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This is the first report of a case of biliopancreatic fistula complicating a pancreatic pseudocyst diagnosed correctly by transabdominal ultrasound. The diagnosis was confirmed by magnetic resonance and endoscopic retrograde cholangiopancreatography. The fistula was treated successfully with biliary stenting. The clinical and imaging features of this exceptional complication are presented along with a brief review of the topic.

Within the past several years, there has been dramatic advances in diagnostic and therapeutic modalities involving EGD and ERCP. Endoscopic sclerotherapy of esophageal varices is effective in controlling acute variceal bleeding in approximately 90% of the patients. Once bleeding is controlled, sclerotherapy may be a useful, long term treatment to prevent recurrent hemorrhage and to improve survival. In the treatment of patients with nonvariceal upper Gl bleeding, endoscopic electrocoagulation and laser photocoagulation does not significantly alter the operative rate or mortality rate. However, a subset of patients with either a visible vessel or angiodysplasia may benefit from endoscopic therapy of upper Gl bleeding. Another innovation, the ultrasonic endoscope has many potential applications, but instrumentation needs to be improved significantly before this diagnostic modality will be of clinical value. In the treatment of biliary tract disease, endoscopic sphincterotomy has revolutionized the therapy of patients with common bile duct stones and sphincter of Oddi disorders. Although sphincter of Oddi manometry is in its infancy, pressure measurements in the sphincter segment appear useful in identifying patients with sphincter of Oddi dysfunction who will benefit from sphincterotomy. Following endoscopic sphincterotomy, transpapillary biliary catheters, endoprosthesis and Gruntzig's balloons can be placed endoscopically into the common bile duct. These techniques are beneficial in the therapy of patients with large common bile duct stones as well as in short or long term management of patients with benign or malignant strictures of the biliary tree.

Endoscopic papillotomy is nine years old. During this time it obtained a well defined place in the treatment of common bile duct stones and of papillary stenosis. In about 85% this method proved to be successful without any problems. To lower the risk and to improve the results now smaller steps must be done. Within the last 4 years we have learned to manage even big stones with a reduced risk by stone dissolution and by a new lithotripsy device. Biliary pancreatitis has become an indication for an early duodenoscopy and even papillotomy. Acute obstructive suppurative cholangitis may be treated by endoscopy with a lower risk than by surgical intervention. Even the feared Dormia basket impaction in most cases is no longer an indication for an emergency operation. Mostly it can be treated by a second endoscope together with a new cutting device designed by Mr. Mori. All these small steps have improved the success rate of papillotomy from 94% to 99%, rate of definite stone management from 87% to 92%, reducing the complication rate from 8% to 4% at the same time.

Previous anatomical studies have described a distinct sphincteric structure at the entrance of the common bile and pancreatic ducts in the duodenum. However, from an anatomical point of view, the pancreatic duct sphincter is only present in one third of human specimens. The purpose of the present study was therefore to investigate whether sphincteric activity could be demonstrated in patients in whom the common bile duct sphincter was completely transsected during endoscopic sphincterotomy. Twelve patients had a complete bile duct sphincterotomy because of sphincter of Oddi dyskinesia. The sphincterotomy was checked manometrically in all, and neutralization of the choledochoduodenal gradient recognized. In all patients a distinct pancreatic sphincteric zone with base-line elevation and superimposed phasic activity was demonstrated. In six patients the pancreatic duct sphincter was studied before and after bile duct sphincterotomy, and, although a definite sphincter zone still was present in the pancreatic duct, a reduction in phasic wave amplitude was observed. A similar decreased base-line and pancreatic duct pressure was observed, although not statistically significant.