Background. Although periampullary diverticulum is usually asymptomatic and discovered incidentally in patients during endoscopic retrograde cholangiopancreatography (ERCP), it may lead to post-ERCP morbidity. We compared baseline characteristics and clinical data as well as ERCP results in patients with and without periampullary diverticulum. Methods. Clinical, laboratory, and ERCP data of 780 patients referred to the Taleghani Hospital, as a great referral endoscopy center, in Iran were prospectively analyzed. Results. The periampullary diverticulum was identified in 44 patients (5.6%). Cannulation of common bile duct was more failed in patients with diverticulum compared to others (35.5% versus 11.5, ). Patients with diverticulum had eight times more often common bile duct stone compared to patients without diverticulum (54.5% versus 12.2%, ). Post-ERCP complications were observed in 2.3% and 4.2% of patients with and without diverticulum, respectively, which did not significantly differ in both groups. Conclusion. Because of more failure cannulation in the presence of periampullary diverticulum, ERCP requires more skills in these patients. Prevalence of common bile duct stone was notably higher in patients with diverticulum; therefore, more assessment of bile stone and its complications in these patients is persistently recommended. 1. Introduction Periampullary diverticulum is commonly situated on the second part of the duodenum and usually occurred in the elderly, with a slight female preponderance [1, 2]. It is usually caused by the progression of duodenal motility disorders. Furthermore, progressive weakening of intestinal smooth muscles and increased intraduodenal pressure have been known as main underlying etiologies for this defect [3]. The incidence of this finding widely varies from 1% to 32.8% based on different diagnostic approaches such as barium graphs, endoscopic retrograde cholangiopancreatography (ERCP) evaluation, and autopsy series [4–7]. Although periampullary diverticulum is usually asymptomatic and discovered incidentally in patients during ERCP, its association with various pathological conditions such as choledocholithiasis, perforation, pancreatitis, bleeding, CBD obstruction, and rarely carcinoma has been well recognized in various studies [8–12]. One of the most important problems to the endoscopists is the impact of these diverticula on the success of therapeutic or diagnostic ERCP procedures. In some reports, cannulation difficulty during ERCP was associated with the presence of periampullary diverticulum [3] and, in some
References
[1]
M. K. Leivonen, J. A. A. Halttunen, and E. O. Kivilaakso, “Duodenal diverticulum at endoscopic retrograde cholangiopancreatography, analysis of 123 patients,” Hepato-Gastroenterology, vol. 43, no. 10, pp. 961–966, 1996.
[2]
J. Boix, V. Lorenzo-Zú？iga, F. A？a？os, E. Domènech, R. M. Morillas, and M. A. Gassull, “Impact of periampullary duodenal diverticula at endoscopic retrograde cholangiopancreatography: a proposed classification of periampullary duodenal diverticula,” Surgical Laparoscopy, Endoscopy and Percutaneous Techniques, vol. 16, no. 4, pp. 208–211, 2006.
[3]
D. N. Lobo, T. W. Balfour, and S. Y. Iftikhar, “Periampullary diverticula: consequences of failed ERCP,” Annals of the Royal College of Surgeons of England, vol. 80, no. 5, pp. 326–331, 1998.
[4]
T. Zoepf, D.-S. Zoepf, J. C. Arnold, C. Benz, and J. F. Riemann, “The relationship between juxtapapillary duodenal diverticula and disorders of the biliopancreatic system: analysis of 350 patients,” Gastrointestinal Endoscopy, vol. 54, no. 1, pp. 56–61, 2001.
[5]
A. Rajnakova, P. M. Y. Goh, S. S. Ngoi, and S. G. Lim, “ERCP in patients with periampullary diverticulum,” Hepato-Gastroenterology, vol. 50, no. 51, pp. 625–628, 2003.
[6]
T. C. K. Tham and M. Kelly, “Association of periampullary duodenal diverticula with bile duct stones and with technical success of endoscopic retrograde cholangiopancreatography,” Endoscopy, vol. 36, no. 12, pp. 1050–1053, 2004.
[7]
M. I. Yildirgan, M. Ba？o？lu, I. Yilmaz et al., “Periampullary diverticula causing pancreaticobiliary disease,” Digestive Diseases and Sciences, vol. 49, no. 11-12, pp. 1943–1945, 2004.
[8]
A. R. Dennison, R. M. Watkins, M. J. Sarr, and E. C. G. Lee, “Adenocarcinoma complicating a duodenal diverticulum,” Journal of the Royal College of Surgeons of Edinburgh, vol. 32, no. 1, pp. 44–46, 1987.
[9]
F. Oddo, P. Chevallier, J. Souci, et al., “Aspects radiologiques des complications des diverticules duodenaux,” Journal of Radiology, vol. 80, no. 2, pp. 134–140, 1999.
[10]
F. Yoneyama, K. Miyata, H. Ohta, E. Takeuchi, T. Yamada, and Y. Kobayashi, “Excision of a juxtapapillary duodenal diverticulum causing biliary obstruction: report of three cases,” Journal of Hepato-Biliary-Pancreatic Surgery, vol. 11, no. 1, pp. 69–72, 2004.
[11]
P. Tyagi, P. Sharma, B. C. Sharma, and A. S. Puri, “Periampullary diverticula and technical success of endoscopic retrograde cholangiopancreatography,” Surgical Endoscopy and Other Interventional Techniques, vol. 23, no. 6, pp. 1342–1345, 2009.
[12]
V. Panteris, A. Vezakis, G. Filippou, D. Filippou, D. Karamanolis, and S. Rizos, “Influence of juxtapapillary diverticula on the success or difficulty of cannulation and complication rate,” Gastrointestinal Endoscopy, vol. 68, no. 5, pp. 903–910, 2008.
[13]
M. L. Silviera, M. J. Seamon, B. Porshinsky et al., “Complications related to endoscopic retrograde cholangiopancreatography: a comprehensive clinical review,” Journal of Gastrointestinal and Liver Diseases, vol. 18, no. 1, pp. 73–82, 2009.
[14]
T. H. Lee, D. H. Park, J.-Y. Park et al., “Can wire-guided cannulation prevent post-ERCP pancreatitis? A prospective randomized trial,” Gastrointestinal Endoscopy, vol. 69, no. 3, pp. 444–449, 2009.
[15]
A. A. Bailey, M. J. Bourke, S. J. Williams et al., “A prospective randomized trial of cannulation technique in ERCP: effects on technical success and post-ERCP pancreatitis,” Endoscopy, vol. 40, no. 4, pp. 296–301, 2008.
[16]
A. J. Kaffes, P. V. J. Sriram, G. V. Rao, D. Santosh, and D. N. Reddy, “Early institution of pre-cutting for difficult biliary cannulation: a prospective study comparing conventional versus a modified technique,” Gastrointestinal Endoscopy, vol. 62, no. 5, pp. 669–674, 2005.
[17]
J. M. Waugh and E. V. Johnston, “Primary diverticula of the duodenum,” Annals of Surgery, vol. 141, no. 2, pp. 193–200, 1955.
[18]
R. H. Kennedy and M. H. Thompson, “Are duodenal diverticula associated with choledocholithiasis?” Gut, vol. 29, no. 7, pp. 1003–1006, 1988.
[19]
H. Hagege, A. Berson, G. Pelletier et al., “Association of juxtapapillary diverticula with choledocholithiasis but not with cholecystolithiasis,” Endoscopy, vol. 24, no. 4, pp. 248–251, 1992.
[20]
S. Miyazaki, T. Sakamoto, M. Miyata, Y. Yamasaki, H. Yamasaki, and K. Kuwata, “Function of the sphincter of Oddi in patients with juxtapapillary duodenal diverticula: evaluation by intraoperative biliary manometry under a duodenal pressure load,” The World Journal of Surgery, vol. 19, no. 2, pp. 307–312, 1995.
[21]
N. Shinagawa, T. Fukui, K. Mashita, Y. Kitano, and J. Yura, “The relationship between juxtapapillary duodenal diverticula and the presence of bacteria in the bile,” The Japanese Journal of Surgery, vol. 21, no. 3, pp. 284–291, 1991.
