Correspondence

Complications of Endoscopic Biliary Sphincterotomy

N Engl J Med 1997; 336:963-964March 27, 1997

Article

To the Editor:

In their study of complications of endoscopic biliary sphincterotomy (Sept. 26 issue),1 Freeman et al. found that the rates of complications were similar in patients with bile-duct stones whether sphincterotomy was performed after or in the absence of cholecystectomy. The frequency of complications in patients with intact gallbladders with or without gallstones was not investigated.

In our study of patients treated at 17 endoscopy centers in Austria, the Czech Republic, Hungary, and Poland, we found that the presence of gallstones was of value in predicting the development of cholecystitis after endoscopic sphincterotomy. We included all patients who underwent endoscopic sphincterotomy between 1986 and 1991 (in one center, however, the survey was conducted between 1990 and 1996). Of 8004 endoscopic sphincterotomies, 2857 (35.7 percent) were carried out in patients with intact gallbladders; 2001 patients had stones in both the bile ducts and the gallbladder, and 856 had gallbladders that were free of stones.

Cholecystitis or cholangitis developed within 14 days after endoscopic sphincterotomy in 115 patients (4.0 percent), including 105 who had stones in both the bile ducts and the gallbladder. Among the patients with gallstones, cholecystitis developed in 98, 7 of whom also had cholangitis. Among the patients with no gallstones, only 10 (1.2 percent) had acute cholecystitis, 2 of whom also had cholangitis (P<0.001 for the difference between the groups). Long-term follow-up was possible in 1068 patients (range of follow-up, 5 months to 10 years; median, 6.2 years). Symptomatic cholecystitis occurred in 82 patients with demonstrable gallstones (7.7 percent), 13 of whom also had cholangitis. None of the patients without gallstones had biliary symptoms.

We conclude that after endoscopic sphincterotomy in patients with intact gallbladders, the presence of gallstones is associated with an increased risk of biliary complications.

Zsolt Tulassay, M.D.
Tamas Zagoni, M.D.
Semmelweis Medical University, 1088 Budapest, Hungary

Jan Kotrlik, M.D.
Charles Medical University, 12808 Prague 1, Czech Republic

1 References

1. 1

   Freeman ML, Nelson DB, Sherman S, et al. Complications of endoscopic biliary sphincterotomy. N Engl J Med 1996;335:909-918
   Full Text | Web of Science | Medline

Author/Editor Response

The authors reply:

To the Editor: Tulassay and colleagues rightly point out that cholecystitis can develop in patients with intact gallbladders after endoscopic biliary sphincterotomy. It is not surprising that cholecystitis is more common in patients with gallbladder stones than in patients without such stones, since acalculous cholecystitis is relatively rare. In our study, 10 of 11 cases of cholecystitis after sphincterotomy occurred in patients with preexisting gallbladder stones.

The more difficult question is whether cholecystitis after endoscopic sphincterotomy represents a complication of the endoscopic procedure or merely reflects the natural history of symptomatic gallstones.1 Patients with fever, right-upper-quadrant pain, abnormal liver chemical values, and stones of the common bile duct may already have coexisting cholecystitis, and these conditions may be difficult to distinguish clinically.1,2 In other patients, clinical cholecystitis may develop later after sphincterotomy, but this might have occurred with or without endoscopic intervention. Neither our study nor that of Tulassay et al. can address the question of how often cholecystitis is actually caused by endoscopic retrograde cholangiopancreatography.

Martin L. Freeman, M.D.
Hennepin County Medical Center, Minneapolis, MN 55415-1829

Douglas B. Nelson, M.D.
Minneapolis Veterans Affairs Medical Center, Minneapolis, MN 55417

2 References

1. 1

   Silvis SE. Endoscopic sphincterotomy with an intact gallbladder. Gastrointest Endosc Clin N Am 1991;1:65-77
   

2. 2

   Cotton PB, Lehman G, Vennes J, et al. Endoscopic sphincterotomy complications and their management: an attempt at consensus. Gastrointest Endosc 1991;37:383-393
   CrossRef | Web of Science | Medline

Citing Articles (1)

Citing Articles

1. 1

   A. A. SIDDIQUI, P. MITROO, T. KOWALSKI, D. LOREN. (2006) Endoscopic sphincterotomy with or without cholecystectomy for choledocholithiasis in high-risk surgical patients: a decision analysis. Alimentary Pharmacology and Therapeutics 24:7, 1059-1066
   CrossRef