Periampullary diverticulum (PAD) is duodenal outpunching defined as herniation of the mucosa or submucosa that occurs via a defect in the muscle layer within an area of 2 to 3 cm around the papilla. Although PAD is usually asymptomatic and discovered incidentally during endoscopic retrograde cholangiopancreatography (ERCP), it is associated with different pathological conditions such as common bile duct obstruction, pancreatitis, perforation, bleeding, and rarely carcinoma. ERCP has a low rate of success in patients with PAD, suggesting that this condition may complicate the technical application of the ERCP procedure. Moreover, cannulation of PAD can be challenging, time consuming, and require the higher level of skill of more experienced endoscopists. A large portion of the failures of cannulation in patients with PAD can be attributed to inability of the endoscopist to detect the papilla. In cases where the papilla is identified but does not point in a suitable direction for cannulation, different techniques have been described. Endoscopists must be aware of papilla identification in the presence of PAD and of different cannulation techniques, including their technical feasibility and safety, to allow for an informed decision and ensure the best outcome. Herein, we review the literature on this practical topic and propose an algorithm to increase the success rate of biliary cannulation.

The aim of this study was to evaluate the association between juxtapapillary diverticulum (JD) and acute cholangitis (AC), and to analyze laboratory data to reveal the underlying mechanism. We conducted a retrospective review of 139 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) between April 2008 and March 2013 for diagnosis or treatment of biliary tract conditions. The Wilcoxon signed-rank test was used for comparison of variables between patients with or without JD. The χ (2) test was used to analyze the association between JD and AC duct dilatation. Logistic regression analysis was performed to identify variables with strong correlation with AC. ERCP was attempted in 139 patients, but in one patient the endoscope did not reach the papilla of Vater because of a partial gastrectomy, and in two patients evaluation for JD was not possible because of duodenal or papilla of Vater cancer. Therefore, 136 patients were included in this study. JD was significantly associated with AC (P<0.0001) and bile-duct dilatation (P=0.0107), and AC was strongly associated with bile duct dilatation (P=0.0013). Alkaline phosphatase levels were significantly elevated in patients with JD (P=0.0237). In AC patients without JD, χ (2) for C-reactive protein was 4.48 (P=0.0342), whereas in AC patients with JD, χ (2) values for the white blood cell count, alkaline phosphatase, and aspartate aminotransferase were 2.62, 3.1, and 3.61, respectively (P=0.025, 0.015, and 0.0336, respectively). JD was strongly associated with AC. Logistic regression analysis suggested that bile flow was disturbed with JD.

The aim of this study was to examine the relation between periampullary diverticula (PAD) and biliary tract stones.

A total of 732 cases of patients with PAD identified from among 6,221 patients who underwent endoscopic retrograde cholangiopancreatography were compared to 750 controls (without PAD) in terms of biliary stone formation, incidence of sphincter of Oddi dysfunction (SOD), and choledocholithiasis. The biliary tract diseases were diagnosed based on medical history, clinical symptoms and signs, and imaging findings using ultrasonography, computed tomography, or magnetic resonance cholangiopancreatography.

The PAD group contained a significantly larger number of patients with biliary stones including stones in the primary common bile duct, SOD with bile duct stones (p < 0.05), and choledocholithiasis after cholecystectomy (p < 0.01).

There is a close correlation between PAD and the formation of biliary tract stones. A particularly close correlation was found between PAD and choledocholithiasis after cholecystectomy. PAD may be an important risk factor for the occurrence or recurrence of biliary tract stones.

Periampullary diverticula (PAD) are extraluminal outpouchings of the duodenum arising within a radius of 2-3 cm from the ampulla of Vater. They are frequently encountered in elderly patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and contribute to failure of ERCP. This review details the relationship of PAD to pancreaticobiliary disease and the influence of PAD on the management of patients.

The United States National Library of Medicine Medline database was searched for articles on and related to PAD published in English within the past 15 years. Major earlier works were also reviewed.

The prevalence of PAD increases with age and could be as high as 27 per cent. PAD are associated with an incompetent sphincter of Oddi and colonization of bile duct with beta-glucuronidase-producing organisms. PAD are implicated in the pathogenesis of pigment common bile duct stones, but there is no conclusive evidence to associate them with cholecystolithiasis or pancreatitis. PAD are a major cause of failure of ERCP, but success rates of more than 90 per cent have been achieved in specialist centres.

With an ageing population, there will be an increase in elderly patients with PAD and symptomatic pancreaticobiliary disease. Continuing improvements in radiological and endoscopic techniques should enable this vulnerable group to be treated effectively and safely.

The prevalence of biliopancreatic disorders is high in patients with periampullary diverticula. However, endoscopic retrograde cholangiopancreatography (ERCP) in patients with the papilla deep inside duodenal diverticula is difficult.

Two patients were included in this study, each with the papilla deep inside a diverticulum and in whom an initial ERCP was unsuccessful. A biopsy forceps to pinch the duodenal mucosa distal to the papilla and pull the papilla out of the diverticulum and a cannula were inserted into the working channel of a duodenoscope together (the two-devices-in-one-channel method). With coordination of the two instruments, cannulation of the bile duct was attempted.

In both patients ERCP was successful using this procedure and no complications followed.

The two-devices-in-one-channel method is useful when performing ERCP in patients with the papilla inside juxtapapillary diverticula.

Previous studies have suggested a relationship between bile duct stones and periampullary duodenal diverticula. The aim of the present study was to examine this association in more detail, including step-wise logistic regression to identify independent predictors for the presence of diverticula. Clinical, endoscopic and radiological data were analysed from 794 consecutive subjects with bile duct stones; 44 with primary duct stones (without gall-bladder stones) and 750 with bile duct stones associated with current or previous gall-bladder stones. Frequencies of diverticula in subjects with bile duct stones were compared with those in age-matched controls who had undergone upper gastro-intestinal endoscopy using a side-viewing endoscope (n = 100) or who had undergone endoscopic retrograde cholangiopancreatography (ERCP) for pancreatic cancer (n = 100). The frequencies of diverticula in subjects with primary duct stones (70%) and bile duct stones with current or previous gall-bladder stones (25%) were significantly higher than in both control groups (7 and 8%, respectively). When subjects with bile duct stones were analysed by step-wise logistic regression, age and bile duct diameter were independent predictors of the presence of diverticula, but diverticula were unrelated to gender, mode of presentation, number of bile duct stones and outcome after endoscopic sphincterotomy. A significant association exists between duodenal diverticula and bile duct stones, perhaps because diverticula predispose to stone formation through the combined effects of bile stasis and bacterial contamination of bile.