Outcome of endoscopic sphincterotomy in patients with pain of suspected biliary or papillary origin and inconclusive cholangiography findings

Background and Study Aims: We prospectively studied the outcome of endoscop ic sphincterotomy in symptomatic patients with elevated liver enzyme levels but no clear evidence of biliary pathology on transabdominal ultrasound an d 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 gallstone s or significant common bile duct dilatation were evaluated. Elevated bilir ubin levels (up to 7.2 mg/dl) were found in 18 patients. The majority of pa tients (n = 21) had a gallbladder in situ, The findings from bile duct expl oration following sphincterotomy were recorded, and pain (as measured by vi sual analogue scale) as well as laboratory findings was assessed. Results: Wire-guided sphincterotomy was successful in all patients while un complicated pancreatitis occurred in one instance. In 16 patients (55 %) th ere was macroscopic evidence of small stones (n = 2), sludge (n = 12) or bo th (n = 2) following bile duct exploration. In addition, microscopy showed bile crystals in all four patients who had no macroscopic findings. All fou r patients with elevation of pancreatic enzymes prior to treatment, and fou r of those eight patients with previous cholecystectomy, showed evidence of biliary pathology, The initial median pain intensity was 8 (range 1-10); 2 6 patients became pain-free within 3 months following endoscopic sphinctero tomy, While 26 of 28 patients (93%) remained asymptomatic over a median fol low-up period of 19 months (range 12-26), one died of an unrelated malignan cy 6 months after therapy. Conclusions: Endoscopic sphincterotomy may be acceptable in patients with t ypical clinical presentation suggesting a papillary or biliary origin of pa in without further diagnostic work-up. Contrary to expectations, diagnostic ERC was insensitive in detection of the biliary etiology of symptoms in th is selected group of patients.