, Ruddell W SJ, Axon A TR. Pseudostone at ERCP due to juxtapapillary diverticulum. Clin Radiol. 1981; 32 173-176
- 19 Leivonen M K, Halttunen J AA, Kivilaakso E O. Duodenal diverticulum at endoscopic retrograde cholangiopancreaticography: analysis of 123 patients. Hepatogastroenterology. 1996; 43 961-966
- 20 Lauri A, Horton R C, Davidson B R. et al . Endoscopic management of bile duct stones: management related to stone size. Gut. 1993; 34 1718-1721
- 21 Vandervoort J, Soetikno R M, Tham T C. et al . Risk factors for complications after performance of ERCP. Gastrointest Endosc. 2002; 56 652-656
- 22 Freeman M L, Nelson D B, Sherman S. et al . Complications of endoscopic biliary sphincterotomy. N Engl J Med. 1996; 335 909-918
- 23 Boender J, Nix G AJJ, de Ridder M AJ. et al . Endoscopic papillotomy for common duct stones: factors influencing the complication rate. Endoscopy. 1994; 26 209-216
T. C. K. Tham, M. D.
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