title: Outcome of endoscopic sphincterotomy in patients with pain of suspected biliary or papillary origin and inconclusive cholangiography findings.
abstract: OBJECTIVE
  We prospectively studied the outcome of endoscopic sphincterotomy in symptomatic patients with elevated liver enzyme levels but no clear evidence of biliary pathology on transabdominal ultrasound and diagnostic endoscopic retrograde cholangiography (ERC).
  
  
  METHODS
  29 consecutive patients with biliary-type pain (two or more out of eight criteria), elevated liver enzyme levels and no evidence of gallstones or significant common bile duct dilatation were evaluated. Elevated bilirubin levels (up to 7.2 mg/dl) were found in 18 patients. The majority of patients (n = 21) had a gallbladder in situ. The findings from bile duct exploration following sphincterotomy were recorded, and pain (as measured by visual analogue scale) as well as laboratory findings was assessed.
  
  
  RESULTS
  Wire-guided sphincterotomy was successful in all patients while uncomplicated pancreatitis occurred in one instance. In 16 patients (55%) there was macroscopic evidence of small stones (n = 2), sludge (n = 12) or both (n = 2) following bile duct exploration. In addition, microscopy showed bile crystals in all four patients who had no macroscopic findings. All four patients with elevation of pancreatic enzymes prior to treatment, and four of those eight patients with previous cholecystectomy, showed evidence of biliary pathology. The initial median pain intensity was 8 (range 1-10); 26 patients became pain-free within 3 months following endoscopic sphincterotomy. While 26 of 28 patients (93%) remained asymptomatic over a median follow-up period of 19 months (range 12-26), one died of an unrelated malignancy 6 months after therapy.
  
  
  CONCLUSIONS
  Endoscopic sphincterotomy may be acceptable in patients with typical clinical presentation suggesting a papillary or biliary origin of pain without further diagnostic work-up. Contrary to expectations, diagnostic ERC was insensitive in detection of the biliary etiology of symptoms in this selected group of patients.
authors.affiliation: Dept. of Interdisciplinary Endoscopy, University Hospital Eppendorf Hamburg, Germany. brand@uke.uni-hamburg.de
authors.forename: B
authors.initials: B
authors.lastname: Brand
authors.forename: L
authors.initials: L
authors.lastname: Wiese
authors.forename: F
authors.initials: F
authors.lastname: Thonke
authors.forename: P V
authors.initials: PV
authors.lastname: Sriram
authors.forename: S
authors.initials: S
authors.lastname: Jaeckle
authors.forename: U
authors.initials: U
authors.lastname: Seitz
authors.forename: S
authors.initials: S
authors.lastname: Bohnacker
authors.forename: N
authors.initials: N
authors.lastname: Soehendra
mesh_terms: D000328:Adult; D000368:Aged; D001660:Biliary Tract Diseases / Q000000981:diagnostic imaging* / Q000601:surgery*; D002760:Cholangiopancreatography, Endoscopic Retrograde; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010146:Pain / Q000000981:diagnostic imaging* / Q000601:surgery*; D011237:Predictive Value of Tests; D011446:Prospective Studies; D016717:Sphincterotomy, Endoscopic; D016896:Treatment Outcome