Daniel J. Ellis, MD1, Divyesh Nemakayala, MD2, Janak N. Shah, MD3, Ricardo V. Romero, MD3, John A. Evans, MD3, Abdul H. El Chafic, MD3; 1Ochsner Medical Center, Jefferson, LA; 2Ochsner Clinic Foundation, Jefferson, LA; 3Ochsner Medical Center, New Orleans, LA
Introduction: Common bile duct (CBD) dilation can result from diverse benign or malignant etiologies. Imaging including magnetic resonance cholangiopancreatography can be inconclusive for the etiology of CBD dilation, and additional workup including endoscopic ultrasound (EUS) is often necessary given superior diagnostic sensitivity and the ability for tissue acquisition. Herein, we report an unusual case of recurrent biliary obstruction from intermittent invagination of the of the major papilla into the distal CBD.
Methods: A 58-year-old female with history of migraines and fibromyalgia presented for evaluation of intermittent right sided abdominal pain lasting several hours with associated with dark urine and clay-colored stools. No provoking or palliating factors. Attacks occurred at least monthly, with no symptoms in the interlude. No history of elevated liver tests while patient was asymptomatic (between attacks). CT imaging showed biliary dilation of 13 mm compared to only 7 mm a year prior. She was not on any medications to precipitate biliary dilation, and gallbladder remained in situ. No alcohol or smoking history. No family history of malignancy. As per our current practice for evaluating possible biliary obstruction, the patient was offered an EUS with possible ERCP. EUS demonstrated normal gallbladder, biliary dilation and intermittent invagination of major papilla into the distal CBD (figure a). An ERCP was performed, which showed an invaginated ampulla that extruded only after peri-ampullary tissue retraction via forceps (figures b,c). No other specific ampullary pathology was seen. The distal peri-ampullary portion was hooked with one jaw of an endoclip to maintain tissue retraction and extrusion of the ampulla, and to facilitate cannulation (figure d). A biliary sphincterotomy was performed (figure e) and balloon sweep showed no sludge or stones. Five months later the patient reports no recurrence of attacks, dark urine, or clay colored stool. Discussion: We report a rare case in which intermittent invagination of the major papilla into the distal CBD precipitated symptoms of episodic biliary obstruction. This was successfully managed by biliary sphincterotomy.
Figure. a) Endoscopic ultrasound showing invagination of the major papilla (arrow) into the distal common bile duct (CBD) resulting in CBD dilatation. b) Endoscopic retrograde cholangiopancreatography (ERCP) image notable for obscured major papilla (circle) which becomes visible (c) only after endoscopic manipulation (arrow). d) The peri-ampullary tissue was hooked with an endoclip (black arrow) to maintain exposure and evaluation of the ampulla (yellow arrow) and facilitate cannulation. e) Cannulation and biliary sphincterotomy was performed for duct evaluation and definitive management.
Disclosures: Daniel Ellis indicated no relevant financial relationships. Divyesh Nemakayala indicated no relevant financial relationships. Janak Shah indicated no relevant financial relationships. Ricardo Romero indicated no relevant financial relationships. John Evans indicated no relevant financial relationships. Abdul El Chafic: Boston Scientific – Consultant.