During endoscopic retrograde cholangiopancreatography (ERCP) in a 52-year-old man
with acute cholangitis, the major papilla could not be found, but a slit-like bile-stained
orifice was present at the anterior part of the deformed bulb. Dilatation of the biliary
tree was seen and a 7-Fr plastic stent was introduced to drain the biliary system
(Figure [1]). Clinical resolution was obtained within a few days, and the patient remained asymptomatic
at 5 months after the procedure.
Figure 1 Endoscopic view showing the location of the ectopic orifice on the bulb (arrow), and
a plastic biliary stent draining through it. The duodenal lumen is narrow (arrowhead).
In a 38-year-old woman with acute cholangitis, ERCP was successful via cannulation
of an orifice 5 mm in diameter located at the anterior surface of the deformed bulb.
Dilatation of the biliary ducts was seen on cholangiography. The distal part of the
common bile duct appeared hook-like and tapered (Figure [2]). Some sludge was removed using a balloon catheter. After cleansing of the common
bile duct, the patient's condition improved in the following days and did not recur
over a 2-year follow-up.
Figure 2 Endoscopic retrograde cholangiopancreatography (ERCP) shows the diffuse dilatation
of the biliary tree and the hook-like ending of the common bile duct (arrowhead).
There have been a few reported cases in which the common bile duct has been found
to empty into the duodenal bulb [1]
[2]
[3]. Such cases usually presented with cholangitis, however like ours, most of the patients
described have had a history of duodenal ulcer. In our opinion, the constant exposure
to bile acid in the duodenal bulb leads to the peptic ulcer. This may explain the
occurrence of cholangitis at later stage, when the duodenal bulb is severely deformed
because of the repeated attacks.
The ectopic opening is usually a small or slit-like orifice, while a normal papilla
is rarely seen. On cholangiography, the dilated common bile duct shows a tapered narrowing
and a hook-shaped distal end in 75 % of cases [2]
[3]
[4]
[5]. The primary therapy should be ERCP-related measures, such as balloon catheterization
or stenting [3]. Endoscopic sphincterotomy should be avoided because of the risk of perforation.
