Papillary Stenosis

Papillary stenosis is fibrotic narrowing of the major duodenal papilla causing obstruction to bile or pancreatic juice flow. It is treated with sphincterotomy when objective evidence of obstruction exists.

It may follow stone passage, pancreatitis, previous sphincterotomy, instrumentation or inflammation, and is also described with adenomyosis of the papilla and sphincter of Oddi dysfunction. Most patients are women aged 30 to 60 years after cholecystectomy.

The biliary type I (biliary type pain, liver enzymes over 2 times the upper limit on two occasions, and a common bile duct over 8 mm) is the group most likely to benefit from sphincterotomy. Type II has one or two of these features, and type III has pain alone.

Pathophysiology.

Chronic inflammation and fibrosis of the sphincter, or sphincter dysfunction, raises basal sphincter pressure and obstructs bile or pancreatic flow, causing duct dilatation, pain, liver enzyme rise and recurrent pancreatitis.

Episodic right upper quadrant or epigastric pain lasting 30 minutes or longer, radiating to the back or shoulder, and sometimes with nausea, vomiting and jaundice. Recurrent pancreatitis occurs in pancreatic type disease.

Red flags.

• Fever with jaundice (cholangitis).
• Severe or recurrent pancreatitis.
• Weight loss.

Liver tests and lipase during pain. Ultrasound and magnetic resonance cholangiopancreatography (with secretin) assess duct size and exclude stones, strictures and tumours. Endoscopic ultrasound excludes small stones, microlithiasis, chronic pancreatitis and ampullary tumour. Sphincter of Oddi manometry (basal pressure over 40 mmHg) is rarely used because of pancreatitis risk.

Differential diagnosis.

• Common bile duct stone.
• Chronic pancreatitis.
• Ampullary adenoma or carcinoma.
• Biliary dyskinesia.
• Peptic ulcer disease.
• Functional abdominal pain.

Endoscopic sphincterotomy (biliary, with pancreatic sphincterotomy in selected pancreatic cases) is the treatment for type I and for selected patients with documented obstruction. It is not advised for type III disease, because large studies show no benefit and a high rate of complications.

Prevent pancreatitis with a pancreatic stent (5 French) in high risk patients and aggressive hydration.

• Indomethacin: 100 mg rectally once, immediately before or after the procedure; single dose; maximum 100 mg; monitor renal function and bleeding; avoid in peptic ulcer, renal impairment and allergy to non-steroidal anti-inflammatory drugs.
• Ringer lactate: 3 mL/kg/h IV during and for 8 hours after the procedure, with a 20 mL/kg bolus at the start; maximum as limited by cardiac and renal status; monitor for fluid overload; reduce in heart failure or renal impairment.

For patients with type II or III disease or who decline procedures:

• Nifedipine (limited evidence): 10 to 20 mg orally twice daily for a 4-week course; maximum 40 mg daily in this use; monitor blood pressure, heart rate and oedema; avoid in hypotension and reduce in hepatic impairment.
• Amitriptyline: 10 to 25 mg orally at night for visceral pain; maximum 75 mg daily in this use; monitor ECG, sedation and anticholinergic effects; avoid in recent myocardial infarction and arrhythmia; reduce in older adults.

Monitoring. Symptoms and liver tests at 4 to 6 weeks and 6 months; ultrasound if pain recurs.

Referral and escalation. Pancreaticobiliary endoscopy expert for sphincter procedures.