- Email: [email protected]
Biliary microlithiasis
Letters to the Editor
caused by stone(s) impacted in the gallbladder neck or the cystic duct impinging on the common hepatic duct. Unfortunately, information on technical details of the endoscopic procedure was not included in their article. Recently, I reported my experience with the treatment of this syndrome, with particular emphasis on the technical details of endoscopic stone removal.2 Briefly, I manipulate both with a cannula and guidewire in order to introduce the guidewire into the cystic duct and gallbladder, use super-stiff guidewires, and, in case of small stones, inflate at first attempt only half the normal amount of air into the balloon before withdrawal. If unsuccessful, or in case of larger stones, I use a biliary dilation catheter, gentle balloon dilation, and normal amounts of air in the stone extraction balloon. I find that the use of super-stiff guidewires, in particular, is of utmost importance for successful endoscopic stone removal in Mirizzi syndromedsimilar to the rendezvous procedures for the treatment of difficult bile duct injuries.3 I believe that, in experienced hands, an endoscopic attempt to remove the impacted stone should be the treatment of choice to begin with in type I Mirizzi syndrome. If successful, the surgeon would then proceed with laparoscopic cholecystectomy, and unnecessary laparotomy could be avoided. If unsuccessful, endoscopic stent placement into the common bile duct is indicated, and then the surgeon has to choose between a laparoscopic and an open approach.
period. There was no significant difference in cannulation success between the JPDD group (mean age 70 years; 56% female, 44% male) and the control group, which comprised 470 patients without diverticula matched for age and sex (92.4% vs 92.9%). Yet we found a higher incidence of choledocholithiasis in those with diverticula (70.7% vs 49.4%). Furthermore, the complication rate was higher in those patients with JPDD, due to a higher rate of bleeding after sphincterotomy. Significant bleeding, requiring tamponade injection with epinephrine, developed in 17 (3.4%) patients with diverticula compared to 5 (1.2%) patients without diverticula. An increased bleeding risk was also reported in a review of 350 patients with diverticula by Zoepf et al.6 There was no difference in other complications between the groups. Abdur R. Aftab, MD Fergal Donnellan, MD Faisal Zeb, MD Garry Courtney, MD Department of Gastroenterology St Luke’s Hospital Kilkenny, Ireland REFERENCES
1. Pelaez-Luna M, Levy MJ, Arora AS, et al. Mirizzi syndrome presenting as painless jaundice: a rare entity diagnosed by EUS. Gastrointest Endosc 2008;67:974-5. 2. Gro¨nroos JM. Mirizzi syndrome: consider endoscopic stone removal. ANZ J Surg 2007;77:716-7. 3. Gro¨nroos JM. How to avoid unnecessary laparotomies in iatrogenic bile duct injuries? Am J Surg 2008 Sept 19 [Epub ahead of print].
1. Panteris V, Vezakis A, Filippou G, et al. Influence of juxtapapillary diverticula on the success or difficulty of cannulation and complication rate. Gastrointest Endosc 2008;68:903-10. 2. Christoforidis E, Goulimaris I, Kanellos I, et al. The role of juxtapapillary duodenal diverticula in biliary stone disease. Gastrointest Endosc 2002; 55:543-7. 3. Novacek G, Walgram M, Bauer P, et al. The relationship between juxtapapillary duodenal diverticula and biliary stone disease. Eur J Gastroenterol Hepatol 1997;9:375-9. 4. Rajnakova A, Goh PM, Ngoi SS, et al. ERCP in patients with periampullary diverticulum. Hepatogastroenterology 2003;50:625-8. 5. Tham TC, Kelly M. Association of periampullary duodenal diverticula with bile duct stones and with technical success of endoscopic retrograde cholangiopancreatography. Endoscopy 2004;36:1050-3. 6. Zoepf T, Zoepf DS, Arnold JC, et al. The relationship between juxtapapillary duodenal diverticula and disorders of the biliopancreatic system: analysis of 350 patients. Gastrointest Endosc 2001;54:56-61.
doi:10.1016/j.gie.2008.09.016
doi:10.1016/j.gie.2008.09.015
The clinical significance of juxtapapillary duodenal diverticula identified at ERCP
Biliary microlithiasis
Juha M. Gro¨nroos, MD Departments of Surgery and Emergency University of Turku Turku, Finland REFERENCES
To the Editor: To the Editor: 1
We read with interest the article by Panteris et al on the influence of juxtapapillary duodenal diverticula (JPDD) on ERCP outcomes. The significance of such diverticula has yielded several conflicting results regarding the incidence of choledocholithiasis,2,3 difficulty of cannulation, and rate of complications.4,5 However, these reports are limited by their sample size. From our own prospectively maintained ERCP database, we identified JPDD in 487 (18.6%) patients over a 9-year www.giejournal.org
The article by Okoro et al1 on ursodeoxycholic acid (urso) therapy for treating biliary microlithiasis raises more questions than it answers. First, their method of collecting duodenal aspirate for bile crystals would have been subject to sampling error. They do not provide any information regarding what was the mean volume and range of the collected aspirates. Second, they excluded a few patients who had 1 crystal in their aspirate, with their lower limit for inclusion in the study being at least 3 crystals in the specimen, which seems arbitrary. Third, as there was Volume 69, No. 6 : 2009 GASTROINTESTINAL ENDOSCOPY 1197
Letters to the Editor
no placebo group, the results on symptom improvement are difficult to interpret. Finally, what about the group that was excluded due to lack of crystals in their duodenal aspirate, which constituted the majority? How does one explain their symptoms? The authors do not discuss this issue, which seems pertinent in this context. The most likely explanation would be sphincter of Oddi dysfunction (type III), and their lack of sphincter of Oddi manometry data has been alluded to.2 Although their hypothesis is sound, their trial design is poor, and one would be keen to see a more robust study in order to answer their original question. Shyam Menon, MRCP(UK) Department of Gastroenterology Sandwell General Hospital West Bromwich, UK REFERENCES 1. Okoro N, Patel A, Goldstein M, et al. Ursodeoxycholic acid treatment for patients with postcholecystectomy pain and bile microlithiasis. Gastrointest Endosc 2008;68:69-74. 2. Ahmed F, Sherman S. Should patients with biliary-type pain after cholecystectomy be evaluated for microlithiasis? Gastrointest Endosc 2008;68:75-7. doi:10.1016/j.gie.2008.09.019
Response: We thank Dr Shyam Menon for his interest and comments in our study. In general, there are 2 methods for endoscopic collection of bile fluid: one is collecting of bile from the bile duct when performing ERCP, the other, collecting from the duodenum near the major papilla at endoscopy. It is suspected that pseudomicrolithiasis induced by ERCP contrast may increase the false positive rate of bile microlithiasis when the sample is obtained from the bile duct.1 We are not aware of any problems with obtaining bile from the duodenum. The volume of bile obtained from each patient indeed was not the same and varied between 1 mL and 5 mL. It may be a good idea to measure the volume of the bile and explore any relationships between volume and microlithiasis. The criterion that 3 or more crystals per highpower field to diagnose bile microlithiasis was used by all prior studies2 and was adopted to make our study comparable with others. Cholecystectomy is associated with persistent or recurrent pain in about a third of all patients3,4 and has many causes, including sphincter of Oddi dysfunction.5 Our goal was to determine whether bile microlithiasis is a cause for postcholecystectomy pain, and we showed a clinical benefit from medical therapy in patients with postcholecystectomy pain and bile microlithaisis.6 Unquestionably, more studies are needed.
1198 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 6 : 2009
Qiang Cai, MD, PhD Division of Digestive Diseases Emory University School of Medicine Atlanta, Georgia, USA REFERENCES 1. Parasher VK, Roman K, Sukumar R, et al. Can ERCP contrast agents cause pseudomicrolithiasis? Their effect on the final outcome of bile analysis in patients with suspected microlithiasis. Gastrointest Endosc 2000;51:401-4. 2. Quallich LG, Stern MA, Rich M, et al. Bile duct crystals do not contribute to sphincter of Oddi dysfunction. Gastrointest Endosc 2002;55:163-6. 3. Bodvall B. The post cholecystectomy syndrome. Clin Gastroenterol 1973;2:102-26. 4. Lasson A. The post-cholecystectomy syndrome: diagnostic and therapeutic strategy. Scand J Gastroenterol 1987;22:897-902. 5. Desautels SG, Silvka A, Hutson WR, et al. Postcholecystectomy pain syndrome: pathophysiology of abdominal pain in sphincter of Oddi type III. Gastroenterology 1999;116:996-1000. 6. Ahmed F, Sherman S. Should patients with biliary-type after cholecystectomy be evaluated for microlithiasis? Gastrointest Endosc 2008;68:75-7. doi:10.1016/j.gie.2008.10.024
Capsule endoscopy for obscure GI bleeding To the Editor: Hindryckx et al1 assessed the clinical impact of capsule endoscopy (CE) in obscure GI bleeding (OGIB). However, it is not clear from their study whether patients were screened for celiac disease prior to further investigations for OGIB. Only one case of celiac disease was diagnosed in their study after a ‘‘negative’’ CE examination during which an ‘‘abnormal mucosal pattern’’ was detected, raising the issue of whether there were other undiagnosed patients with celiac disease in the cohort. One would assume that all patients with OGIB, unless overt, would have duodenal biopsy specimens taken at the time of their index gastroscopy in order to rule out celiac disease. The authors also do not provide any data on how many patients were on anticoagulant/antiplatelet medications prior to their study. Only 7 patients (7.6%) ultimately stopped these (4/55 in the positive-outcome group and 3/37 in the negative-outcome group). One would have expected these drugs in such patients to have been stopped at the beginning, unless the indications for their use were strong. It is precisely this group of transfusion-dependent patients that needs CE as part of their diagnostic algorithm to enhance the diagnostic yield, and the authors provide important evidence to support this strategy. Shyam Menon, MRCP(UK) Department of Gastroenterology Sandwell General Hospital West Bromwich, UK
www.giejournal.org
caused by stone(s) impacted in the gallbladder neck or the cystic duct impinging on the common hepatic duct. Unfortunately, information on technical details of the endoscopic procedure was not included in their article. Recently, I reported my experience with the treatment of this syndrome, with particular emphasis on the technical details of endoscopic stone removal.2 Briefly, I manipulate both with a cannula and guidewire in order to introduce the guidewire into the cystic duct and gallbladder, use super-stiff guidewires, and, in case of small stones, inflate at first attempt only half the normal amount of air into the balloon before withdrawal. If unsuccessful, or in case of larger stones, I use a biliary dilation catheter, gentle balloon dilation, and normal amounts of air in the stone extraction balloon. I find that the use of super-stiff guidewires, in particular, is of utmost importance for successful endoscopic stone removal in Mirizzi syndromedsimilar to the rendezvous procedures for the treatment of difficult bile duct injuries.3 I believe that, in experienced hands, an endoscopic attempt to remove the impacted stone should be the treatment of choice to begin with in type I Mirizzi syndrome. If successful, the surgeon would then proceed with laparoscopic cholecystectomy, and unnecessary laparotomy could be avoided. If unsuccessful, endoscopic stent placement into the common bile duct is indicated, and then the surgeon has to choose between a laparoscopic and an open approach.
period. There was no significant difference in cannulation success between the JPDD group (mean age 70 years; 56% female, 44% male) and the control group, which comprised 470 patients without diverticula matched for age and sex (92.4% vs 92.9%). Yet we found a higher incidence of choledocholithiasis in those with diverticula (70.7% vs 49.4%). Furthermore, the complication rate was higher in those patients with JPDD, due to a higher rate of bleeding after sphincterotomy. Significant bleeding, requiring tamponade injection with epinephrine, developed in 17 (3.4%) patients with diverticula compared to 5 (1.2%) patients without diverticula. An increased bleeding risk was also reported in a review of 350 patients with diverticula by Zoepf et al.6 There was no difference in other complications between the groups. Abdur R. Aftab, MD Fergal Donnellan, MD Faisal Zeb, MD Garry Courtney, MD Department of Gastroenterology St Luke’s Hospital Kilkenny, Ireland REFERENCES
1. Pelaez-Luna M, Levy MJ, Arora AS, et al. Mirizzi syndrome presenting as painless jaundice: a rare entity diagnosed by EUS. Gastrointest Endosc 2008;67:974-5. 2. Gro¨nroos JM. Mirizzi syndrome: consider endoscopic stone removal. ANZ J Surg 2007;77:716-7. 3. Gro¨nroos JM. How to avoid unnecessary laparotomies in iatrogenic bile duct injuries? Am J Surg 2008 Sept 19 [Epub ahead of print].
1. Panteris V, Vezakis A, Filippou G, et al. Influence of juxtapapillary diverticula on the success or difficulty of cannulation and complication rate. Gastrointest Endosc 2008;68:903-10. 2. Christoforidis E, Goulimaris I, Kanellos I, et al. The role of juxtapapillary duodenal diverticula in biliary stone disease. Gastrointest Endosc 2002; 55:543-7. 3. Novacek G, Walgram M, Bauer P, et al. The relationship between juxtapapillary duodenal diverticula and biliary stone disease. Eur J Gastroenterol Hepatol 1997;9:375-9. 4. Rajnakova A, Goh PM, Ngoi SS, et al. ERCP in patients with periampullary diverticulum. Hepatogastroenterology 2003;50:625-8. 5. Tham TC, Kelly M. Association of periampullary duodenal diverticula with bile duct stones and with technical success of endoscopic retrograde cholangiopancreatography. Endoscopy 2004;36:1050-3. 6. Zoepf T, Zoepf DS, Arnold JC, et al. The relationship between juxtapapillary duodenal diverticula and disorders of the biliopancreatic system: analysis of 350 patients. Gastrointest Endosc 2001;54:56-61.
doi:10.1016/j.gie.2008.09.016
doi:10.1016/j.gie.2008.09.015
The clinical significance of juxtapapillary duodenal diverticula identified at ERCP
Biliary microlithiasis
Juha M. Gro¨nroos, MD Departments of Surgery and Emergency University of Turku Turku, Finland REFERENCES
To the Editor: To the Editor: 1
We read with interest the article by Panteris et al on the influence of juxtapapillary duodenal diverticula (JPDD) on ERCP outcomes. The significance of such diverticula has yielded several conflicting results regarding the incidence of choledocholithiasis,2,3 difficulty of cannulation, and rate of complications.4,5 However, these reports are limited by their sample size. From our own prospectively maintained ERCP database, we identified JPDD in 487 (18.6%) patients over a 9-year www.giejournal.org
The article by Okoro et al1 on ursodeoxycholic acid (urso) therapy for treating biliary microlithiasis raises more questions than it answers. First, their method of collecting duodenal aspirate for bile crystals would have been subject to sampling error. They do not provide any information regarding what was the mean volume and range of the collected aspirates. Second, they excluded a few patients who had 1 crystal in their aspirate, with their lower limit for inclusion in the study being at least 3 crystals in the specimen, which seems arbitrary. Third, as there was Volume 69, No. 6 : 2009 GASTROINTESTINAL ENDOSCOPY 1197
Letters to the Editor
no placebo group, the results on symptom improvement are difficult to interpret. Finally, what about the group that was excluded due to lack of crystals in their duodenal aspirate, which constituted the majority? How does one explain their symptoms? The authors do not discuss this issue, which seems pertinent in this context. The most likely explanation would be sphincter of Oddi dysfunction (type III), and their lack of sphincter of Oddi manometry data has been alluded to.2 Although their hypothesis is sound, their trial design is poor, and one would be keen to see a more robust study in order to answer their original question. Shyam Menon, MRCP(UK) Department of Gastroenterology Sandwell General Hospital West Bromwich, UK REFERENCES 1. Okoro N, Patel A, Goldstein M, et al. Ursodeoxycholic acid treatment for patients with postcholecystectomy pain and bile microlithiasis. Gastrointest Endosc 2008;68:69-74. 2. Ahmed F, Sherman S. Should patients with biliary-type pain after cholecystectomy be evaluated for microlithiasis? Gastrointest Endosc 2008;68:75-7. doi:10.1016/j.gie.2008.09.019
Response: We thank Dr Shyam Menon for his interest and comments in our study. In general, there are 2 methods for endoscopic collection of bile fluid: one is collecting of bile from the bile duct when performing ERCP, the other, collecting from the duodenum near the major papilla at endoscopy. It is suspected that pseudomicrolithiasis induced by ERCP contrast may increase the false positive rate of bile microlithiasis when the sample is obtained from the bile duct.1 We are not aware of any problems with obtaining bile from the duodenum. The volume of bile obtained from each patient indeed was not the same and varied between 1 mL and 5 mL. It may be a good idea to measure the volume of the bile and explore any relationships between volume and microlithiasis. The criterion that 3 or more crystals per highpower field to diagnose bile microlithiasis was used by all prior studies2 and was adopted to make our study comparable with others. Cholecystectomy is associated with persistent or recurrent pain in about a third of all patients3,4 and has many causes, including sphincter of Oddi dysfunction.5 Our goal was to determine whether bile microlithiasis is a cause for postcholecystectomy pain, and we showed a clinical benefit from medical therapy in patients with postcholecystectomy pain and bile microlithaisis.6 Unquestionably, more studies are needed.
1198 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 6 : 2009
Qiang Cai, MD, PhD Division of Digestive Diseases Emory University School of Medicine Atlanta, Georgia, USA REFERENCES 1. Parasher VK, Roman K, Sukumar R, et al. Can ERCP contrast agents cause pseudomicrolithiasis? Their effect on the final outcome of bile analysis in patients with suspected microlithiasis. Gastrointest Endosc 2000;51:401-4. 2. Quallich LG, Stern MA, Rich M, et al. Bile duct crystals do not contribute to sphincter of Oddi dysfunction. Gastrointest Endosc 2002;55:163-6. 3. Bodvall B. The post cholecystectomy syndrome. Clin Gastroenterol 1973;2:102-26. 4. Lasson A. The post-cholecystectomy syndrome: diagnostic and therapeutic strategy. Scand J Gastroenterol 1987;22:897-902. 5. Desautels SG, Silvka A, Hutson WR, et al. Postcholecystectomy pain syndrome: pathophysiology of abdominal pain in sphincter of Oddi type III. Gastroenterology 1999;116:996-1000. 6. Ahmed F, Sherman S. Should patients with biliary-type after cholecystectomy be evaluated for microlithiasis? Gastrointest Endosc 2008;68:75-7. doi:10.1016/j.gie.2008.10.024
Capsule endoscopy for obscure GI bleeding To the Editor: Hindryckx et al1 assessed the clinical impact of capsule endoscopy (CE) in obscure GI bleeding (OGIB). However, it is not clear from their study whether patients were screened for celiac disease prior to further investigations for OGIB. Only one case of celiac disease was diagnosed in their study after a ‘‘negative’’ CE examination during which an ‘‘abnormal mucosal pattern’’ was detected, raising the issue of whether there were other undiagnosed patients with celiac disease in the cohort. One would assume that all patients with OGIB, unless overt, would have duodenal biopsy specimens taken at the time of their index gastroscopy in order to rule out celiac disease. The authors also do not provide any data on how many patients were on anticoagulant/antiplatelet medications prior to their study. Only 7 patients (7.6%) ultimately stopped these (4/55 in the positive-outcome group and 3/37 in the negative-outcome group). One would have expected these drugs in such patients to have been stopped at the beginning, unless the indications for their use were strong. It is precisely this group of transfusion-dependent patients that needs CE as part of their diagnostic algorithm to enhance the diagnostic yield, and the authors provide important evidence to support this strategy. Shyam Menon, MRCP(UK) Department of Gastroenterology Sandwell General Hospital West Bromwich, UK
www.giejournal.org