HPB Surgery, 1998, Vol. 11, pp. 23-26
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Spontaneous Passage of Gallbladder
Calculi-Facilitation by Endoscopic Sphincterotomy
B. C. SHARMA*, D. K. AGARWAL, S. S. BAIJAL and V. A. SARASWAT
Departments of Gastroenterology and Radiology, Sanjay Gandhi Postgraduate Institute ofMedical Sciences, Lucknow (India)
(Received 2 January 1996; In final form 15 May 1997)
After Endoscopic sphincterotopy (ES) gallbladder
motility increases leading to expulsion of crystals
and stones. But this is not a universal phenomenon.
We evaluated cholangiographic findings in patients
emptying their gallbladder after ES for common
bile duct (CBD) stones. Cholangiographic features
of twenty patients expelling gallbladder calculi
after ES were studied. Controls included 20 age and
sex matched patients with gallstones and CBD
stones, who did not expel gallstones after ES. Of 20
cases in study group, 9 recovered more than 20
stones each in the stool within 7 days of ES. Repeat
ERCP showed empty gallbladder in all, whereas
CBD was full of stones in 11 of the 20 cases. In the
study group, low insertion of the cystic duct was
more common (10 vs 0, p<0.04), the cystic duct
made a narrow angle (20+5 vs 50+10, p<0.04)
with CBD before insertion and cystic duct diameter
was higher (5 mm vs 2.5 mm, p<0.04) as compared
to controls. We conclude that in patients under-
going ES with intact gallbladder and small gall-
bladder calculi, spontaneous emptying of
gallbladder calculi occurs, if cystic duct is wider,
has low insertion and makes narrow angle with
CBD before insertion.
Keywords: Cholelithiasis, choledocholithiasis, cholangitis,
papillotomy, cystic duct, cholangiogram
INTRODUCTION
Endoscopic sphincterotopy (ES) is an established
mode of treatment for retained or recurrent
stones in the common bile duct after cholecys-
tectomy. With increasing experience, the indica-
tions for ES have expanded to include patients
with gallstones and common bile duct stones
with poor operative risks. In some centres ES is
performed in patients with an intact gallbladder,
who present with cholestasis, cholangitis and
gallstone pancreatitis regardless of surgical risk
[2]. It has been reported both in experimental
and clinical studies that ablation of the papillary
sphincter enhances gallbladder emptying. After
ES gallbladder motility increases and expels
crystals and stones [3-9]. But this phenomena is
not a universal finding. Only in a few patients
has it been found on routine check ERCP that,
following ES, the gallbladder becomes empty
and stones come to lie in the common bile duct.
Though gallbladder motility increases after ES in
*Corresponding author: Prestent address: 591, Sector 2, Panchkula, Haryana (India).
23
24 B.C. SHARMA et al.
all patients, only a few empty their gallbladder
and this fact tempted us to make a detailed
evaluation of cholangiographic findings in 20 of
our patients, exhibiting this phenomena.
PATIENTS AND METHODS
Of 120 patients who had undergone ES with the
gallbladder in situ, 20 patients cleared their
gallbladder of stones. Endoscopic procedure
was performed using a JFIT 10 or TJF 10
sideviewing duodenoscope ES(1-2 cm) was
done using a standard sphincterotome. Dormia
extraction was tried in every patient. The check
ERCP was done in every patient at an interval of
7 to 30 days, after the first procedure. All the
patients were requested to check their stools for
stones after ES. Cholangiographic findings were
studied in patients expelling calculi from gall-
bladder after ES with special reference to
number and size of gallbladder calculi, common
bile duct diameter, number and size of common
bile duct calculi, cystic duct diameter, level of
cystic duct insertion and angle cystic duct makes
with common bile duct before insertion. Mea-
surement of common bile duct and cystic duct
were taken at the site of their maximum
diameter. Cystic duct was considered to run
parallel to common duct, if the course of the two
ducts was closely adherent for at least 1 cm. For
determining the location of the junction along
the length of extrahepatic biliary tree, the
distance from ampulla to bifurcation of the duct
was divided into three equal parts and ex-
pressed a proximal, middle and distal one-third.
Cystic duct joining common duct in distal one-
third was considered as low insertion of cystic
duct [10]. The cholangiographic findings were
compared with 20 age and sex matched
controls, having multiple small gallstones with
common bile duct stones and functioning
gallbladder. They had undergone ES for com-
mon bile duct stones, had clear common bile
duct on check ERCP but did not expel
gallbladder stones after ES. In controls also the
check ERCP was performed at intervals ranging
from 7-30 days.
RESULTS
Patients included 8 men and 12 women with a
mean age of 42 years (range 30 to 60 years). All
the patients has cholelithiasis with choledocho-
lithiasis and 6 patients has associated cholangi-
tis. Liver function tests were as shown in Table I.
In all of the 20 patients cholangiograms revealed
1 to 5 common duct stones, which were actively
extracted after doing ES and the common bile
duct was cleared in every patient. Of 20 patients,
9 recovered more than 20 stones in the stool
within 7 days of ES. Repeat ERCP done at
intervals of 7 to 30 days, showed an empty
gallbladder in all, whereas the common bile duct
was full of small stones (4 to 6 mm) in 11 out of
20 patients.
On cholangiographic evaluation (Tab. II), the
gallbladder was opacified in all the cases and
revealed multiple (10 to 35) calculi of 4 to 6 mm.
TABLE Liver function tests before and after ES, n 20
Before ES After 7 days
Mean 4- SD (range) Mean 4- SD (range)
1. Total bilirubin (mg/dL)
2. Direct bilirubin (mg/dL)
3. Alkaline phashatase (IU/L)
4. AST (IU/L)
5. ALT (IU/L)
6. Albumin (g/dL)
5.5 4- 4.4 (0.6-14.3)
4.1 4- 4.0 (0.1 12)
381.7 4- 281 (132-810)
99.2 4- 88.1 (48-290)
105 4- 87.7 (31-317)
3.8 4- 0.4 (3.1-4.5)
1.1 4- 0.6 (0.4-1.6)
0.3 4- 0.1 (0.2-0.4)
126 4- 26 (98-130)
38.6 4- 14.7 (22-50)
32.6 4- 11.3 (20-42)
3.2 4- 0.4 (2.9-3.5)
ENDOSCOPIC SPHINCTEROTOMY 25
TABLE II Cholangiographic features
Patients Controls
n 20 n 20
P value
A. Gall bladder calculi
Size 4-6 mm 4 6 mm
Number multiple multiple
B. Common bile duct
Diameter 10 mm (7-20 mm) 10 mm (6-20 mm)
Calculi multiple multiple
C. Cystic duct
Diameter 5 mm (4-6 mm) 2.5 mm (2-3 mm)
Insertion
Normal 10 cases 20 cases
Low 10 cases 0
Angle 20 + 5 50 + 10
NS
NS
< 0.04
<0.04
< 0.04
Cystic duct had insertion in lower part of
common bile duct in 10 patients. In 6 patients
it was running parallel to common bile duct
before insertion. In all 20 patients the cystic duct
made on acute and narrow angle (20 4- 6 range
10-30 with common bile duct before insertion.
In controls gallbladder calculi were multiple and
varied from 4 to 6 mm in size. Cystic duct
insertion was in middle portion of common bile
duct in all patients and at insertion cystic duct
made angle of 50 4- 10 (range 40-60 with
common bile duct.
DISCUSSION
ES is an established mode of treatment for
choledocholithiasis for last 20 years with com-
plications rate of 8% to 10% and mortality of 1%
to 2% [7]. Nowdays ES is widely used for
treating common bile duct stones in patients
with an intact gallbladder. These are the patients
who are elderly, frail and a poor risk for surgery
or patients with acute, biliary disease and gall
stone pancreatitis. The fate of the gallbladder in
such patients depends on whether the gallblad-
der harbors calculi or not. The incidence of acute
cholecystitis in patients with acalculous gall-
bladder is 0 to 1% even after long term followup
for 7 to 9 years [8]. In patients with gallstones,
the incidence of acute cholecystitis is reported to
be 16%[9]. After ES in patients with gallbladder
in situ, biliary symptoms occur more frequently
in patients with gallbladder calculi as compared
to patients with acalculous gallbladder [11]. In
earlier studies, there are scattered case reports,
where gallbladder calculi are cleared after ES
[4, 3, 6]. This is an important finding as the
gallbladder in such cases will behave like those
with acalculous gallbladder in term of develop-
ing acute cholecystitis. Such patients with
acalculous gallbladder may not require routine
cholecystectomy after ES as recommended by
some workers. This phenomenon of facilitation
of spontaneous passage of gallbladder calculi
can be explained by enhanced gallbladder
emptying after ES. Hutton etal studied sponta-
neous passage of glass beads from gallbladder
after ES in dogs [3]. One month after bead
implantation, dogs with intact sphincter passed
52%, 26%, 22%, 10%, 0% and 0% of beads with
diameters of 2, 3, 4, 5, 6 and 8 mm respectively.
For the same respective bead diameters, dogs
with sphincterotomy passed 90%, 90%, 88%,
75%, 75% and 42% of beads. In a separate set of
dogs, cholescintigraphic study performed after
sphincterotomy revealed increased gallbladder
ejection fraction from 0.46 to 0.76. In addition
sphincterotomy also lowered resting and chole-
cystokinin stimulated gallbladder volume. Simi-
lar results have been reported in other
experimental studies. In human studies, ES
was found to lower resting gallbladder volume
and caerulin stimulated residual gallbladder
26 B.C. SHARMA et al.
volume. ES also significantly increased ejection
fraction and rate constant for gallbladder emp-
tying [12, 13].
Spontaneous passage of gallbladder calculi
after ES occurs only in some patients, so apart
from alteration in mechanical functions of
gallbladder after ES, others factors: cystic duct
length, diameter and insertion and common bile
duct diameter are thought to be important. After
critical evaluation of cholangiographic findings,
we could identify certain distinct features. In all
the patients when expelled their the gallbladder
has multiple small stones, broader cystic duct,
low insertion of cystic duct and the cystic duct
made narrow angle with common bile duct in all
the cases whereas in normal cases it was found
to vary from 40 to 60
Based on these findings we consider that apart
from enhanced gallbladder motility normal
cholangiographic variations to also play a role
in determining whether patients will expel gall
bladder calculi after ES or not. However
a prospective larger study is needed to draw
further definite conclusions. In patients under-
going ES with intact gallbladder and small sized
gallbladder claculi, if these cholangiographic
features are present, the chances of spontaneous
passage of gallbladder calculi are there. Unless
there is a pressing need such cases can be
followed up the with hope of spontaneous
emptying of gallbladder. However if stones are
large and cystic duct diameter is small then
cystic duct occlusion may occur leading to
complications like mucocoele and empyema.
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