Endoscopy 2001; 33(5): 405-408
DOI: 10.1055/s-2001-14272
Original Article
© Georg Thieme Verlag Stuttgart · New York

Outcome of Endoscopic Sphincterotomy in Patients with Pain of Suspected Biliary Or Papillary Origin and Inconclusive Cholangiography Findings

B. Brand, L. Wiese, F. Thonke, P. V. J. Sriram, S. Jaeckle, U. Seitz, S. Bohnacker, N. Soehendra
  • Dept. of Interdisciplinary Endoscopy, University Hospital Eppendorf, Hamburg, Germany
Further Information

Publication History

Publication Date:
31 December 2001 (online)

Background and Study Aims: We prospectively studied the outcome of endoscopic sphincterotomy in symptomatic patients with elevated liver enzyme levels but no clear evidence of biliary pathology on transabdominal ultrasound and diagnostic endoscopic retrograde cholangiography (ERC).

Methods: 29 consecutive patients with biliary-type pain (two or more out of eight criteria), elevated liver enzyme levels and no evidence of gallstones or significant common bile duct dilatation were evaluated. Elevated bilirubin levels (up to 7.2 mg/dl) were found in 18 patients. The majority of patients (n = 21) had a gallbladder in situ. The findings from bile duct exploration following sphincterotomy were recorded, and pain (as measured by visual analogue scale) as well as laboratory findings was assessed.

Results: Wire-guided sphincterotomy was successful in all patients while uncomplicated pancreatitis occurred in one instance. In 16 patients (55 %) there was macro-scopic evidence of small stones (n = 2), sludge (n = 12) or both (n = 2) following bile duct exploration. In addition, microscopy showed bile crystals in all four patients who had no macroscopic findings. All four patients with elevation of pancreatic enzymes prior to treatment, and four of those eight patients with previous cholecystectomy, showed evidence of biliary pathology. The initial median pain intensity was 8 (range 1-10); 26 patients became pain-free within 3 months following endoscopic sphincterotomy. While 26 of 28 patients (93 %) remained asymptomatic over a median follow-up period of 19 months (range 12-26), one died of an unrelated malignancy 6 months after therapy.

Conclusions: Endoscopic sphincterotomy may be acceptable in patients with typical clinical presentation suggesting a papillary or biliary origin of pain without further diagnostic work-up. Contrary to expectations, diagnostic ERC was insensitive in detection of the biliary etiology of symptoms in this selected group of patients.

References

  • 1 Ponchon T. Diagnostic endoscopic retrograde cholangiopancreatography.  Endoscopy. 2000;  32 200-208
  • 2 Costamagna G. Therapeutic biliary endoscopy.  Endoscopy. 2000;  32 209-216
  • 3 Allescher H D. Clinical impact of sphincter of Oddi dyskinesia.  Endoscopy. 1998;  30 A231-A236
  • 4 Deviere J, Matos C. Which test for common bile duct stones? Magnetic resonance cholangiography.  Endoscopy. 1997;  29 666-668
  • 5 Palazzo L. Which test for common bile duct stones? Endoscopic and intraductal ultrasonogaphy.  Endoscopy. 1997;  29 655-665
  • 6 Egbert A M. Gallstone symptoms: myth and reality.  Postgrad Med. 1991;  90 119-126
  • 7 Buscail L, Escourou J, Delvaux M, et al. Microscopic examination of bile directly collected during endoscopic cannulation of the papilla.  Dig Dis Sci. 1992;  37 116-120
  • 8 Wehrmann T, Seifert H, Seipp M, et al. Endoscopic injection of botulinum toxin for biliary sphincter of Oddi dysfunction.  Endoscopy. 1998;  30 702-707
  • 9 Rolny P. Endoscopic bile duct stent placement as a predictor of outcome following endoscopic sphincterotomy in patients with suspected sphincter of Oddi dysfunction.  Eur J Gastroenterol Hepatol. 1997;  9 467-471
  • 10 Prat P, Amuyal G, Amouyal P, et al.. Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common bile duct lithiasis.  Lancet. 1996;  347 75-79
  • 11 Burtin P, Palazzo L, Canard J M, et al. Diagnostic strategies for extrahepatic cholestasis of indefinite origin: endoscopic ultrasonography or retrograde cholangiography? Results of a prospective study.  Endoscopy. 1997;  29 349-355
  • 12 Botoman V A, Kozarek R A, Novell L A, et al. Long-term outcome after endoscopic sphincterotomy in patients with biliary colic and suspected sphincter of Oddi dysfunction.  Gastrointest Endosc. 1994;  40 165-170
  • 13 Diehl A K. Symptoms of gallstone disease.  Baillière’s Clin Gastroenterol. 1992;  6 635-657
  • 14 Brand B, Groth J, Stange E F. Fasting gallbladder volumes and GB-emptying is different in patients with symptomatic vs. asymptomatic stones.  Gastroenterology. 1995;  108 (Suppl 4) A407
  • 15 Freeman M L. Complications of endoscopic biliary sphincterotomy: a review.  Endoscopy. 1997;  29 288-297
  • 16 Seitz U, Bapaye A, Bohnacker S, et al. Advances in therapeutic endoscopic treatment of common bile duct stones.  World J Surg. 1998;  22 1133-1144
  • 17 Pereira-Lima J C, Jakobs R, Winter U H, et al. Long term results (7 - 10 years) of endoscopic papillotomy for cholecystolithiasis. Multivariate analysis of prognostic factors for the recurrence of biliary symptoms.  Gastrointest Endosc. 1998;  48 457-464

Dr. B. Brand

Dept. of Interdisciplinary Endoscopy
University Hospital Eppendorf

Martinistrasse 52
20246 Hamburg
Germany


Fax: Fax:+ 49-40-428034420

Email: E-mail:brand@uke.uni-hamburg.de

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