Post written by Erik Haraldsson, MD, from the Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, and the Department of Surgery, Skaraborg Hospital, Skövde, Sweden.

The focus of the study was to evaluate to what extent the various endoscopic appearances of the major duodenal papilla influence bile duct cannulation, utilizing the recently proposed endoscopic classification of the endoscopic appearance together with a definition of difficult bile duct cannulation proposed by the Scandinavian Association for Digestive Endoscopy.

Difficulties during bile duct cannulation are known to influence the incidence of post-ERCP pancreatitis (PEP). All endoscopists know that the appearance of the papilla varies a lot. Until now, no prospective attempt been made at evaluating how and if the various endoscopic appearances really have an influence on cannulation difficulties.

The primary outcome measure of the study was the difference in frequency of difficult cannulation between the different predefined papilla types. The major result from this study was that Type 2, Small papilla, and Type 3, Protruding or pendulous papilla were more frequently difficult to cannulate compared to Type 1, regular papilla.  Furthermore, the frequency of failed cannulation was higher among the patients where an inexperienced endoscopist had started cannulation attempts eventhough a senior colleague took over and continued cannulation efforts after 5 min. This was mostly pronounced for Type 2, Small papilla. These findings were not expected and therefore not evaluated properly. This aspect needs further investigation to determine if the different endoscopic appearance influences the risk for PEP independently from cannulation difficulties.

Figure 1. Classification of the endoscopic appearance of the papilla of Vater. Type 1 “regular papilla,” most common type with no distinctive features, “classic appearance.” Type 2 “small papilla,” small, often flat with a diameter not bigger than 3 mm (∼2 sphincterotome diameter). Type 3 “protruding or pendulous papilla,” papilla that is protruding or bulging into the duodenal lumen, sometimes hanging down, pendulous with the orifice oriented caudally. Type 4 “creased or ridged papilla,” the ductal mucosa seems to extend distally out of the orifice either on a ridge or in a crease.

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