Double major papilla: a very rare endoscopic picture

Panagiotis Katsinelos, Stergios Gkagkalis, Grigoris Chatzimavroudis, Kostas Fasoulas

G. Gennimatas General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece

Department of Endoscopy and Motility Unit, G. Gennimatas General Hospital, Aristotle University of Thessaloniki,
Thessaloniki, Greece

Conflict of Interest: None

Correspondence to: Panagiotis Katsinelos, MD, PhD,
Ass. Prof. of Gastroenterology, Head, Department of Endoscopy
and Motility Unit, G. Gennimatas General Hospital,
Medical School, Aristotle University of Thessaloniki,
Ethnikis Aminis 41, 54635 Thessaloniki, Greece,
Tel: +30 2310 963341, Fax: +30 2310 210401,
e-mail: gchatzimav@yahoo.gr

Received 23 January 2012; accepted 13 March 2012

Variations in the bile duct and pancreatic duct opening are related to the process of rotation and recanalization during embryologic development. Complete non-union of distal common bile duct and duct of Wirsung gives rise to a double papilla of Vater [1].

A 48-year-old woman presented to the emergency room complaining of severe upper abdominal pain which later shifted to the right upper quadrant. Physical examination was remarkable for right upper quadrant and epigastric tenderness. Laboratory data showed abnormal liver chemistry and white blood count of 13000/mm³. Abdominal ultrasound demonstrated a dilated common bile duct (diameter 11 mm) and MRI cholangiography revealed choledocholithiasis and a small stone embedded in the ampulla. Endoscopic retrograde cholangiopancreatography (ERCP) was performed showing a small biliary stone in the orifice of upper major papilla and the presence of a second major papilla located about 1 cm inferior to the upper one (Fig. 1). Cannulation of upper and lower papilla showed a dilated common bile duct with stones and a normal pancreatogram, respectively (Fig. 2). Endoscopic sphincterotomy of upper papilla was performed with extraction of biliary stones.

A search in PubMed yielded only four documented cases of double papilla of Vater [2-5]. The existence of this rare anatomic anomaly does not predispose to any pancreatobiliary disease, but is an opportunity for another learning experience contributing to expert competency in ERCP and improved quality of care for patients.

References

1. Sterling JA. The biliary tract with special reference to the common bile duct. Williams & Wilkins: Baltimore; 1995, pp. 29-40.

2. Simon MA, Moreira VF, Merono E, Seara JF, del Olmo L. The double papilla of Vater. Gastrointest Endosc 1985;31:353-354.

3. Francis J, Kadakia S. Anomalous double orifice of a single major papilla of Vater. Gastrointest Endosc 1994;40:324-325.

4. Rajnakova A, Tan W, Goh P. Double papilla of Vater: a rare anomaly observed in endoscopic retrograde cholangiopancreatography. Surg Laparosc Endosc 1998;8:345-348.

5. Katsinelos P, Chatzimavroudis G, Fasoulas K, et al. Double major papilla of Vater - a rare endoscopic finding during endoscopic retrograde cholangiopancreatography: a case report. Cases J 2009;2:163.