Association of duodenal papillary morphology with underlying periampullary ductal structures in adult post-MRCP/ERCP patients

Abstract

Background: Various duodenal papilla morphologies {large/small protrusions, unstructured/gyrus/annular/longitudinal patterns) were shown to predict difficult cannulation, and different periampullary ductal variants (acute distal common bile duct (CBD) angle ?30o , non-draining Santorini duct, ansa pancreatitis, V type and B-P type CBD-PD junctions) were correlated to pancreatitis

Objectives: To explore the association of papilla morphology with periampullary ductal vatiations.

Methodology: We performed a retrospective analysis of 61 patients with naïve papilla who underwent magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP). From MRCP images, the periampullary ducts were classified according to cystic duct (CD) insertion, CD course, distal CBD angle, PD variation, and CBD-PD junction. From duodenoscopy videos, the papilla was classified according to the oral protrusion and papilla pattern.

Results: Fisher’s exact tests for independence showed a significant result between papilla protrusion and distal CBD angle (p = 0.002) with 87% of large protrusions having acute distal CBD angle ?30o. Though not statistically significant, (a) large protrusion had more parallel CD course (52.2%); and (b) gyrus papilla had more PD dominant CBD-PD junction (66.7%).

Conclusion: Large protrusions predict acute distal CBD angle of ?30o , which is related to difficult cannulation. Though not statistically significant, large protrusions have a more parallel CD course which could theoretically contribute to difficult cannulation if there is distal CD insertion; and gyrus papilla has more PD dominant junction which, as shown in earlier studies, is associated with difficult cannulation for inexperienced endoscopists.