Brand B, Wiese L, Thonke F, Sriram P V, Jaeckle S, Seitz U, Bohnacker S, Soehendra N
Dept. of Interdisciplinary Endoscopy, University Hospital Eppendorf Hamburg, Germany.
Endoscopy. 2001 May;33(5):405-8. doi: 10.1055/s-2001-14272.
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).
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.
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.
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.
我们对有症状且肝酶水平升高，但经腹部超声和诊断性内镜逆行胆管造影（ERC）未发现明确胆道病变证据的患者进行了内镜括约肌切开术的前瞻性研究。
对29例有胆绞痛型疼痛（八项标准中两项或更多）、肝酶水平升高且无胆结石或胆总管明显扩张证据的患者进行评估。18例患者胆红素水平升高（最高达7.2mg/dl）。大多数患者（n = 21）胆囊原位存在。记录括约肌切开术后胆管探查的结果，并评估疼痛（采用视觉模拟评分法测量）以及实验室检查结果。
所有患者均成功进行了导丝引导下的括约肌切开术，仅1例发生了无并发症的胰腺炎。胆管探查后，16例患者（55%）有肉眼可见的小结石（n = 2）、胆泥（n = 12）或两者皆有（n = 2）的证据。此外，显微镜检查显示，在所有无肉眼可见病变的4例患者中均发现了胆汁结晶。所有4例治疗前胰酶升高的患者，以及8例曾行胆囊切除术的患者中的4例，均显示有胆道病变的证据。初始疼痛强度中位数为8（范围1 - 10）；26例患者在内镜括约肌切开术后3个月内疼痛消失。在中位随访期19个月（范围12 - 26个月）内，28例患者中有26例（93%）无症状，1例在治疗后6个月死于无关的恶性肿瘤。
对于临床表现典型提示疼痛源于乳头或胆道但未进一步进行诊断性检查的患者，内镜括约肌切开术可能是可以接受的。与预期相反，诊断性ERC在检测这组特定患者的症状性胆道病因方面不敏感。
