0016-5170/83/2902-0132$02.00/0GASTROINTESTINAL ENDOSCOPYCopyright © 1983 by the American Society for Gastrointestinal Endoscopy

Spectrum

Variations in the normal duodenal papilla S. E. Silvis, MDJ. A. Vennes, MD

Marsha Dreyer, GIA

Minneapolis, Minnesota

Figure 1. After the duodenoscope has entered the second portionof the duodenum, the first clue to identification of the papilla is thelongitudinal fold, which breaks the normal circular folds of theduodenum. When a longitudinal fold is present, the papilla is almostinvariably located on or near this fold. It can be in any position onthe fold. In this example, it is the very small red dot at themidportion of the longitudinal fold. The exception to the papillabeing on the longitudinal fold is in patients who have had a duoden­otomy where the surgical incision will appear as a longitudinal fold.

Figure 2. When a periampullary diverticulum is present (thedark hole in the upper right hand corner), the papilla of Vateralmost invariably sits on the rim of the diverticulum. It is rare thatthe papilla actually is within the diverticulum where it cannot becannulated. However, it can frequently be difficult to find the papillaon this rim.

Figure 3. This illustration shows the same patient after thecannula has been inserted and demonstrates that the common ductruns in the wall of the diverticulum. It is frequently difficult to getan ideal position for cannulation; one must cannulate from a consid­erable distance, as shown here. If the orifice is well identified andthe alignment of the cannula to the duct is perfect, the cannula willoften slip into the duct without difficulty. Periampullary diverticulaare pseudodiverticula and contain no muscular wall. Therefore,instruments such as cannulas or endoscopes should not be intro­duced into these diverticula.

Figure 4. When a large longitudinal fold is present, typically thepapilla sits at the distal or caudal end of the fold. After the papillais accurately identified, it should be examined carefully for one ormore orifices. Here, the papilla is obviously not in the properposition, nor close enough for easy cannulation. It should be in the12:00-2:00 o'clock position and considerably closer; in addition, thecannula is approaching the papilla at an angle to the course of thecommon duct.

Figure 5. More commonly than in the previous illustration, thepapilla is quite small and the actual papillary orifice is representedonly by a small reticular area at the far end of the longitudinal fold.This type of papilla should be examined very carefully before anattempt at cannulation is made.

Figure 6. This photograph illustrates one of the problems inlocating the papilla even when a longitudinal fold is present. Priorto lifting of the circumferential fold, this papilla was tucked in underthat fold and could not be seen. If one examines the papilla veryclosely, it is apparent that there are two orifices, one just above thebulging mucosa from the duct orifice and one just below. In our

From the Department ofMedicine, Veterans Administration Med·ical Center, Minneapolis, Minnesota. Reprint requests: S. E. Silvis,VA Medical Center, 54th Street and 48th Avenue South, Minne­apolis, Minnesota 55417.

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experience, two separate orifices are distinctly uncommon. Whenthey occur, they are seldom readily apparent and can be identifiedonly by careful examination of the papilla before an attempt atcannulation is made. There are rare occasions when two separateorifices can be clearly identified without cannulating both orifices.

Figure 7. In a number of patients, only a very sh(,rt longitudinalfold is present. A small dimple representing the major papilla canbe seen in this illustration.

Figure 8. In contrast to the previous papilla, here is a verypatulous papilla which is very easy to cannulate. These patulouspapillas seem to be more common in patients with common ductstones.

Figure 9. This photograph portrays a difficult problem in theidentification of the papilla. A very small papilla is seen at thecenter of this photograph without any longitudinal fold or any breakin the circular folds. To identify such a tiny papilla, excellentduodenal motility control must be present and considerable patiencein the search is necessary. If there is bile in the duodenum, washingcarefully and following the bile back to its origin has, on a numberof occasions, been helpful. Frequently once these small flat papillasare identified, they are rather easy to cannulate.

Figure 10. This is a photograph of the papilla of Santorini. Asillustrated here, it may be as large or larger than some of thepapillas of Vater, but the minor papilla has different characteristics.It tends to have a color similar to the duodenal mucosa. (Theredness of the tip of this papilla is due to attempts at cannulationfrom misidentification as the papilla of Vater.) The Santorini papillatends to be hard and will not take a cannula, and generally a clear­cut orifice cannot be identified. With practice and a tapered cannula,a small percent of the papillas of Santorini can be cannulated. Thisshould not be attempted until after the major papilla has beencannulated and it is demonstrated that part of the pancreatic ductalsystem does not fill from the major papilla. In most patients, evenwith a fairly prominent papilla of Santorini, the duct system will fIllentirely from the papilla of Vater.

Figure 11. This illustration shows both the papilla of Santorini(upper center of the field) and the papilla of Vater (lower right) inthe same photograph. The upper papilla is always Santorini and thelower, the major papilla, with the common bile duct orifice. Againnote the approximately equal size of the two papillas. Therefore,size cannot be a valid differential point between the major andaccessory papilla.

Figure 12. The overall size of the papilla varies markedly froma few millimeters to over 1 cm. We do not feel that any interpretationof papillary inflammation can be made from the appearance of thepapilla and that papillitis is a histological diagnosis which may nothave clinical correlates. This papilla is very large but the endoscopicretrograde cholangiopancreatography was entirely normal.

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