Clinical features of gallstone impaction at the ampulla of Vater and the effectiveness of endoscopic biliary drainage without papillotomy

Background and study aims: Gallstone impaction at the ampulla of Vater is a critical condition, and the standard treatment is endoscopic papillotomy. However, the clinical features remain largely unclear, and some patients are reluctant to undergo papillotomy because of a bleeding tendency.

The aim of this study was to clarify the clinical features of gallstone impaction at the ampulla of Vater and to examine the effectiveness of endoscopic biliary drainage without papillotomy.

Patients and methods: We retrospectively examined 30 patients who had undergone endoscopic treatment for gallstone impaction at the ampulla of Vater between 2010 and 2015.

Results: According to the severity classification for acute cholangitis in the Tokyo Guidelines (TG13), the condition was mild in 8 patients, moderate in 14, and severe in only 8 (27 %), despite the stone impaction at the ampulla of Vater. Hyperamylasemia was observed in 18 patients (60 %); computed tomography (CT) revealed clear pancreatitis in 5 cases (17 %). Patients were classified into Group A (13 patients who received biliary drainage with papillotomy) and Group B (17 patients receiving biliary drainage without papillotomy). All patients in Group B had 1 or more types of hemorrhage risk. There were no differences between the 2 groups in the success rate of biliary drainage, the rate of elevated serum amylase the following day, or procedure-related complications. Serum amylase levels decreased the following day in all patients, even in Group B (including the 10 patients with hyperamylasemia and the 3 patients with clear pancreatitis on CT).

Conclusions: Even with stone impaction at the ampulla of Vater, typical clinical features of cholangitis and pancreatitis are relatively rare. Biliary drainage without papillotomy is acceptable for gallstone impaction at the ampulla of Vater.

• References

• 1 Leung JW, Banez VP, Chung SC. Precut (needle knife) papillotomy for impacted common bile duct stone at the ampulla. Am J Gastroenterol 1990; 85: 991-993
• 2 Binmoeller KF, Katon RM. Needle knife papillotomy for an impacted common bile duct stone during pregnancy. Gastrointest Endosc 1990; 36: 607-609
• 3 Joo KR, Cha JM, Jung SW et al. Case review of impacted bile duct stone at duodenal papilla: detection and endoscopic treatment. Yonsei Med J 2010; 51: 534-539
• 4 Al-Karawi MA, Ahmed AM, Mohamed AR. Endoscopic choledochoduodenostomy (ECDT): A practical approach to management of impacted papillary gallstones and ampullary tumors. Ann Saudi Med 1992; 12: 352-354
• 5 Okabe Y, Kaji R, Ishida Y et al. Successful endoscopic extraction of a large impacted choledocholithiasis in the ampulla of vater: two interesting cases. Dig Endosc 2010; 22: 103-S106
• 6 McAlister VC, Roy A, Passi RB. Harpoon extraction of a common bile duct stone impacted at the ampulla of Vater with needle-knife sphincterotome. Gastrointest Endosc 1993; 39: 111-112
• 7 Hamada T, Yasunaga H, Nakai Y et al. Bleeding after endoscopic sphincterotomy or papillary balloon dilation among users of antithrombotic agents. Endoscopy 2015; 47: 997-1004
• 8 Hori Y, Naitoh I, Nakazawa T et al. Feasibility of endoscopic retrograde cholangiopancreatography-related procedures in hemodialysis patients. J Gastroenterol Hepatol 2014; 29: 648-652
• 9 Park DH, Kim MH, Lee SK et al. Endoscopic sphincterotomy vs. endoscopic papillary balloon dilation for choledocholithiasis in patients with liver cirrhosis and coagulopathy. Gastrointest Endosc 2004; 60: 180-185
• 10 Kiriyama S, Takada T, Strasberg SM et al. TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci 2013; 20: 24-34
• 11 Tenner S, Baillie J, DeWitt J et al. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol 2013; 108: 1400-1415
• 12 Banks PA, Bollen TL, Dervenis C et al. Classification of acute pancreatitis -- 2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102-111
• 13 Gando S, Saitoh D, Ogura H et al. A multicenter, prospective validation study of the Japanese Association for Acute Medicine disseminated intravascular coagulation scoring system in patients with severe sepsis. Crit Care 2013; 17: R111
• 14 Miura F, Takada T, Strasberg SM et al. TG13 flowchart for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2013; 20: 47-54
• 15 Kamisawa T, Takuma K, Tabata T et al. Clinical implications of accessory pancreatic duct. World J Gastroenterol 2010; 16: 4499-4503
• 16 Misra SP, Dwivedi M. Is conventional sphincterotomy possible in patients with common bile duct stones impacted at the ampulla of Vater?. Trop Gastroenterol 2007; 28: 162-165