Abstract: Objective:To investigate the diagnosis and treatment of ectopic opening of the common bile duct in the duodenal bulb.
Methods:The clinical data of 3 patients who were admitted to the Binzhou People′s Hospital and 9 patients who were admitted to the Tianjin People′s Hospital from January 2006 to December 2013 with ectopic opening of the common bile duct in the duodenal bulb were retrospectively analyzed. Seven patients had choledocholithiasis and 5 had stenosis at the end of common bile duct. The medical histories and clinical features in patients were analyzed and routine blood test and serum liver function test were done. All the patients received the endoscopic retrograde cholangiopancreatography (ERCP) examination and were cured. All the patients were followed up via outpatient examination and telephone interview up to August 2014.
Results:Six patients had histories of cholangitis recurrence and 2 had histories of duodenal ulcer recurrence. All the patients had pain in the right hypochondriac region of the abdomen. Seven patients had fever, chills, skin yellowing sclera and tenderness in the right hypochondriac region of the abdomen. The levels of alkaline phosphatase (ALP) and glutamyltranspeptidase (GGT) in 11 patients, the levels of TBil and DBil in 8 patients and the count of WBC in 7 patients were increased. (1)The results of ERCP showed as follows: there was no papillar opening at the second and third segment of duodenum. The cracklike opening located at the duodenal postbulb with rough and erosive mucosal surfaces and intermittent outflow of bile. Duodenal ulcer was detected in 5 patients and duodenal bulb metamorphosis in 3 patients. All the 12 patients received successfully intubations. (2)The results of retrograde cholangiography showed as follows: the end of common bile duct of 12 patients was taper and sickleshaped. Intraand extrahepatic bile duct dilation was detected in 10 patients, choledocholithiasis in 7 patients and clear findings for the pancreatic duct in 5 patients. Among the 12 patients, 8 received balloon dilation (5 with stenosis at the end of common bile duct , 3 with choledocholithiasis), 3 received laparoscopic common bile duct exploration (LCBDE) combined with cholangioenterostomy due to diameter of stone more than 1.5 cm and ectopic opening stenosis of the common bile duct in the duodenal bulb. One patient was treated by percutaneous transhepatic cholangiography (PTC) lithotomy of common bile duct after unsuccessful ERCP without bleeding and pancreatitisrelated complications. The symptoms of cholangitis in 3 patients were alleviated after balloon dilation, 2 patients had recurrence of cholangitis and were cured by RouxenY cholangioenterostomy. The mean open surgery time and mean duration of postoperative hospital stay in 5 patients were 85 minutes (range, 60-150 minutes) and 10 days (range, 8-14 days), respectively. All the 12 patients were followed up with a median time of 38 months (range, 8-90 months).  During the followup, 10 patients survived well without recurrence of cholangitis and cholelithiasis. Two patients had recurrence of cholangitis at postoperative month 2 and month 14, including 1 patient with the recurrence of common bile duct sandlike stones, and they were readmitted to hospital and treated by RouxenY cholangioenterostomy without recurrence by followup.
Conclusions:The clinical symptoms of ectopic opening of the common bile duct in the duodenal bulb included recurrence of cholangitis, duodenal ulcer history, pain in the right hypochondriac region of the abdomen, skin yellowing sclera, abnormal liver function, cracklike openings in the duodenal bulb by ERCP examination with outflow of bile, cholangiographyguided taper and sickleshaped end of common bile duct. The treatment should be aimed at the concomitant diseases.