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Two cases of disinsertion of the papilla following closed trauma to the abdomen were treated by suction of the papilla by a Y loop associated with temporary pyloric exclusion, gastroenterostomy and a feeding jejunostomy. The postoperative course was uneventful in the two patients. This technique is therefore indicated for associated pancreatic lesions which do not require cephalic duodenopancreatectomy.

Diameters of the common bile duct (CBD) and common hepatic duct (CHD) were measured before and after endoscopic sphincterotomy (EPT) in 100 patients. There was a significant reduction of the lumen diameter in both the CBD and CHD (p less than 0.01) after EPT. A comparison between 32 patients without symptoms (such as pain, residual stones, and elevated levels of liver enzymes) and 19 patients with remaining symptoms after EPT, showed a statistically significant reduction in both CBD and CHD diameters (p less than 0.001) in the former group, and no statistically proven changes in the diameters in the latter group, since a change of less than 1.5 mm was not considered significant. Therefore, the absence of a reduction or a dilatation of the diameter of the CBD after EPT may suggest that these patients may have persisting complaints after EPT. Measurements on models (phantoms) show that body position of the patient during endoscopic retrograde cholangiopancreatography (ERCP) has little and negligible influence on the measured diameters of the CBD and CHD.

This is a case report of ascaris worm in the common bile duct in a 61 year old lady. Ultrasound diagnosis was initially made based on the presence of linear hyperreflective foci within the common bile duct. ERCP confirmed a single worm within the duct. Balloon extraction was then successfully carried out following papillotomy. This case illustrates the value of ultrasound in the definitive diagnosis of biliary ascariasis and the therapeutic role of ERCP.

Although the transjugular approach has long been used to provide safe access to the liver, it has not been used for placement of stents in biliary obstruction. The recent development of an expandable metallic endoprosthesis now makes this method more feasible. The case of a patient with malignant biliary obstruction complicated by ascites is presented herein. Palliation was achieved with an expandable biliary endoprosthesis placed by the transjugular-hepatic vein approach.

In eight patients with stones in the bile duct, the concretions were removed percutaneously; in six, they were pushed into the duodenum following dilatation of the papilla and in two patients they were removed percutaneously by a transhepatic route using a Dormier basket. In two patients a stenosis at a choledocho-jejunostomy was successfully dilated by a percutaneously introduced balloon catheter. In five patients stenoses due to tumours of the bile duct were dilated percutaneously and an endoprosthesis introduced. There were no serious complications. The percutaneous transhepatic approach for the treatment of bile duct stones and of malignant obstruction is a valuable alternative to endoscopic and surgical treatment.

Hemorrhage is the most frequent complication of endoscopic sphincterotomy, with a reported incidence of 2 to 9 per cent. Previous reports have generally defined this complication clinically, leaving the issue of occult bleeding after sphincterotomy essentially unaddressed. Seventy-five serial sphincterotomies were reviewed to further assess this complication. Nine patients had clinically evident hemorrhage and 27 patients had occult bleeding manifested only by a decrement in hematologic parameters, for a total postsphincterotomy bleeding rate of 48 per cent. No statistically significant risk factors for bleeding were delineated. Endoscopically recognized bleeding at the time of the sphincterotomy was 47 per cent sensitive and 85 per cent specific in predicting postprocedural bleeding. Significant delayed hemorrhage was manifest in three patients, one of whom had clinically occult bleeding. We conclude that bleeding complicates endoscopic sphincterotomy much more frequently than previously reported, although often in a clinically occult manner. Significant delayed bleeding can occur, and may not be clinically apparent. Bleeding recognized endoscopically at the time of sphincterotomy is an insensitive but relatively specific predictor of postprocedural bleeding. As use of endoscopic sphincterotomy increases, careful surveillance for hemorrhagic complications, as well as efforts to identify factors predisposing to the same, will be of increasing importance.

The PTCS is a method for diagnostic and therapeutic purpose in patients with common bile duct diseases not suitable for transpapillary approach. The present paper describes a technique which shortens the usual time of treatment and reduces injury. Lithotripsy of common bile duct stones, endoscopic controlled biopsy, introduction and removal of bile duct endoprosthesis as well as percutaneous papillotomy is possible.

Since the first description by Glisson in 1681 many papers about the sphincter of Oddi have been published contributing to the understanding of its physiology. Sphincter manometry has brought to light new facts that allow a better understanding of old concepts such as the biliary dyskinesia and the post-cholecystectomy syndrome as well as a more rational evaluation of the clinical results of the sphincterectomy. A review of the physiologic, pharmacologic, diagnostic and therapeutic aspects of the dysfunction of the sphincter of Oddi is presented.

A 41 year old woman developed obstructive biliary tract disease 3 years after cholecystectomy. A surgical attempt to relieve the obstruction failed and a benign stricture of the common duct was shown at cholangiography. Percutaneous dilatation of the stricture was performed through the draining tube with excellent clinical and laboratory results.

Portobiliary fistula is a rare complication of percutaneous biliary drainage. The authors report its occurrence in four patients who had multiple percutaneous biliary procedures. One patient was treated by simple tamponade over several days, the other three by temporary balloon tamponade and permanent coil occlusion.

In middle Europe biliary complications caused by Ascaris lumbricoides are very rare. We report on endoscopic removal of an Ascaris out of the common bile duct in a 81-years-old woman.

Eighteen elderly patients with acute attacks of gallstone pancreatitis underwent early endoscopic sphincterotomy of the papilla of Vater. Eleven patients were considered to be at high risk for surgery due to chronic cardiorespiratory or renal problems. The outcome of these patients was compared with that of 20 consecutive elderly patients with gallstone pancreatitis treated at the same time by means other than endoscopic sphincterotomy. Endoscopic sphincterotomy resulted in an immediate clinical improvement in all patients, except in one patient who developed transient cholangitis; there was no mortality. In contrast, there was one death (5%) and 20% morbidity in the controls. Mean hospitalization period was shorter in patients undergoing sphincterotomy (6 compared with 9.5 days), although the patients managed by sphincterotomy were initially more seriously ill than controls. Only two of the 11 high-risk patients underwent elective cholecystectomy; all others were well during a mean follow-up of 22 months. It is concluded that early endoscopic sphincterotomy is highly effective and safe in acute attacks of gallstone pancreatitis in elderly high-risk patients.

In a prospective study of 70 patients undergoing therapeutic endoscopy, the incidence of bacteremia was established. It was observed in 20 after bougienage, 30% after the placement of an endoprosthesis, 15% after endoscopic sphincterotomy, and 25% after percutaneous biliary drainage. Although clinical symptoms were observed in only a few of these patients, perioperative antibiotic therapy is recommended in elderly patients with malignant diseases, diabetes mellitus, renal insufficiency or liver disorders.

Morphologic alterations in the major duodenal papilla were studied in 36 corpses of people with opisthorchiasis. Experience with the treatment of 1135 patients with acute opisthorchiasic cholecystocholangitis (AOChCh) has been analysed. Conservative treatment was used in 852 patients, operations were performed on 283 patients, 31 of them died. The trigger for the appearance of AOChCh is thought to be occlusion of the common bile duct and the presence of infection in bile ducts. The treatment should be started by conservative methods. Surgery is indicated if they proved to be ineffective.

Choledochocele or type III choledochal cyst is a rare lesion of the biliary tree. It may be of acquired or congenital etiology and can assume one of two anatomic variants. Either the common bile duct and the pancreatic duct enter the choledochocele together, or it is formed by the common bile duct alone with the pancreatic duct entering as a separate opening. The most frequent presenting symptoms are abdominal pain, pancreatitis, and jaundice. Traditional therapy has been either marsupialization of the cyst into the duodenum or complete surgical excision. This paper cites the eighth patient reported in the English-language literature whose choledochocele was treated endoscopically. It is the authors' opinion that either an endoscopic papillotomy or an endoscopic fistulotomy with extension of the incision over the cyst is the simpler and preferred method of treatment.

Nonoperative decompression procedures for the relief of obstructive jaundice have been used in both malignant and benign processes. These techniques have proven to be as effective as surgical procedures in the palliative management of malignant biliary stenosis. However, nonoperative decompression procedures have certain advantages, in that they reduce morbidity and mortality associated with palliative surgical procedures, resulting in a decrease in the length of hospital stay and convalescence. Endoscopic transduodenal and percutaneous methods continue to evolve with improved techniques. Herein, we describe a new technique of transduodenal endoscopic decompression of a malignant obstruction of the common bile duct using a large caliber (15 French) endoprosthesis. This is the first report of successful endoscopic placement of such a large caliber endoprosthesis reported in the United States. Subsequently, three other prostheses have been placed in a similar manner. The procedure uses a combined endoscopic-fluoroscopic method and is performed in the same setting as endoscopic retrograde cholangiopancreatography in patients with cancer of the pancreas, cholangiocarcinomas, metastatic disease, and benign strictures.

Actinomycosis of the common bile duct can masquerade as cholecystitis. This is the first report of a case. The bacteriologic and pathologic characteristics are described. This opportunistic saprophytic organism took advantage of 15 years of prednisone therapy for rheumatoid arthritis. The actinomycosis was successfully treated with tetracycline-deoxycycline for 6 weeks.

Biliary "sump" syndrome is a rare but embarrassing problem after side-to-side choledochojejunostomy or choledochoduodenostomy. Four patients with they syndrome treated nonoperatively by endoscopic sphincterotomy are described. Three of these had had choledochojejunostomy previously and the other inadvertent choledochoduodenostomy at prior common duct exploration. Cholangitic symptoms or biliary obstruction disappeared and the patients have been well for periods ranging from 2 to 5.5 years. Endoscopic sphincterotomy can eliminate the stasis area of the common duct distal to the lateral anastomosis, obviating relaparotomy, and may deserve first consideration in patients with the sump syndrome.

A new self-retaining catheter was devised for percutaneous drainage of small bile ducts. The device allows safe external drainage without the risk of catheter dislocation even in high bile duct obstruction. The catheter is also suitable for percutaneous nephrostomy in non-dilated pyelocaliceal system.

Nine cases of acute pancreatitis due to parasites in the common bile duct (Ascaris lumbricoides 4, Clonorchis sinensis 5) are reported. Eight cases were discovered at laparotomy and one at postmortem. The indications for operation were worsening pancreatitis, sepsis or cholangitis. Decompression of the biliary system and removal of parasites resulted in the recovery of the eight cases operated upon. In endemic areas, all patients with acute pancreatitis should be screened for parasites. Antibiotics and/or antihelminthics should be given if they are found. Surgery is necessary for those with worms causing biliary or pancreatic obstruction who do not respond.

Nineteen patients with distal juxtapapillary choledochoduodenal fistula diagnosed by endoscopic retrograde cholangiopancreatography are reported. Eighty-four percent of the patients had undergone previous operations on the biliary tract. Fistula appears to be mostly secondary to common bile duct exploration with rigid probes or to a technical mistake in performing sphincteroplasty. Spontaneous fistula secondary to the passage of a stone into the duodenal lumen may also occur. Common duct stones were responsible for the symptoms in most cases (70%). Endoscopic sphincterotomy showed good results in cholecystectomized patients with stones. Surgery directed to the fistula or biliary by-pass are not recommended. Uncomplicated fistula probably does not require treatment.

Successful function of an indwelling biliary endoprosthesis requires precise initial positioning relative to the stricture site. Delayed failures may occur as a result of migration either proximally or distally. The authors describe a method for retrieval of a distally displaced endoprosthesis using a vascular balloon-dilatation catheter.

This report analyzes the literature on sphincter of Oddi dysfunction as it applies to biliary-type pain. The sensitivities and specificities of the tests used to diagnose this condition (e.g., size of bile duct, drainage time of bile duct, provocative tests with morphine, sphincter of Oddi manometry) are poorly defined. Recent studies suggest that noninvasive tests such as quantitative nuclear scintigraphy and fatty meal sonography may aid in diagnosing functional common bile duct obstruction. Continuous manometry of the biliary tree with microtransducer technologies may allow a greater understanding of the causes of pain in this group of patients. Only 1 case report of pharmacologic management for this disorder exists in the literature. Endoscopic sphincterotomy may be helpful in relieving the pain that occurs in this condition but is associated with increased risks. There is no consensus in the literature as to the best test that will predict response to sphincterotomy. Controlled trials of medical therapies are needed.

A newborn twin with an antenatal diagnosis of gastroschisis underwent staged repair of the abdominal wall defect. She developed multiple fistulae due to ischemic bowel and then abdominal wall dehiscence requiring additional surgical interventions. Obstructive jaundice, first evident at 3 weeks of age, became progressively severe. A stricture of the common bile duct was diagnosed by percutaneous transhepatic cholangiography. The stricture was treated by percutaneous biliary drainage, biliary stenting, and balloon dilation of the common bile duct. These procedures, commonly used in adults for biliary decompression, may be useful alternatives to surgical intervention in infants and children with obstructive jaundice due to bile duct stricture.

From a consecutive series of 451 patients with post-cholecystectomy symptoms referred for endoscopic retrograde cholangiopancreatography (ERCP), 40 (9 per cent) were diagnosed as having sphincter of Oddi dysfunction. Eight patients were excluded from the study because of incomplete data (n = 6) or additional diagnoses (n = 2). Thirty of the patients had successful ERCP and endoscopic sphincterotomy (ES); this failed in the remaining two because of severe papillary stenosis (6.3 per cent). Endoscopic biliary manometry was performed in 23 patients (77 per cent). Immediate post-ES complications occurred in eight patients (25 per cent). At a median follow-up of 46 months (range 10-88 months) 19 patients had a good outcome (63.3 per cent) and 11 patients had a poor outcome (36.7 per cent). Patients with a good outcome tended to have a delay of months or years following cholecystectomy before the development of symptoms (median 6 years versus 0 years, P = 0.0003). At ERCP, patients with a good outcome had greater common bile duct diameters (mean +/- s.d. mm, 12.6 +/- 3.6 versus 8.8 +/- 1.8, P = 0.0003) and delayed drainage from the biliary tree of injected contrast (13 versus 2 patients, P = 0.02). Endoscopic biliary manometry was abnormal in all 15 patients with a good outcome in whom it was performed but in only 3 out of 8 patients with a poor outcome (P = 0.003). Sphincter of Oddi dysfunction is an important, albeit uncommon, cause of post-cholecystectomy symptoms. ES provides symptomatic relief in the majority of patients but improved criteria for predicting outcome are required.

Postoperative cholangiography using the T-drain canal (PCST) with flexible fibre endoscopes was done in five patients. Cases were palliative papillary drainage in malignant occlusion, passage of the intact papilla, expulsion of concrement through the cut papilla, bougienage of inflammatory bile duct stenosis with lavage removal of stone, and an endoscopic selective peripheral bile duct drainage. In one female bile duct stone wedging after endoscopic sphincterotomy of the papilla during chemical litholysis had occurred previously. For removal of residual concrements PCST competes with catheter extraction, chemolitholysis, dilatation of the papilla and endoscopic sphincterotomy. Thus far, complications are not serious. In cases of good cooperation between surgeon and endoscopist PCST could develop into a routine method.

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.

We report on two patients in whom balloon tamponade was applied for management of severe hemorrhage following endoscopic sphincterotomy (EST). In both patients after EST severe hemorrhage from the papillary orifice was treated by immediate introduction of a special balloon catheter (balloon catheter, model Mainz, Vygon, Aachen). In both patients after 10 minutes no further bleeding was visualized. We conclude that this simple procedure should be taken into account for the conservative treatment of severe hemorrhage following EST.

Ever since its description approximately 100 years ago, the sphincter of Oddi has been surrounded by controversy. First, whether it indeed existed, second, whether it had a significant physiological role in man and more recently whether abnormalities in its function give rise to a clinical syndrome. Data from animal and human studies, using sensitive techniques, have helped define the physiological role of the sphincter of Oddi, and more recent studies are determining the factors which control sphincter of Oddi function. These studies support Oddi's original description that the sphincter has a major role in the control of flow of bile and pancreatic juice into the duodenum, and equally importantly helps prevent the reflux of duodenal contents into the biliary and pancreatic ductal systems. The controversy of whether abnormalities in sphincter of Oddi motility result in clinical syndromes has not been totally resolved. Part of the difficulty has been inability to document normal and hence abnormal function of the sphincter. With the emergence of endoscopic biliary manometry as a sensitive and reproducible technique, however, the motility of the human sphincter of Oddi has come under closer scrutiny and allowed definition of possible disorders. We have used the term sphincter of Oddi dysfunction to define manometric abnormalities in patients who present with signs and symptoms consistent with a biliary or pancreatic ductal origin. Based on the manometry, we have subdivided the dysfunction into two groups; a group characterised by a stenotic pattern - that is, raised sphincter basal pressure - and a second group having a dyskinetic pattern - that is, paradoxical response to cholecystokinin injection, rapid contraction frequency, high percentage of retrograde contractions, or short periods of raised basal percentage of retrograde contractions, or short periods of raised basal pressure. It is apparent from the mamometry but also from the clinical data that the patients are a heterogeneous group and thus any therapy would need to be tailored for each patient and abnormality. The most recent therapeutic data suggest that patients with the stenotic pattern on manometry respond to division of the sphincter, however, those patients with the dyskinetic manometric pattern show no significant effect after sphincterotomy. Further prospective trials evaluating therapeutic options are under way and their results are eagerly awaited.

Spontaneous rupture of the common bile duct in adults is very rare. The authors report only the 14th case in the Western literature. A 25-year-old woman had signs of peritonitis suggestive of a perforated appendix, but at operation the appendix appeared normal and a large amount of bile was found in the peritoneal cavity. A 2-mm tear was found on the anterior wall of the common bile duct. The patient recovered without complications after T-tube drainage and cholecystectomy. In this patient none of the factors thought to cause spontaneous rupture of the common bile duct were present, so the authors conclude that the case may be classified as idiopathic spontaneous rupture of the common bile duct.