Ectopic opening of the common bile duct and duodenal stenosis: an overlooked association

Abstract

Background: Ectopic opening of the common bile duct into the duodenal bulb (EO-CBD-DB) is a rare disease that may be complicated by duodenal ulcer, deformity, stenosis and biliary stones. The aim of this study is to report clinical presentations, endoscopic diagnosis and treatment of this entity as well as to investigate its association with duodenal stenosis.

Methods: Gastroduodenoscopic findings and radiological imaging were evaluated for ectopic papilla and duodenal stenosis. Diagnostic methods, endoscopic procedures and long-term outcomes of the endoscopic treatment were presented.

Results: EO-CBD-DB was found in 74 (77.1%) of the 96 patients with duodenal deformity/stenosis (79 male, 17 female, mean age: 58.5, range: 30-87 years). The papilla with normal appearance was retracted to the bulb in 11 while it was at its usual location in the remaining 11. The history of biliodigestive surgery was more common in patients with EO-CBD-DB who were frequently presented with the common bile duct stone-related symptoms than the other patients. Thirteen (17.6%) of the patients with EO-CBD-DB were referred to surgery. Endoscopic treatment was completed in 60 (81.1%) patients after an average of 1.7 (range: 1-6) procedures. These patients were on follow-up for 24.8 (range: 2-46) months. Endoscopic intervention was required in 12 (20%) of them because of recurrent biliary problems. Treatment of the patient who had stricture due to biliary injury during laparoscopic cholecystectomy is still continued.

Conclusions: The presence of EO-CBD-DB should be considered particularly in middle-aged male patients who have duodenal deformity/stenosis. Endoscopic treatment is feasible in these patients. The long-term outcomes of endoscopic therapy need to be compared with surgical treatment.

Figure 1

Typical endoscopic view. Slit-like biliary and pancreatic orifices easy to cannulate.

Figure 2

Typical cholangiogram. Hook-shaped appearance.

Figure 3

Magnetic resonance imaging. Hook-shaped appearance and CBD stones are observed.

Figure 4

CBD orifice proximal to apical stenosis.

Figure 5

Passing AS with the help of dilatation balloon. After filling dilatation balloon at the level of stenosis, it is pulled up to the tip of endoscope. Then, endoscope and balloon are pushed together. Note the endoscope and the balloon are on the same direction.

Figure 6

Cannulation of ectopic CBD opening in case of AS. Blind cannulation while endoscope is proximal to AS (A). Tight AS and air in the bile ducts (left); cannulation on the stomach side shown (right)(B). Stone removal on the stomach side in the same patient (C).

Figure 7

Cannulation in a patient with gastroenterostomy. Side-to-side HJ is on view.