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Reflux of duodenal contents and cholangitis after endoscopic biliary sphincterotomy
Letters to the Editor
REFERENCES 1. Calvet X, Vergara M, Brullet E, et al. Addition of a second endoscopic treatment following epinephrine injection improves outcome in highrisk bleeding ulcers. Gastroenterology 2004;126:441-50. 2. Cheng HC, Chang WL, Yeh YC, et al. Seven-day intravenous low-dose omeprazole infusion reduces peptic ulcer rebleeding for patients with comorbidities. Gastrointest Endosc 2009;70:433-9. 3. Cheng HC, Chuang SA, Kao YH, et al. Increased risk of rebleeding of peptic ulcer bleeding in patients with comorbid illness receiving omeprazole infusion. Hepatogastroenterology 2003;50:2270-3. 4. Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl J Med 2000;343:310-6. 5. Cheng HC, Kao AW, Chuang CH, et al. The efficacy of high- and low-dose intravenous omeprazole in preventing rebleeding for patients with bleeding peptic ulcers and comorbid illnesses. Dig Dis Sci 2005;50:1194-201. 6. Rockall TA, Logan RF, Devlin HB, et al. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National Audit of Acute Upper Gastrointestinal Haemorrhage. Lancet 1996;347:1138-40. 7. Tseng GY, Fang CT, Lin HJ, et al. Efficacy of an intravenous proton pump inhibitor after endoscopic therapy with epinephrine injection for peptic ulcer bleeding in patients with uraemia: a case-control study. Aliment Pharmacol Ther 2009;30:406-13. 8. Devlin JW, Welage LS. The cost-effectiveness of proton pump inhibitors for bleeding peptic ulcers: the unanswered questions. Crit Care Med 2004;32:1415-6. 9. Laine L, Shah A, Bemanian S. Intragastric pH with oral vs intravenous bolus plus infusion proton-pump inhibitor therapy in patients with bleeding ulcers. Gastroenterology 2008;134:1836-41. 10. Javid G, Zargar SA, U-Saif R, et al. Comparison of p.o. or i.v. proton pump inhibitors on 72-h intragastric pH in bleeding peptic ulcer. J Gastroenterol Hepatol 2009;24:1236-43. 11. Tsai JJ, Hsu YC, Perng CL, et al. Oral or intravenous proton pump inhibitor in patients with peptic ulcer bleeding after successful endoscopic epinephrine injection. Br J Clin Pharmacol 2009;67:326-32. 12. Cheng HC, Yang HB, Chang WL, et al. Lacking of up-regulation of serum response factor on gastric ulcer correlates to persistence of stigmata of recent hemorrhage and rebleeding. [Abstract] J Gastroenterol Hepatol 2009;24(Suppl 1):A26. doi:10.1016/j.gie.2009.12.022
Reflux of duodenal contents and cholangitis after endoscopic biliary sphincterotomy To the Editor: There is a Latin expression that defines some form of cholangitis, possibly from duodenobiliary reflux, cholangitis sine materia (bile infection without any stuff), that is, cholangitis without obstruction of the biliary tree (for instance due to common bile duct stones or strictures). This has been seen after surgical procedures, like choledochoduodenostomy, in which a large opening remains between the common bile duct and the duodenal bulb, or with surgical biliary sphincteroplasty in the papilla of Vater. Under such circumstances, it is easy for duodenal contents to enter into the biliary tree and cause contamination. Interestingly, Misra and Dwivedi1 did not find this phenomenon (cholangitis sine materia) in patients having stents crossing the papilla that were used to palliate malignant obstructive jaundice. But the life span of www.giejournal.org
patients with neoplasia is limited compared with others having benign biliary conditions. Furthermore, duodenobiliary reflux can be of solid2 or semisolid content and remain within the bile duct, causing debris and making a nest for stone-like material. Misra and Dwivedi1 found that cholangitis occurred in these circumstances. Since 1973, endoscopic biliary sphincterotomy (EBS) is the standard of treatment for common bile duct stones and other papillary problems, such as sphincter of Oddi dysfunction. The extent of EBS should be tailored to the specific problem to treat. But it is not uncommon that large orifices remain after EBS. In my experience, problems related to duodenobiliary reflux are not an infrequent cause for ERCP reintervention. In order to preserve sphincter of Oddi function, endoscopic papillary balloon dilation was proposed some years ago. Unfortunately, the good results achieved in Eastern countries3 have not been reproduced in the United States and Europe.4,5 However, if we cannot close the gate completely after stone extraction, as it occurs with endoscopic papillary balloon dilation, we can prevent it from remaining wide open. The advent of performing a limited EBS extent, followed by large-diameter balloon dilation,6,7 can be a successful half-way measure, perhaps reducing the likelihood of duodenobiliary reflux and its complications. Jesús García-Cano, MD, PhD Department of Digestive Diseases Loubna Elmardi, MD Department of Internal Medicine Erik Ureña, MD Department of Family Practice Hospital Virgen de la Luz Cuenca, Spain
REFERENCES 1. Misra SP, Dwivedi M. Reflux of duodenal contents and cholangitis in patients undergoing self-expanding metal stent placement. Gastrointest Endosc 2009;70:317-21. 2. Tringali A, Mutigniani M, Costamagna G. Lead pellets can enter a biliary stent. Gastrointest Endosc 2001;53:88. 3. Jeong S, Ki S-H, Lee DH, et al. Endoscopic large-balloon sphincteroplasty without preceding sphincterotomy for the removal of large bile duct stones: a preliminary study. Gastrointest Endosc 2009;70:915-22. 4. Disario JA, Freeman ML, Bjorkman DJ, et al. Endoscopic balloon dilation compared with sphincterotomy for extraction of bile duct stones. Gastroenterology 2004;127:1291-9. 5. García-Cano J. Fatal pancreatitis after endoscopic balloon dilation for extraction of common bile duct stones in an 80-year-old woman. Endoscopy 2006;38:431. 6. Attasaranya S, Cheon YK, Vittal H, et al. Large-diameter biliary orifice balloon dilation to aid in endoscopic bile duct stone removal: a multicenter series. Gastrointest Endosc 2008;67:1046-52. 7. García-Cano J, Taberna-Arana L, Jimeno-Ayllón C, et al. Biliary sphincterotomy dilatation for the extraction of difficult common bile duct stones. Rev Esp Enferm Dig 2009;101:541-5. doi:10.1016/j.gie.2009.10.002
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REFERENCES 1. Calvet X, Vergara M, Brullet E, et al. Addition of a second endoscopic treatment following epinephrine injection improves outcome in highrisk bleeding ulcers. Gastroenterology 2004;126:441-50. 2. Cheng HC, Chang WL, Yeh YC, et al. Seven-day intravenous low-dose omeprazole infusion reduces peptic ulcer rebleeding for patients with comorbidities. Gastrointest Endosc 2009;70:433-9. 3. Cheng HC, Chuang SA, Kao YH, et al. Increased risk of rebleeding of peptic ulcer bleeding in patients with comorbid illness receiving omeprazole infusion. Hepatogastroenterology 2003;50:2270-3. 4. Lau JY, Sung JJ, Lee KK, et al. Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Engl J Med 2000;343:310-6. 5. Cheng HC, Kao AW, Chuang CH, et al. The efficacy of high- and low-dose intravenous omeprazole in preventing rebleeding for patients with bleeding peptic ulcers and comorbid illnesses. Dig Dis Sci 2005;50:1194-201. 6. Rockall TA, Logan RF, Devlin HB, et al. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National Audit of Acute Upper Gastrointestinal Haemorrhage. Lancet 1996;347:1138-40. 7. Tseng GY, Fang CT, Lin HJ, et al. Efficacy of an intravenous proton pump inhibitor after endoscopic therapy with epinephrine injection for peptic ulcer bleeding in patients with uraemia: a case-control study. Aliment Pharmacol Ther 2009;30:406-13. 8. Devlin JW, Welage LS. The cost-effectiveness of proton pump inhibitors for bleeding peptic ulcers: the unanswered questions. Crit Care Med 2004;32:1415-6. 9. Laine L, Shah A, Bemanian S. Intragastric pH with oral vs intravenous bolus plus infusion proton-pump inhibitor therapy in patients with bleeding ulcers. Gastroenterology 2008;134:1836-41. 10. Javid G, Zargar SA, U-Saif R, et al. Comparison of p.o. or i.v. proton pump inhibitors on 72-h intragastric pH in bleeding peptic ulcer. J Gastroenterol Hepatol 2009;24:1236-43. 11. Tsai JJ, Hsu YC, Perng CL, et al. Oral or intravenous proton pump inhibitor in patients with peptic ulcer bleeding after successful endoscopic epinephrine injection. Br J Clin Pharmacol 2009;67:326-32. 12. Cheng HC, Yang HB, Chang WL, et al. Lacking of up-regulation of serum response factor on gastric ulcer correlates to persistence of stigmata of recent hemorrhage and rebleeding. [Abstract] J Gastroenterol Hepatol 2009;24(Suppl 1):A26. doi:10.1016/j.gie.2009.12.022
Reflux of duodenal contents and cholangitis after endoscopic biliary sphincterotomy To the Editor: There is a Latin expression that defines some form of cholangitis, possibly from duodenobiliary reflux, cholangitis sine materia (bile infection without any stuff), that is, cholangitis without obstruction of the biliary tree (for instance due to common bile duct stones or strictures). This has been seen after surgical procedures, like choledochoduodenostomy, in which a large opening remains between the common bile duct and the duodenal bulb, or with surgical biliary sphincteroplasty in the papilla of Vater. Under such circumstances, it is easy for duodenal contents to enter into the biliary tree and cause contamination. Interestingly, Misra and Dwivedi1 did not find this phenomenon (cholangitis sine materia) in patients having stents crossing the papilla that were used to palliate malignant obstructive jaundice. But the life span of www.giejournal.org
patients with neoplasia is limited compared with others having benign biliary conditions. Furthermore, duodenobiliary reflux can be of solid2 or semisolid content and remain within the bile duct, causing debris and making a nest for stone-like material. Misra and Dwivedi1 found that cholangitis occurred in these circumstances. Since 1973, endoscopic biliary sphincterotomy (EBS) is the standard of treatment for common bile duct stones and other papillary problems, such as sphincter of Oddi dysfunction. The extent of EBS should be tailored to the specific problem to treat. But it is not uncommon that large orifices remain after EBS. In my experience, problems related to duodenobiliary reflux are not an infrequent cause for ERCP reintervention. In order to preserve sphincter of Oddi function, endoscopic papillary balloon dilation was proposed some years ago. Unfortunately, the good results achieved in Eastern countries3 have not been reproduced in the United States and Europe.4,5 However, if we cannot close the gate completely after stone extraction, as it occurs with endoscopic papillary balloon dilation, we can prevent it from remaining wide open. The advent of performing a limited EBS extent, followed by large-diameter balloon dilation,6,7 can be a successful half-way measure, perhaps reducing the likelihood of duodenobiliary reflux and its complications. Jesús García-Cano, MD, PhD Department of Digestive Diseases Loubna Elmardi, MD Department of Internal Medicine Erik Ureña, MD Department of Family Practice Hospital Virgen de la Luz Cuenca, Spain
REFERENCES 1. Misra SP, Dwivedi M. Reflux of duodenal contents and cholangitis in patients undergoing self-expanding metal stent placement. Gastrointest Endosc 2009;70:317-21. 2. Tringali A, Mutigniani M, Costamagna G. Lead pellets can enter a biliary stent. Gastrointest Endosc 2001;53:88. 3. Jeong S, Ki S-H, Lee DH, et al. Endoscopic large-balloon sphincteroplasty without preceding sphincterotomy for the removal of large bile duct stones: a preliminary study. Gastrointest Endosc 2009;70:915-22. 4. Disario JA, Freeman ML, Bjorkman DJ, et al. Endoscopic balloon dilation compared with sphincterotomy for extraction of bile duct stones. Gastroenterology 2004;127:1291-9. 5. García-Cano J. Fatal pancreatitis after endoscopic balloon dilation for extraction of common bile duct stones in an 80-year-old woman. Endoscopy 2006;38:431. 6. Attasaranya S, Cheon YK, Vittal H, et al. Large-diameter biliary orifice balloon dilation to aid in endoscopic bile duct stone removal: a multicenter series. Gastrointest Endosc 2008;67:1046-52. 7. García-Cano J, Taberna-Arana L, Jimeno-Ayllón C, et al. Biliary sphincterotomy dilatation for the extraction of difficult common bile duct stones. Rev Esp Enferm Dig 2009;101:541-5. doi:10.1016/j.gie.2009.10.002
Volume 72, No. 1 : 2010 GASTROINTESTINAL ENDOSCOPY
225