Clinical Endoscopy

Impact of Periampullary Diverticulum on ERCP Performance: A Matched Case-Control Study: Juan E. Corral, Omar Y. Mousa, Paul T. Kröner, Victoria Gomez, Frank J. Lukens; Clin Endosc 2019;52(1):65-71. Published online August 21, 2018; DOI: https://doi.org/10.5946/ce.2018.070

Background
/Aims: Periampullary diverticulum (PAD) is frequently encountered during endoscopic retrograde cholangiopancreatography (ERCP) and has been associated with stone formation in the bile duct. The effects of PAD on the ERCP procedure have been often debated. We aimed to compare the therapeutic success of ERCP between patients with PAD and matched controls.
Methods
We reviewed all ERCPs with findings of PAD in a national database (n=1,089) and compared them with age- and gendermatched controls in a 1:3 fashion (n=3,267). Demographics, endoscopic findings, visualization of main structures, and therapeutic success rates were compared between groups. Secondary analysis compared PAD cases and controls who had gallstone disease.
Results
The average cohort age was 68.4±14.3 years and 55.1% were male. ERCP success was similar in both groups, and no significant inter-group differences were found in the multivariate analysis. The presence of PAD did not affect the rates of sphincterotomy or visualization of main biliary structures. Secondary analysis showed similar success rates for gallstone removal between patients with PAD and controls.
Conclusions
PAD may not be considered a hinderance to ERCP success. Further research is needed to determine the best approach to cannulate the ampulla and provide endoscopic therapy for different subtypes of PAD.

Citations

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Taira Kuroda, Hideki Miyata, Kozue Kanemitsu-Okada, Emi Yanagihara, Hironobu Saneto, Taisei Murakami, Hirofumi Izumoto, Kei Onishi, Shogo Kitahata, Tomoe Kawamura, Ryuichiro Iwasaki, Fujimasa Tada, Eiji Tsubouchi, Atsushi Hiraoka, Tomoyuki Ninomiya
Digestive Diseases and Sciences.2025; 70(2): 843. CrossRef
Effect of periampullary diverticulum morphology on ERCP cannulation and clinical results
Yavuz Cagir, Muhammed Bahaddin Durak, Cem Simsek, Ilhami Yuksel
Scandinavian Journal of Gastroenterology.2025; 60(4): 292. CrossRef
Association of periampullary diverticulum types with post-ERCP hyperamylasemia: a retrospective observational study
Serdar Akca, Galip Egemen Atar, Serkan Ocal, Osman Cagin Buldukoglu, Gokhan Koker, Muhammed Devran Isik, Besir Kaya, Hatice Deniz, Ferda Akbay Harmandar, Ayhan Hilmi Cekin
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Arvid Gustafsson, Bobby Tingstedt, Greger Olsson
Therapeutic Advances in Gastroenterology.2024;[Epub] CrossRef
Impact of periampullary diverticula on the rates of successful cannulation and ERCP complications: An up‐to‐date systematic review and meta‐analysis
Xiao Xi Xie, Xiao Li, Yong Hao Chen, Chong Geng, Chun Hui Wang
Journal of Digestive Diseases.2024; 25(9-10): 573. CrossRef
Impact of periampullary diverticulum on biliary cannulation: A retrospective cohort study
Jing Liang Ho, Aruni Seneviratna, Cherng Hann Benjamin Yip
Advances in Digestive Medicine.2023; 10(4): 232. CrossRef
A new classification of periampullary diverticulum: cannulation of papilla on the inner margins of the diverticulum (Type IIa) is more challenging
He-xian Shi, Yong-qiang Ye, Hai-wang Zhao, De-cai Kong, Shan-zhou Huang, Qian Yan, Yu-bin Chen, Ping Zhang, Sheng Chen, Bao-hua Hou, Chuan-zhao Zhang
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A Case of Narrow Opened Priampullary Diverticular Bleeding with Diagnostic Difficulty: Jin Nam Kim, M.D., Hong Sik Lee, M.D., Jae Hong Ahn, M.D., Seung Young Kim, M.D., Dong Il Kim, M.D., Sang Woo Lee, M.D. and Jae Hyun Choi, M.D.; Korean J Gastrointest Endosc 2009;38(5):275-378. Published online May 30, 2009

Abstract PDF: A duodenal diverticulum is most common in the medial aspect of the second portion of the duodenum and rarely causes symptoms. An obstruction, bleeding, perforation, jaundice and pancreatitis are uncommon complications of a duodenal diverticulum. Bleeding from the periampullary diverticulum should be considered in the diagnosis of a patient who presents with upper gastrointestinal bleeding of unknown origin. The second portion of the duodenum is sometimes difficult to observe entirely from the tangent line with the use of a forward-viewing endoscope. The diagnosis and treatment of periampullary diverticular bleeding may be achieved more easily by use of a side-viewing endoscope. We report here a case of narrow opened periampullary diverticular bleeding diagnosed by the use of a side-viewing endoscope with difficulty. (Korean J Gastrointest Endosc 2009; 38:275-278)

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Analysis of Risk Factors Associated with the Severity of Biliary Pancreatitis: Hyo Jeong Oh, M.D., Tae Hyeon Kim, M.D., Chang Soo Choi, M.D., Ji Hye Kweon, M.D., Pyoung Suk Lim, M.D., Sae Ron Shin, M.D.*, Suck Chei Choi, M.D. and Yong-Ho Nah, M.D.; Korean J Gastrointest Endosc 2007;35(6):385-390. Published online December 30, 2007

Abstract PDF: Background
/Aims: The aim of the study was to investigate the risk factors for biliary pancreatitis according to severity. Methods: This study retrospectively reviewed 58 patients who underwent endoscopic retrograde cholangiopancreatography for the management of acute biliary pancreatitis between November 2001 and June 2004. The severity of pancreatitis was classified as severe or mild pancreatitis according to the Glasgow scale. Multiple clinical and radiological factors were analyzed for a relationship with the severity of pancreatitis and coexisting biliary pathology. Results: Ten patients (17%) had severe pancreatitis (the SP group) and the remaining 48 patients (83%) had mild pancreatitis (the MP group). The diameter of the common bile duct CBD) and cystic duct, and the number and the size of gallstones were not significantly different between the two groups of patients. The number of patients without a periampullary diverticulum in the SP group (90.0%) was significantly higher than in the MP group (39.6%). Most of the SP patients (90.0%) had CBD stones (＜5 mm) or CBD sludge, but the prevalence of CBD stones (＜5 mm) or CBD sludge was lower in the MP group (54.2%, p=0.04). The absence of a periampullary diverticulum was identified as a risk factor according to severity by the use of logistic regression analysis (odds ratio=25; p=0.01). Conclusions: The development of severe biliary pancreatitis was influenced by risk factors such as a CBD stone less than 5 mm or sludge and the absence of a periampullary diverticulum. (Korean J Gastrointest Endosc 2007;35:385-390)

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Analysis of Endoscopic Sphincterotomy in Patients with Periampullary Diverticulum: according to the Location of the Diverticulum: Hyun Ah Yoon, M.D., Myung Hwan Roh, M.D., Yang Hyun Baek, M.D., Yung Hoon Kim, M.D., Hyun Seung Yoo, M.D., Sung Wook Lee, M.D., Jin Seok Jang, M.D., Jong Hun Lee, M.D., Sang Yung Han, M.D. and Seok Reyol Choi, M.D.; Korean J Gastrointest Endosc 2007;35(3):152-158. Published online September 30, 2007

Abstract PDF: Background
/Aims: Endoscopic sphincterotomy (EST) involves more complications and medical problems when a periampullary diverticulum (PD) is present. The data about EST for treating a small population of PD patients is controversial and any recent data is rare. The aim of this study is to evaluate the results of performing EST for a large population of PD patients. Methods: We retrospectively enrolled 178 patients with PD and 178 patients without PD and these patients underwent EST for removal of common bile duct (CBD) stones during the years 2003～2005 at Dong-A University Hospital. We classified PD patients, according to the location of the ampulla and diverticulum, into 3 groups and we considered removal of the CBD stones as success. Results: The success rates of EST in the two groups were similar: 91.0% in the PD group and 98.8% in the control group (p=0.0341). Failures were more frequently observed when the papilla was located inside of the diverticulum than for the other locations (p=0.0341). The complications cholangitis and pancreatitis after EST were similar for the two groups, but bleeding was more frequently observed in the PD group (p=0.0067). Conclusions: More skill for performing EST is needed to prevent bleeding in PD patients and it is more difficult to remove CBD stones when the papilla was located inside of the diverticulum. (Korean J Gastrointest Endosc 2007;35:152-158)

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Massive Bleeding from the Dieulafoy Lesion at the Brim of Large Periampullary Diverticulum: Wan Sik Lee, Jae Hong Park, Jeung Ho Park, Soo Jung Lee, Chang Hwan Park, Young Eun Joo, Hyun Soo Kim, Sung Kyu Choi, Jong Sun Rew, Sei Jong Kim; Korean J Gastrointest Endosc 2003;27(5):463-463. Published online November 20, 2003

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담도 배액관 유도 유두부 절개술 - 난해한 유두부주위 게실 및 위 부분절제술 환자에서 - ( A Stent-Guided Sphincterotomy in Patients with a Difficult Periampullary Diverticulum or with a Billroth-II Gastrectomy ): Korean J Gastrointest Endosc 2000;20(1):26-32. Published online November 30, 1999

Abstract PDF: Background
/Aims: Patients with a congenitally or surgically altered anatomy such as a large diverticulum in which an ampullary orifice exists or a Billroth-II gastrectomy, have an increased complication rate after endoscopic sphincterotomy (EST) compared to normal anatomies. An experience involving a stent-guided sphincterotomy using an endoprosthesis is herein reported. Methods: 10 patients with a Billroth-II gastrectomy and 9 patients with a large diverticulum received a stent-guided EST. In the diverticula cases, all the ampullary orifices were located either inside the diverticulum or in an unusual position. All patients had common bile duct stones and symptoms of cholangitis. After a 0.035 inch guide wire was inserted through the side-viewing duodenoscope, a 10 Fr. endoprosthesis (MTW, Germany) was inserted and a needle-knife sphincterotome was introduced. In patients with a Billroth-II anatomy, the incision was made from the papillary orifice of the 12 o'clock position toward 6 o'clock. In patients with periampullary diverticula, the incision was made with sweeps of the needle-knife in a 6 to 12 o'clock direction. The cautery current was applied to the mucosa along the stent and the stent was retrieved by a polypectomy snare through the biopsy channel without removal of an endoscope. Results: Among the 19 patients, the guide wire and stent insertion were possible in all except one patient due to the inability of selective cannulation. An EST was performed in all patients after stent insertion. There were no serious complications during and after the stent-guided EST except for two minor bleedings which were treated with a coagulation current using the needle-knife. Consequently, complete endoscopic stone removal was achieved in all patients including three patients in whom a mechanical lithotriptor was needed. Conclusions: In stent-guided EST, the stent not only guides the adequate direction of the incision but also allows a controlled incision under a favorable visual field. Therefore, blind cutting and exploration during EST can be avoided and successful EST is possible even in difficult situations such as that created by an altered anatomy. (Korean J Gastrointest Endosc 2000;20:26~32)

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원저 : 담도 췌장 ; 십이지장 유두주위 게실과 담석의 연관성 ( Original Articles : Biliary Tract & Pancreas ; Association of Periampullary Diverticula with Primary Choledocholithiasis but not with Secondary Choledocholithiasis ): Korean J Gastrointest Endosc 1997;17(4):501-506. Published online November 30, 1996

Abstract PDF: Background
/Aims: Several endoscopie studies found an association between periam- puilary diverticula and biliary calculi, however, the results of the reports are inconsistent when considering the anatomical location of the stones. The aims of our study are to evaluate the association between periampullary diverticula and gallstones according to their location iand to clarify the origin of the common bile duct stones by analyzing the composition of the stones. Methods: During a period of 10 months, 611 of 632 consecutive cases of endoscopic retrograde cholangiopancreatography(ERCP) were prospectively en- rolled. The data of periampullary diverticula and gallstones were analyzed according to the location of the stones. The stones available were initially grouped on the basis of their grass marphology and cross-sectional appearance, and finally analyzed by quantitative infrared spectroscopy. (Korean J Gastrointest Endosc 17: 501-506, 1997) (continue)

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원저 : 식도 위장관 ; 십이지장 유두주위 게실의 임상적 특성 ( Original Articles : Esophagus , Stomach & Intestine ; Clinical Characteristics of Periampullary Diverticulum ): Korean J Gastrointest Endosc 1996;16(6):937-944. Published online November 30, 1995

Abstract PDF: Background
/Aims: Periampuilary diverticulum has been known to be associated with various bilio-pancreatic diseases such as choledocholithiasis and disturbs performing selective cannuiation of ERCP and EST. This present study aims to investigate anatomical morphology of periampullary diverticulum and to determine whether periampullary diverticulurn influences difficulty and complication performing of ERCP and to analyse the relationship between periampullary diverticulum and choledocholithiasis. Methods: We reviewed records of chart and diverticular pictures in 1389 cases of underwent ERCP and evaluated the incidence, size, direction, location of periampullary diverticulum and its influence against performing of ERCP and investigated its relationship with bilio-pancreatic diseases such as choledocholithiasis. (Korean J Gastrointest 16: 937~944, 1996) (continue..)

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