Correspondence

Biliary Sludge Extruding into the Duodenum

N Engl J Med 1999; 340:892-893March 18, 1999

Article

To the Editor:

Hokama and Kinjo (Oct. 22 issue)1 show us a clear endoscopic view of biliary sludge extruding from the papilla of a patient with cholangitis. The authors, however, have failed to mention whether they attempted endoscopic sphincterotomy or any biliary-drainage procedure at the time of the endoscopic retrograde cholangiopancreatography. The patient subsequently underwent open choledocholithotomy with T-tube drainage and died of postoperative sepsis. Although endoscopic retrograde cholangiopancreatography is the safest approach to biliary decompression,2 open exploration of the common bile duct may still be an acceptable option when other, less invasive drainage procedures cannot be performed or are not successful.3 There is, however, agreement that endoscopic retrograde cholangiopancreatography for diagnosis only is not appropriate.4

In this case, certain circumstances could have ruled out sphincterotomy (such as uncorrectable coagulopathy) or endoscopic removal of a stone (such as the presence of a large stone above a stricture, as this patient's relatively high serum bilirubin level may have indicated). Even then, however, insertion of a biliary stent or drain is usually possible and is certainly indicated.5 If any of these factors or any technical problems were present, the authors should have stated so.

Manuel Pérez-Miranda, M.D.
José Carlos Sarmentero, M.D.
Hospital Del Río Hortega, 47010 Valladolid, Spain

5 References

1. 1

   Hokama A, Kinjo F. Biliary sludge extruding into the duodenum. N Engl J Med 1998;339:1210-1210
   Full Text | Web of Science | Medline

2. 2

   Lai ECS, Mok FPT, Tan ESY, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med 1992;326:1582-1586
   Full Text | Web of Science | Medline

3. 3

   Scovill WA. Open common bile duct exploration: when is it indicated? In: Cameron JL, ed. Current surgical therapy. 6th ed. St. Louis: Mosby, 1998:420-3.
   

4. 4

   Schuman BM. The evolution of diagnostic ERCP. Gastrointest Endosc 1990;36:155-156
   CrossRef | Web of Science | Medline

5. 5

   Lee JG, Leung JW. Endoscopic management of difficult common bile duct stones. Gastrointest Endosc Clin N Am 1996;6:43-55
   Medline

Author/Editor Response

The authors and a colleague reply:

To the Editor: In our patient, endoscopic retrograde cholangiopancreatography revealed several large stones located above a stricture. Because we expected that impaction of stones would prevent stone extraction after endoscopic sphincterotomy or balloon dilation of the papilla, we attempted temporary nasobiliary drainage by endoscopy, but this procedure was unsuccessful because of difficulty in placing the catheter proximal to the site of obstruction. We recognize that an increased delay in biliary drainage increases the risk of septic shock when primary conservative management fails.1 We therefore decided in this case that subsequent definitive surgery was appropriate and was indicated because of the patient's general condition.

Akira Hokama, M.D., Ph.D.
Fukunori Kinjo, M.D., Ph.D.
Atsushi Saito, M.D., Ph.D.
University of the Ryukyus, Okinawa 903-0215, Japan

1 References

1. 1

   Boender J, Nix GA, de Ridder MA, et al. Endoscopic sphincterotomy and biliary drainage in patients with cholangitis due to common bile duct stones. Am J Gastroenterol 1995;90:233-238
   Web of Science | Medline