Atlas of Gastroenterological Endoscopy
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Duodeno-biliary fistula resulting in obstruction of the papilla and pancreatic diarrhea
Fistulous duct Catheterisation of the fistula
The patient presents with recurrent attacks of epigastric pain coinciding with chronic diarrhea, which 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
x-ray fistulous duct The biliary tree is visualized by application 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
Terumo guide wire 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. See also duodenal fistula.
  • Terumodraht = terumo guide wire