Macroscopic appearance of the major duodenal papilla influences bile duct cannulation : a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP

Background and Aims: Certain appearances of the major duodenal papilla have been claimed to make cannulation more difficult during ERCP. This study uses a validated classification of the endoscopic appearance of the major duodenal papilla to determine if certain types of papilla predispose to difficult cannulation. Methods: Patients with a naive papilla scheduled for ERCP were included. The papilla was classified into 1 of 4 papilla types before cannulation started. Time to successful bile duct cannulation, attempts, and number of pancreatic duct passages were recorded. Difficult cannulation was defined as after 5 minutes, 5 attempts, or 2 pancreatic guidewire passages. Results: A total of 1401 patients were included from 9 different centers in the Nordic countries. The overall frequency of difficult cannulation was 42% (95% confidence interval [CI], 39%-44%). Type 2 small papilla (52%; 95% CI, 45%-59%) and type 3 protruding or pendulous papilla (48%; 95% CI, 42%-53%) were more frequently difficult to cannulate compared with type 1 regular papilla (36%; 95% CI, 33%-40%; both P <.001). If an inexperienced endoscopist started cannulation, the frequency of failed cannulation increased from 1.9% to 6.3% (P <.0001), even though they were replaced by a senior endoscopist after 5 minutes. Conclusions: The endoscopic appearance of the major duodenal papilla influences bile duct cannulation. Small type 2 and protruding or pendulous type 3 papillae are more frequently difficult to cannulate. In addition, cannulation might even fail more frequently if a beginner starts cannulation. These findings should be taken into consideration when performing studies regarding bile duct cannulation and in training future generations of endoscopists.Peer reviewe

Curriculum for diagnostic endoscopic ultrasound training in Europe : European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

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Macroscopic appearance of the major duodenal papilla influences bile duct cannulation: a prospective multicenter study by the Scandinavian Association for Digestive Endoscopy Study Group for ERCP

Background and AimsCertain appearances of the major duodenal papilla have been claimed to make cannulation more difficult during ERCP. This study uses a validated classification of the endoscopic appearance of the major duodenal papilla to determine if certain types of papilla predispose to difficult cannulation.MethodsPatients with a naïve papilla scheduled for ERCP were included. The papilla was classified into 1 of 4 papilla types before cannulation started. Time to successful bile duct cannulation, attempts, and number of pancreatic duct passages were recorded. Difficult cannulation was defined as after 5 minutes, 5 attempts, or 2 pancreatic guidewire passages.ResultsA total of 1401 patients were included from 9 different centers in the Nordic countries. The overall frequency of difficult cannulation was 42% (95% confidence interval [CI], 39%-44%). Type 2 small papilla (52%; 95% CI, 45%-59%) and type 3 protruding or pendulous papilla (48%; 95% CI, 42%-53%) were more frequently difficult to cannulate compared with type 1 regular papilla (36%; 95% CI, 33%-40%; both P P ConclusionsThe endoscopic appearance of the major duodenal papilla influences bile duct cannulation. Small type 2 and protruding or pendulous type 3 papillae are more frequently difficult to cannulate. In addition, cannulation might even fail more frequently if a beginner starts cannulation. These findings should be taken into consideration when performing studies regarding bile duct cannulation and in training future generations of endoscopists.</div

Gastrointestinal transit in health and disease

The uptake of nutrients occurs mainly in the small bowel. However, the time nutrients and other contents spend in the small bowel, i.e. the small bowel transit time is widely uncharacterised in man. Available methods for studying small bowel transit are expensive, time consuming and have limited accessibility. The aim was to develop a practical method for studying small bowel transit as well as gastric emptying and colonic transit in one day. The second aim was to characterise gastrointestinal transit in health and in some common gastrointestinal diseases. The method was based on the use of radiopaque spheres in a test meal to measure gastric emptying and small bowel transit. The spheres were followed using fluoroscopy. Colonic transit was based on ten radiopaque rings given daily for six days with fluoroscopy on day seven, i.e. the measurement day. Detailed gastrointestinal transit parameters were obtained in a large number of healthy subjects as well as in patients with celiac disease before and after treatment and in patients with liver disease and portal hypertension. In addition, patients with idiopathic bile acid malabsorption were studied prospectively. In total 636 transit measurements in healthy subjects and different patients were performed. This one-day transit measurement procedure was non-invasive, reproducible and inexpensive and it was easy to perform. The radiation exposure during the measurement was 2 mS, which is less than the one-year background radiation in Sweden. In healthy subjects, women had slower transit in all segments of the gut. Overweight healthy women had faster small bowel transit and faster transit through the distal colon compared with lean women. The majority of patients with idiopathic bile acid malabsorption were overweight and had accelerated transit in the small bowel and distal colon compared with healthy subjects. Delayed small bowel transit was observed in male patients with untreated celiac disease and in male patients with liver disease. Body mass index increased and small bowel transit accelerated in the celiac patients after treatment. In women with untreated celiac disease, overweight was associated with faster small bowel transit. In liver disease, Small bowel bacterial overgrowth was associated with delayed small bowel transit. Conclusions: This newly developed transit measurement procedure is a valuable tool for the evaluation of large patient materials with suspected transit abnormalities. Gender influences gut transit in health and may influence transit in disease. The association of overweight with accelerated transit on the one hand and celiac disease and liver disease, i.e. disorders of malnutrition with delayed transit, on the other, indicates that gastrointestinal transit may adapt to varying nutritional status in man

Endoscopic ultrasound in the monitoring of the intestinal allograft

Objective Chronic rejection (CR) of the small intestinal allograft includes mucosal fibrosis, bowel thickening and arteriopathy in the outer wall layers and the mesentery. CR lacks non-invasive markers and reliable diagnostic methods. We evaluated endoscopic ultrasound (EUS) as a novel approach for monitoring of the intestinal allograft with respect to CR.Design In intestinal graft recipients, EUS and enteroscopy with ileal mucosal biopsy were performed via the ileostomy. At EUS, the wall thickness of the intestinal graft was measured in standard mode, whereas the resistive index (RI) of the supplying artery was assessed in pulsed Doppler mode. At enteroscopy, the intestinal mucosa was assessed. Findings were compared with histopathology and clinical follow-up.Results EUS was successfully performed in all 11 patients (adequate clinical course (AC) n=9; CR n=2) after a median interval of 1537 days (range: 170–5204), post-transplantation. The total diameter of the wall (layer I–V) was comparable in all patients. Meanwhile, the diameter of the outermost part (layer IV–V; that is, muscularis propria–serosa) was among the two CR patients (range: 1.3–1.4 mm) in the upper end of measurements as compared with the nine AC patients (range: 0.5–1.4 mm). The RI was &gt;0.9 in both CR patients, while the RI was ≤0.8 in all AC patients. Both CR patients had abnormal findings at enteroscopy and histopathology and deceased during follow-up.Conclusion EUS is a promising tool providing detailed information on the intestinal graft morphology and rheology, which may be used for assessment of potential CR in long-term follow-up of intestinal allograft recipients