title: Clinical features of gallstone impaction at the ampulla of Vater and the effectiveness of endoscopic biliary drainage without papillotomy.
abstract: OBJECTIVE
  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.
  
  
  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.
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan.
authors.forename: Yuichi
authors.initials: Y
authors.lastname: Takano
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan.
authors.forename: Masatsugu
authors.initials: M
authors.lastname: Nagahama
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan.
authors.forename: Naotaka
authors.initials: N
authors.lastname: Maruoka
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan.
authors.forename: Eiichi
authors.initials: E
authors.lastname: Yamamura
authors.affiliation: Department of Diagnostic Pathology, Showa University Fujigaoka Hospital, Yokohama, Kanagawa Japan.
authors.forename: Nobuyuki
authors.initials: N
authors.lastname: Ohike
authors.affiliation: Department of Diagnostic Pathology, Showa University Fujigaoka Hospital, Yokohama, Kanagawa Japan.
authors.forename: Tomoko
authors.initials: T
authors.lastname: Norose
authors.affiliation: Division of Gastroenterology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Kanagawa, Japan.
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Takahashi