In the field of medicine, papillary stenosis refers to a narrowing of the greater papilla duodeni, also known as the papilla duodeni Vateri. The papilla is a mucosal fold within the duodenum into which the two excretory ducts of the pancreas and gallbladder open together. Narrowing of the papilla can have a wide variety of causes and obstructs the outflow of digestive enzymes provided by the gallbladder and pancreas.
What is papillary stenosis?
Approximately in the middle of the circa 25-centimeter-long duodenum, which connects directly to the stomach, there is a characteristic fold of mucosa. The large bile duct (ductus choledochus) and the pancreatic duct (ductus pancreaticus) open together into the mucosal fold. From the papilla duodeni Vateri, digestive enzymes secreted by the liver and pancreas trickle into the passing food pulp. If the common orifice is partially displaced or narrowed, papillary stenosis is present. Serious narrowing or total blockage results in a backlog of enzymes in the gallbladder and pancreas, and the food pulp in the intestine is not supplied, or is inadequately supplied, with the necessary enzymes that serve to break down fats, proteins, and carbohydrates, among other things.
Causes
The causes leading to papillary stenosis may be pathologic processes in or on the papilla itself, the two feeder ducts, or, for example, solid calculi that obstruct the papilla Vateri. Inflammation of the bile ducts or the feeder duct of the pancreas with corresponding narrowing may be caused by bacterial infection. The pathogenic bacteria either originate from the bloodstream or are transported from the intestine into one of the two feeder ducts during an ERCP (endoscopic retrograde cholangiopancreatography), for example. ERCP offers the possibility to inspect the papilla and the two feeder ducts endoscopically and to make changes or even remove gallstones. Inflammation can also be promoted by gallstones and back up of enzymes. In rare cases, bacterial inflammation appears as the culprit, usually socialized with autoimmune disease. In very rare cases, scarring adhesions can form after surgery or after ERCP, leading to papillary stenosis. Other possibilities of outflow obstruction may result from space displacement of developing tumors in the area of the optic nerve or both feeding ducts.
Symptoms, complaints, and signs
Papillary stenosis announces itself with pain in the upper abdomen, depending on its severity. Initially relatively nonspecific abdominal pain becomes more specific and severe if papillary stenosis persists and cholestasis or pancreatitis, or both, develop because of the backlog of enzymes and digestive juices. Cholestasis caused by papillary stenosis is an extrahepatic cholestasis accompanied by nausea and vomiting and shows signs of jaundice (icterus) because of the onset of hyperbilirubinemia. The first thing to notice is yellowing of the eyes and a brownish discoloration of the urine. Pancreatitis also manifests itself with pain in the upper abdomen, often radiating to the lower thoracic spine and somewhat comparable to lumbago. In severe cases, symptoms of icterus may also appear and serious problems may develop. If papillary stenosis is due to “mechanical” causes such as painless adhesions or painless benign tumors, the same symptoms will present as the severity of the stenosis increases.
Diagnosis and disease progression
If papillary stenosis is suspected, a thorough history can be used to determine whether gallstones have ever been present or whether there have been problems with the pancreas or gallbladder. In many cases, high-resolution sonography allows conclusions to be drawn about the condition of the papilla and whether a stenosis is present. If there is still uncertainty, an endoscopic retrograde cholangiopancreaticography (ERCP), can provide clarity. ERCP provides direct endoscopic insight into the papilla and the two feeding ducts, the choledochal duct and the pancreatic duct.For purely diagnostic purposes, ERCP is gradually being superseded by MRCP, magnetic resonance cholangiopancreatography, because it is a noninvasive procedure with no risk of injury or infection. However, it is naturally a purely imaging, diagnostic procedure that is not suitable for any necessary interventions. The course of disease symptoms caused by papillary stenosis depends on the progression of the stenosis. If the stenosis persists, it will provoke the development of pancreatitis and cholestasis with all the associated problems.
Complications
Papillary stenosis has a very negative impact on the overall quality of life of the affected person and can significantly reduce it. As a rule, the affected person suffers from severe abdominal pain in this case, which, however, occurs without a particular and visible reason. Furthermore, there is vomiting and also permanent nausea. In the further course of the disease, jaundice also develops, which causes damage to the kidneys. The eyes of the affected person also turn yellow. The pain in the abdomen can also spread to the other regions of the affected person and thus lead to sleep problems, especially at night. Patients appear irritable due to the papillary stenosis and not infrequently suffer from depression. The permanent abdominal pain often leads to a loss of appetite, so that the affected person also loses weight. The treatment of papillary stenosis is carried out with the help of medication. In some cases, however, the disease may heal itself. There are no particular complications. As a rule, the patient’s life expectancy is also not affected.
When should you go to the doctor?
Persistent or recurrent pain in the stomach area should be presented to a doctor. If there is internal weakness, a decrease in physical performance, and a decrease in the ability of the affected person to cope with stress, a physician is needed. Nausea, vomiting or a yellowing of the skin as well as eyes are signs of a health disorder and must be clarified. If existing pain leads to problems with locomotion or coping with everyday life, a doctor is needed. Until consultation with the physician, the use of pain medication should be avoided due to possible complications. Continued experience of stress, decreased enjoyment of life, and reduced quality of life should be discussed with a physician. If there are disturbances of the digestive tract, a noise in the gastrointestinal tract, a loss of appetite as well as a decrease in body weight, a doctor should be consulted. If irregularities in the upper part of the body continue to spread or back problems develop, these are warning signs of the organism. There is possibly a disease that needs treatment. Disturbances during urination, discoloration or an unusual odor of the urine are further indications that should be discussed with a doctor. If depressive moods are present or withdrawal behavior is evident, a doctor is needed. Many patients of papilledema stenosis complain of feeling sick, unwell, or generally dissatisfied with their lives.
Treatment and therapy
Treatment of papilledema stenosis depends on the cause. The first goal of therapy is to identify and correct the reason for causing the stenosis. In many cases, this can be the treatment of an inflammation in order to reduce the swelling in the area of the papilla or the feeding ducts, so that the stenosis virtually resolves itself. In most cases, an ERCP may be performed, during which not only the exact diagnosis is made, but interventions can be performed immediately, such as removal of gallstones or dilatation of the papilla or the biliary or pancreatic duct. In addition, stents or drains can be placed and necessary incisions can also be made using a papillotome and cutting wire.
Outlook and prognosis
The prognosis of papillary stenosis should generally be documented as favorable. As soon as medical care is sought, medications are administered that already provide relief from symptoms within a short period of time. Recovery may be achieved after a few days or weeks.Without the cooperation of medical professionals, an increase in complaints is to be expected. The pathogens can spread further in the organism and lead to pain or dysfunction in other places. In addition, the risk of secondary diseases is increased. Depending on the intensity of the existing health irregularities, surgical intervention may be considered. Thanks to medical advances, complications from this procedure are low. Normally, even with this method of treatment, the patient can be discharged as symptom-free after a few weeks. In the further course, control examinations should take place at regular intervals in order to be able to react immediately in case of possible changes or abnormalities. Long-term impairments or permanent health complaints can be avoided with good medical care and a healthy lifestyle. If papilledema stenosis develops again in the course of life, the prognosis outlook remains unchanged. The best results are achieved when therapy is started early. However, especially in high-risk patients such as children or the elderly, a rapid response should be made if the irregularities develop again.
Prevention
Direct preventive measures that could prevent papilledema stenosis are nonexistent. A lifestyle that provides for relaxation periods in addition to stressful situations can be considered generally preventive. Likewise, a diet consisting in part of foods left in their natural state is beneficial. Persons in whose families several cases of papillary stenosis are known have a somewhat increased risk. Occurring diffuse pain in the upper abdomen should then be clarified a little carefully.
Follow-up
In most cases of papilledema stenosis, the measures of follow-up care are significantly limited or not available to the affected person at all. Therefore, the patient should see a doctor at the first signs of the disease to prevent the occurrence of further complications. Self-healing cannot occur in this case. However, if left untreated, the affected person may die from papilledema stenosis. In most cases, the affected person is dependent on a surgical intervention, which can permanently alleviate the symptoms. Ideally, this should be done immediately after diagnosis. After such an operation, the affected person should rest and take care of his body. Stressful activities or exertion should be avoided in order not to put unnecessary strain on the body. Likewise, in most cases, the diet must be strongly adjusted, so that fatty meals are to be avoided. The life expectancy of the affected person in this disease depends very much on the time of diagnosis and also on the severity of the papillary stenosis, so that a general prediction cannot be made. However, it may be reduced in some circumstances.
What you can do yourself
In any case of papilledema stenosis, medical treatment is necessary. Accompanying this, a number of measures can be taken to alleviate the typical gastrointestinal complaints. First of all, those affected should change their diet. A light diet is just as suitable as a diet individually adapted to the symptoms. Patients should consult a nutritionist for this. In addition, the gastrointestinal tract must be protected. Coffee and alcohol should be avoided. Since papillary stenosis also affects the gallbladder, it can lead to severe gallstone disease, which is best treated by regular fluid intake. First and foremost, patients should follow the doctor’s instructions. Papillary stenosis always requires medical therapy, but this can be supported by some self-help measures. Since the narrowing can take on different forms, the measures must first be discussed with the physician. The physician can often give further tips for a therapy and also support the patient in finding a suitable self-help group. In this way, papilledema stenosis can be reliably treated without further discomfort, complications or long-term consequences.
