Detection of Helicobacter pylori DNA in human biliary tree and its association with hepatolithiasis

Recently, several authors have reported that Helicobacter pylori DNA has been found in human bile. The aim of this study is to investigate the presence of H. pylori in the biliary tree of Koreans, including the bile, biliary epithelium, and gallstones. This study analyzed intrahepatic bile, bile duct tissue, and gallstones from 43 patients with hepatobiliary disease (PTCS group), gallbladder bile and tissue from 23 patients with gallbladder disease (CCT group), and eight patients without hepatobiliary disease (control group). H. pylori was examined by PCR with two different primers. PCR was positive in 4/43 (9.3%) by 26 kDa protein antigen primer and in 5/43 (11.6%) by urease A gene primer in bile from the PTCS group. However, in intrahepatic duct tissue, PCR was positive in only one case. PCR of gallbladder bile, tissue, and intrahepatic duct stones was negative. Upon intrahepatic bile analysis, the pH was significantly lower in PCR-positive than in negative cases (P < 0.05). In conclusion, H. pylori DNA may be present in the bile when there are certain environmental changes, such as lowered pH; however, H. pylori does not colonize the bile duct epithelium. We could find no pathogenetic role for H. pylori in the formation of hepatolithiasis.

Detection of Helicobacter pylori DNA in human biliary tree and its association with hepatolithiasis

Recently, several authors have reported that Helicobacter pylori DNA has been found in human bile. The aim of this study is to investigate the presence of H. pylori in the biliary tree of Koreans, including the bile, biliary epithelium, and gallstones. This study analyzed intrahepatic bile, bile duct tissue, and gallstones from 43 patients with hepatobiliary disease (PTCS group), gallbladder bile and tissue from 23 patients with gallbladder disease (CCT group), and eight patients without hepatobiliary disease (control group). H. pylori was examined by PCR with two different primers. PCR was positive in 4/43 (9.3%) by 26 kDa protein antigen primer and in 5/43 (11.6%) by urease A gene primer in bile from the PTCS group. However, in intrahepatic duct tissue, PCR was positive in only one case. PCR of gallbladder bile, tissue, and intrahepatic duct stones was negative. Upon intrahepatic bile analysis, the pH was significantly lower in PCR-positive than in negative cases (P < 0.05). In conclusion, H. pylori DNA may be present in the bile when there are certain environmental changes, such as lowered pH; however, H. pylori does not colonize the bile duct epithelium. We could find no pathogenetic role for H. pylori in the formation of hepatolithiasis.

Telomerase activity in pure pancreatic juice for the diagnosis of pancreatic cancer may be complementary to K-ras mutation

BACKGROUND

The usefulness of K-ras mutation in pancreatic juice for the diagnosis of pancreatic cancer is questionable. Telomerase is positive in pancreatic cancer but rarely in benign pancreatic diseases. We conducted this study to determine the usefulness of K-ras mutation and telomerase activity in pancreatic juice for the diagnosis of pancreatic cancer.

METHODS

Pancreatic juice collected during endoscopic retrograde cholangiopancreatography was examined in 31 patients: 12 with pancreatic cancer, 11 with chronic pancreatitis, and 8 control patients. The K-ras gene was detected by using the restriction fragment length polymorphism method. Telomerase activity was detected by using the telomeric repeat amplification protocol.

RESULTS

K-ras mutation was positive in 75% (9 of 12) of pancreatic cancers and in 27% (3 of 11) of cases of chronic pancreatitis but in none of the control patients. Telomerase activity was detected in 92% (11 of 12) of pancreatic cancers and in 18% (2 of 11) of cases of chronic pancreatitis. The diagnostic value in pancreatic cancer was comparable between K-ras mutation and telomerase when evaluated separately. However, by combining these 2 methods, the specificity rose to 100%.

CONCLUSIONS

For the diagnosis of pancreatic cancer, telomerase activity in pancreatic juice may possibly be complementary to K-ras mutation because it may decrease the rate of false-positive diagnosis.

Mucin-hypersecreting bile duct tumor characterized by a striking homology with an intraductal papillary mucinous tumor (IPMT) of the pancreas

BACKGROUND AND STUDY AIMS

The mucin-hypersecreting bile duct tumor, which closely resembles an intraductal papillary mucinous tumor (IPMT) of the pancreas, is rare, and its clinical features are not well known. We report our experience of nine patients with this type of tumor, and analyze the data in order to elucidate its clinicopathologic characteristics.

PATIENTS AND METHODS

Between 1995 and 1998, nine consecutive patients (four men, five women; mean age 54) who were diagnosed as having a mucin-hypersecreting bile duct tumor were enrolled in this study.

RESULTS

Recent or previous attacks of biliary pain and acute cholangitis were reported by most of the patients. Characteristics included a widely open ampulla of Vater with extrusion of mucin, and a diffuse dilated intrahepatic and extrahepatic bile duct with amorphous filling defects on cholangiogram. On cholangioscopic examination, a papillary mass or minute mucosal lesion was found in the dilated bile duct containing thick viscid mucin. Nine patients were referred for an operation, and curative resection was performed in eight of them. Using histologic examination, well differentiated adenocarcinoma in the background of benign hyperplasia and adenoma was documented in all patients except one, who showed pure adenoma.

CONCLUSION

The mucin-hypersecreting bile duct tumor can be characterized by a striking homology with IPMT of the pancreas in clinical, radiologic, and pathologic features.

The risk groups for coronary heart disease in Koreans. Assessment by distribution of serum lipid concentrations

Coronary heart disease is the most severe form of disease caused by atherosclerosis; and there is a strong relationship between serum lipid concentrations and atherosclerosis. By decade of life, means, standard deviations and selected percentiles were calculated according to sex for serum concentrations of total cholesterol, low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C) and triglyceride in 69,563 Koreans. The prevalence of dyslipoproteinemias which were related to high risk of coronary heart disease were assessed. The mean concentrations of serum total cholesterol and LDL-C in the Korean population were 5.02 mmol/l and 3.00 mmol/l. The 75th and 90th percentile concentrations of total cholesterol were 5.59 mmol/l and 6.24 mmol/l. The mean concentrations of serum triglyceride and HDL-C were 1.58 mmol/l and 1.30 mmol/l. The hyperlipoproteinemia type IV (4.8%) was the most frequent, followed by Type IIa (4.6%), hypoalphalipoproteinemia (3.3%), and type IIb (0.2%). According to the National Cholesterol Education Program Adult Treatment Panel II, 4.1% of Korean adults needed the initial drug therapy and 10.8% the initial dietary therapy for hypercholesterolemia. The age and sex-specific treatment guidelines for hypercholesterolemia would make it possible that early intervention could be applied to atherosclerosis in Korean adults.

Epidemiological study on Korean gallstone disease: a nationwide cooperative study

To clarify the epidemiological characteristics of gallstone disease in Korea and to evaluate the chronological changes in gallstone disease, the authors performed this first prospective nationwide cooperative study. The subjects were 1263 gallstone patients who were admitted at 19 hospitals in Korea from February to July 1997. Questionnaires were recorded on 1263 patients and gallstones were harvested from 1133 patients. The proportion of patients with gallbladder (GB), common bile duct (CBD), and intrahepatic duct (IHD) stones among total gallstone patients was 64.0%, 21.9%, and 14.1%, respectively. GB stones were categorized as cholesterol (58.1%), black pigment (25.2%), and brown pigment (12.1%) stones. CBD stones were classified as brown pigment (76.1%), cholesterol (18.4%), and black pigment (3.5%) stones. IHD stones were classified as brown pigment (61.4%) and mixed (35.6%) stones. Intrahepatic mixed stones had mean cholesterol and bilirubin contents of 63.4 +/- 20.8% and 23.1 +/- 9.9%, respectively. In contrast, IHD brown pigment stones had mean cholesterol and bilirubin contents of 35.1 +/- 20.5% and 39.6 +/- 17.4%, respectively. Our study showed that the type and composition of gallstones in Korea was somewhat different compared with those in the West. This study also demonstrated that there have been chronological changes in the type and composition of gallstones when compared with previous domestic data. Another nationwide cooperative study may be needed to elucidate and confirm the changing pattern of gallstone disease.

Proton magnetic resonance spectroscopy (1H-MRS) findings for the brain in patients with liver cirrhosis reflect the hepatic functional reserve

OBJECTIVE

Proton magnetic resonance spectroscopy (1H-MRS) has been used to assess the metabolic changes in the brain in patients with liver cirrhosis. Decreased myo-inositol and increased glutamine levels were noted to be the most sensitive spectroscopic markers for cirrhotic patients with hepatic encephalopathy (HE). The purpose of this study was to assess how the abnormalities seen on the 1H-MRS of the brain in patients with liver cirrhosis are related to clinical and laboratory parameters.

METHODS

In a prospective study, localized 1H-MRS was performed in the basal ganglia and parietal white matter regions in liver cirrhosis patients with (n = 48) and without (n = 52) HE and chronic hepatitis (CH) (n = 15), and in normal controls (n = 20).

RESULTS

Among cirrhotic patients, the myo-inositol levels were significantly lower (p < 0.01) and the glutamine levels were higher (p < 0.05) for patients with HE than for those without HE. The myo-inositol and glutamine levels, respectively, were inversely (r = -0.50; p < 0.001) and linearly (r = 0.50; p < 0.001) related to the Child-Pugh score. However, by subgroup analysis of Child-Pugh class C patients, there were no significant differences in the myo-inositol and glutamine levels between cirrhotic patients with (n = 40) and without HE (n = 24). A follow-up study of eight cirrhotic patients with HE showed no significant differences in the myo-inositol and glutamine levels after clinical improvement of HE.

CONCLUSIONS

The abnormalities seen on the 1H-MRS of the brain of patients with liver cirrhosis are not likely to reflect the severity of HE or acute alteration in the level of consciousness. Rather, we believe they represent the chronic metabolic derangement of the brain associated with hepatic functional reserve.

Endoscopic hemostasis in sphincterotomy-induced hemorrhage: its efficacy and safety

BACKGROUND AND STUDY AIMS

Hemorrhage is induced in approximately 0.5-12% of endoscopic biliary sphincterotomy (ES) procedures. We prospectively investigated the risk factors for ES-induced hemorrhage and evaluated the safety as well as the effectiveness of endoscopic hemostasis.

PATIENTS AND METHODS

The study included 1304 patients who underwent ES between July 1996 and June 1998. Epinephrine spray was used initially for hemostatic treatment. If bleeding persisted, an epinephrine injection was given consecutively. In patients with exposed vessels, epinephrine injection followed by alcohol injection was given.

RESULTS

ES-induced hemorrhage occurred in 136 (10.4%) patients. The type of sphincterotome used (needle-knife sphincterotome, P=0.025) and the cutting speed (the so-called "zipper" cut, P = 0.049) were revealed as significant variables with regard to the occurrence of bleeding. Mild, moderate, and severe bleeding were noted in 108 (79.4%), 22 (16.2%), and six (4.4%) patients, respectively. Once bleeding occurred, patients with an associated ampullary lesion (impacted stone or cancer) or with coagulopathy were more likely to bleed profusely. Initial hemostasis was achieved in all patients. However, rebleeding occurred in eight patients who were initially classified as having moderate or severe bleeding. Finally, ES-induced hemorrhage was successfully controlled in all patients after 1-3 treatment sessions (mean 1.1 sessions). The difference in the incidence of complications between the groups treated or not treated by endoscopic hemostasis was not statistically significant.

CONCLUSIONS

ES-induced hemorrhage occurred in 10% of the patients studied. The use of needle-knife sphincterotomy and the cutting speed were independent risk factors for the occurrence of bleeding. Once bleeding occurred, its severity was affected by an associated ampullary lesion (impacted stone or cancer) or coagulopathy. Endoscopic hemostasis with epinephrine and/or alcohol was effective and safe in ES-induced hemorrhage.

A new strategy for the application of CA19-9 in the differentiation of pancreaticobiliary cancer: analysis using a receiver operating characteristic curve

OBJECTIVE

Clinicians might be misled in interpreting an elevated CA19-9 when differentiating pancreaticobiliary cancer from benign clinical conditions such as acute cholangitis or cholestasis, because in these conditions, the concentration of CA19-9 may also be elevated. The aims of our study were to calculate new individual cutoff values for CA19-9 according to clinical situations using a receiver operating characteristic (ROC) curve and to define a new strategy for interpreting CA19-9 in pancreaticobiliary cancer.

METHODS

One hundred sixty patients with pancreatic diseases (cancer 90, benign disease 70), 322 patients with biliary tract diseases (biliary cancer 152, benign disease 170), and 20,035 asymptomatic controls were enrolled in the present study. An ROC curve was described by plotting the sensitivity on the y-axis against 1-specificity on the x-axis for each of several cutoff values.

RESULTS

The area under the ROC curve was significantly greater for pancreatic cancer than for biliary cancer (p < 0.05). For patients with pancreatic cancer, CA19-9 proved to be useful. At a cutoff value of 37 U/ml, sensitivity and specificity were 76.7% and 87.1%, respectively. For patients with biliary cancer, CA19-9 was not helpful. However, when patients with biliary disease were divided into two groups according to the presence of cholangitis or cholestasis, CA19-9 proved to be more useful for the group without cholangitis or cholestasis than for the group with cholangitis or cholestasis (p < 0.05). In the former group, the sensitivity and specificity of CA19-9 were 77.6% and 83%, respectively, at the cutoff value of 37 U/ml. For the latter group, the sensitivity and specificity of CA19-9 were 74% and 41.5% respectively, whereas the specificity reached 87% at 300 U/ml. CA19-9 in diagnosing pancreatic cancer was useful regardless of accompanying acute pancreatitis or cholestasis. The serum concentration of CA19-9 in asymptomatic individuals was 9.42 +/- 9.95 U/ml. Only 1 of 157 patients with a concentration of CA19-9 above 37 U/ml was found to have gallbladder cancer. The positive and negative predictive values were 0.65% and 0.78%, respectively.

CONCLUSIONS

The use of CA19-9 for the differentiation of pancreaticobiliary cancer should be applied individually, depending on the clinical situation.

Choledochal cyst associated the with anomalous union of pancreaticobiliary duct (AUPBD) has a more grave clinical course than choledochal cyst alone

OBJECTIVE

Since choledochal cyst is frequently associated with the anomalous union of pancreaticobiliary duct (AUPBD), AUPBD has been regarded to be the etiologic factor of choledochal cyst. However, the clinical significance of AUPBD an patients with choledochal cyst has not been clearly defined. Therefore, to clarify the significance of AUPBD in choledochal cyst patients, we compared the clinical features of patients with choledochal cyst according to the presence or absence of AUPBD.

METHODS

Among 52 cases which were diagnosed as choledochal cyst out of 5,037 ERCP referrals between August 1990 and December 1996, we selected 44 cases, in which the pancreaticobiliary junction was clearly visualized on cholangio-pancreaticography. These cases were divided into AUPBD-present group (n = 28) and AUPBD-absent group (n = 16). Clinical features were compared between the two groups. Furthermore, in AUPBD-present group, clinical data were also analyzed according to Kimura's classification of AUPBD.

RESULTS

In our study, AUPBD was associated with choledochal cyst in 28 (64%) cases. AUPBD was found only in type I and IV according to Todani's classification of choledochal cyst. There were no significant differences between the AUPBD-present group and the AUPBD-absent group in the incidence of gallstone disease, while the incidence of acute inflammation was 93% (26/28) in the AUPBD-absent group (p < 0.01). Carcinoma developed only in the AUOBD-present group (9/28, 32%) (p < 0.05). Pancreatic disorders (i.e. pancreatic stone, pancreatitis or pancreatic cancer) occurred in 12 of 28 cases in the AUPBD-present group (43%), while only in 1 of 16 cases in the AUPBD-absent group (6%) (p < 0.05).

CONCLUSION

AUPBD associated with choledochal cyst may have implications not only as a possible etiologic factor but also as an important factor that may affect the clinical course, surgical planning and prognosis. In cases with choledochal cyst, we should make an effort to evaluate the presence of AUPBD.

Appendiceal orifice inflammation as a skip lesion in ulcerative colitis: an analysis in relation to medical therapy and disease extent

BACKGROUND

Although several reports have claimed that the appendix can be involved as a skip lesion in ulcerative colitis, they do not exclude the possibility that this skip lesion occurs as a result of medical therapy. Also, little is known about the relation between the presence of appendiceal orifice inflammation and the extent of the disease.

METHODS

The presence of appendiceal orifice inflammation was prospectively assessed both endoscopically and histologically in 94 patients with active ulcerative colitis, the extent of whose disease had not been beyond the hepatic flexure. To evaluate the effect of prior medical therapy on the prevalence of appendiceal orifice inflammation, all cases were divided into two groups. Group A consisted of 66 patients who had been treated before inclusion; group B was composed of 28 patients newly diagnosed at inclusion.

RESULTS

Appendiceal orifice inflammation was diagnosed in 24 (26%) of 94 patients with active subtotal ulcerative colitis, with no statistical difference observed between group A (23%) and group B (32%). In all 94 patients, the frequency of appendiceal orifice inflammation decreased significantly as the extent of disease increased, i.e., 37% in proctitis (n = 49), 17% in left-sided colitis (n = 36), and 0% in extensive colitis (n = 9) (p < 0.05).

CONCLUSIONS

Appendiceal orifice inflammation as a skip lesion of ulcerative colitis is not rare, is more frequently observed in patients with less extensive disease, and is not the result of patchy improvement due to medical therapy.

Prognostic value of DNA flow cytometry in stomach cancer: a 5-year prospective study

The role of DNA flow cytometry in the prediction of prognosis for patients with stomach cancer remains to be defined. Thus we studied prospectively the role of DNA flow cytometry as a prognosis indicator in stomach cancer patients in a high-incidence area. Between November 1990 and December 1992, primary stomach cancer tissues were obtained from the surgical specimens from 217 patients (148 male, 69 female). DNA flow cytometric analyses of DNA ploidy and S-phase fraction were performed and the results were correlated with patient survival. The median age of the patients was 55 years (range 24-78). Aneuploid cell population was found in 114 of 217 samples (53%). Tumour S-phase fraction was obtained in 96 of 103 diploid tumours (93%) and 61 of 114 aneuploid tumours (54%). After median follow-up of 66.1 months, the patients with tumours with an S-phase fraction over 17% had significantly worse survival rates than patients with tumours with S-phase fractions of lower than 8% or 8-17% (45% vs 59% and 63% of patients surviving, P = 0.007). Tumour ploidy status did not correlate with patient survival. Multivariate analyses showed that the TNM stage remained the most important prognostic indicator. The tumour S-phase fraction was also an independent prognostic indicator (relative risk 2.300, 95% CI, 1.252-4.223). Tumour S-phase fraction obtained by DNA flow cytometry is an independent prognostic indicator for the survival of the patients with stomach cancer.

Usefulness of cholangioscopy in patients with focal stricture of the intrahepatic duct unrelated to intrahepatic stones

BACKGROUND

Intrahepatic duct strictures are usually caused by intrahepatic duct stones and cholangitis. However, focal strictures of the intrahepatic duct unrelated to intrahepatic stones often pose diagnostic problems. This study was undertaken to prospectively evaluate the usefulness of percutaneous transhepatic cholangioscopy in patients with focal intrahepatic duct stricture and no evidence of a stone.

METHODS

Seventeen patients with focal strictures of the intrahepatic duct without any evidence of a stone were included. Percutaneous transhepatic cholangioscopic examination including procurement of biopsy specimens was performed after percutaneous transhepatic biliary drainage.

RESULTS

A histopathologic diagnosis was obtained in all patients (9 adenocarcinomas, 1 squamous cell carcinoma, 2 hepatocellular carcinomas, 2 adenomas, and 3 benign strictures). Of the 9 patients with bile duct adenocarcinoma, 8 underwent surgery and a curative resection was possible in 7 patients (88%). Five patients (63%) had early-stage bile duct cancer in which cancer invasion was limited to the mucosa or fibromuscular layer and there was no evidence of lymph node metastasis.

CONCLUSIONS

Percutaneous transhepatic cholangioscopy in patients with focal stricture of the intrahepatic duct unrelated to choledocholithiasis is useful for diagnosis including the detection of early bile duct cancer.

Intestinal tuberculosis with abdominal complications: radiologic and pathologic features

BACKGROUND

To investigate radiologic and pathological features of intestinal tuberculosis with abdominal complications.

METHODS

Twenty-two patients with 23 surgically proven complications (nine intestinal obstructions, eight perforations, three fistulae, and three intestinal bleeds) were analyzed. Medical records, radiologic studies, and pathologic examinations were reviewed with special emphasis on searching for the common features in each group of complication.

RESULTS

The most important single feature in seven of the nine patients with intestinal obstruction was the presence of stricture. In the remaining two patients, bowel adhesion was a primary cause of obstruction. In eight patients with intestinal perforation, both obstruction and ulcerations in the dilated proximal loop were the important features in six, and multiple deep ulcerations without obstruction was a primary cause in the remaining two. The common features in three patients with fistulae were focal or multiple strictures, severe adhesions, and fibrotic bowel wall. Intestinal bleeding originated from diffuse mucosal ulcerations. The abdominal complications occurred during antituberculous therapy in 10 of the 22 patients.

CONCLUSION

Understanding the radiologic and pathologic features of intestinal tuberculosis with complications help in making an appropriate clinical decision for the treatment strategy. Close observation is necessary, especially in those patients who are acutely ill during antituberculous medical therapy. Enteritis-Intestines, diseases-Intestines, infection-Intestines, perforation-Intestines, stenosis or obstruction.

Zinc deficiency manifested by dermatitis and visual dysfunction in a patient with Crohn's disease

We report a case of Crohn's disease with low serum zinc concentration in a 26-year-old woman. She demonstrated acrodermatitis enteropathica and decreased visual acuity during total parenteral nutrition. Subsequent intravenous zinc supplementation resulted in alleviation of the skin lesions and improvement of visual acuity. This case supports the notion that depressed serum zinc in Crohn's disease may cause clinical manifestations, such as acrodermatitis enteropathica and retinal dysfunction, which may be correctable with zinc supplementation.

Biliary papillomatosis: clinical, cholangiographic and cholangioscopic findings

BACKGROUND AND STUDY AIMS

Biliary papillomatosis (BP) is a very rare disease and its clinical features and outcome are not well known. The aims of this study were to describe the characteristic cholangiographic findings and to define the role of cholangioscopic examination in the diagnosis and treatment of this disorder.

PATIENTS AND METHODS

Nine patients (six men and three women, mean age 57 years) were diagnosed as BP among 5361 cases of endoscopic retrograde cholangiography (ERC) from 1990 to 1997 in our institution. The cholangiographic and cholangioscopic findings as well as clinical features were retrospectively analyzed.

RESULTS

ERC findings showed multiple small, round-to-ovoid filling defects in the bile duct and ductal wall irregularity in all the patients. Seven out of nine patients underwent percutaneous transhepatic cholangioscopic (PTC) examination. Additional small papillary lesions in the intrahepatic bile duct were detected by cholangioscopic examination in four patients whose ERC findings only revealed the extrahepatic lesions. Two of these four patients underwent curative resection. In these two patients, the initial surgical plan was changed from Whipple's operation to hepatico-pancratico-duodenectomy after preoperative cholangioscopic examination due to the detection of new lesions in the intrahepatic bile duct.

CONCLUSIONS

ERC findings of BP were highly characteristic. When BP is suspected by conventional imaging including ERC, preoperative percutaneous transhepatic cholangioscopic examination is, however, strongly recommended. This procedure may be beneficial to precisely determine the ductal extension of the disease, hence to decide whether or not hepatic resection is needed as well as to confirm the histology.

Routine biliary sphincterotomy may not be indispensable for endoscopic pancreatic sphincterotomy

BACKGROUND AND STUDY AIMS

It is generally accepted that biliary sphincterotomy is mandatory to avoid possible cholestasis and infection due to edema after pancreatic sphincterotomy. However, biliary sphincterotomy is an invasive procedure and the above claim on dual sphincterotomy has not been proven by a prospective randomized study. The aim of our study was to determine whether cholangitis develops more frequently when the patients have not undergone concomitant biliary sphincterotomy during the endoscopic pancreatic sphincterotomy.

PATIENTS AND METHODS

From January 1990 to November 1997, 60 patients (38 men, 22 women, age range 19-45 years) with non-alcoholic chronic calcifying pancreatitis were prospectively enrolled. The patients with jaundice (bilirubin > or = 3 mg/dl), cholangitis, or parenchymal liver disease were excluded. The patients were randomly subjected either to dual sphincterotomy (group I, n = 30) or to pancreatic sphincterotomy alone (group II, n = 30). Groups I and II were further classified as IA (or IIA) and IB (or IIB), according to the level of serum alkaline phosphatase (sALP) and the diameter of the common bile duct (CBD). Group IA (or IIA) was defined when abnormal in both sALP (> or = 2 times the upper limit of normal) and CBD diameter (> or = 12 mm), whereas group IB (or IIB) was defined when normal, or solely abnormal in sALP or CBD diameter.

RESULTS

As a complication after sphincterotomy, pancreatitis developed in one of eight patients (12.5%) in group IA, whereas cholangitis occurred in one of 22 (4.5%) and hemorrhage in one of 22 (4.5%) cases in group IB. By contrast, in group IIA, the cholangitis developed in 56% (five of nine patients), which was significantly more frequent than in any other groups (P < 0.05). Hemorrhage (one of 21, 4.8%) and pancreatitis (one of 21, 4.8%) occurred in group IIB.

CONCLUSIONS

Our results suggest that dual sphincterotomy may be indicated only in patients who have both dilated choledochus and elevated alkaline phosphatase in chronic pancreatitis. Routine biliary sphincterotomy may not be indispensable for pancreatic sphincterotomy.

Ballooning of the papilla during contrast injection: the semaphore of a choledochocele

BACKGROUND

Choledochocele is a rare abnormality involving the intramural segment of the common bile duct. ERCP is essential to demonstrate a choledochocele. The aim of this study was to investigate the duodenoscopic and cholangiographic findings during ERCP.

METHODS

Over a 4-year period, 17 symptomatic patients (8 men, 9 women; age range 45 to 83 years) were identified as having choledochoceles. The diagnosis of choledochocele was made by both duodenoscopic and cholangiographic findings.

RESULTS

As a characteristic duodenoscopic finding, the enlarged bulging papilla was noted in 8 patients (47%), whereas a normal-appearing papilla was noted in 9 patients (53%) before the injection of contrast media. However, in all 17 patients progressive enlargement or ballooning of the papilla was noted during contrast injection. The maximum diameter of the choledochocele, determined by cholangiography, was significantly larger (19 +/-4 mm) in patients with initially bulging papilla than in those with normal-appearing papilla (9+/-3 mm) (p < 0.05).

CONCLUSIONS

Ballooning of the papilla during contrast injection may be a specific duodenoscopic finding for choledochocele. To avoid missing the diagnosis of a choledochocele, especially when it is small, it is important to watch the papilla carefully during contrast injection.