Duodeno-biliary fistula resulting
in obstruction of the papilla and pancreatic diarrhea
The patient presents with
recurrent attacks of epigastric pain coinciding with chronic
led to a weight loss of 7 kg. There is a history of
cholecystectomy 30 years ago. A fistular orifice with
a diameter of 2 mm (left picture) is found in the right
duodenal wall at gastroscopy.
Deep intubation is easily performed
The biliary tree is visualized by
of contrast medium via the ERCP catheter.
Drainage into the duodenum does´nt occurr
via the papilla, but via the fistula (left figure).
The following ERCP gains normal access to
the pancreatic duct via the papilla. The
chronic grade II pancreatitis is not depicted
here. An EPT is performed for chronic
pancreatitis with obstruction of the pancreatic
duct and diarrhea possibly caused by pancreatic
insufficiency secondary to papillary stenosis.
- Fistelgang = fistula
- Bulbus duodeni = duodenal bulb
- Katheter im Ductus choledochus = catheter in the common bile duct
Antegrade intubation of the bile
duct with a
normal guide wire or a papillotoma fails.
Thus a soft terumo guide wire is advanced
via the fistula into the bile duct and reaches
the duodenum in a retrograde way. The wire
is extracted orally with a snare and used to insert
a papillotoma for performance of a papillotomy.
Thereafter both ducts drain properly in an ante-
grade way. The patient is free of complaints and
has gained considerable weight. Diarrhea has
ceased, enzyme substitution is no longer necessary.
- Terumodraht = terumo guide wire