Double ampulla anatomy identified during endoscopic retrograde cholangiopancreatography
Bibliographic record
Abstract
A 48-year-old female with known cholelithiasis presented to hospital with epigastric pain, acute liver enzyme elevation, and hyperbilirubinemia. Endoscopic retrograde cholangiopancreatography (ERCP) was completed and, as the duodenoscope was positioned across the ampulla, 2 ampullary mounds were observed (Figure 1). The upper ampullary mound was successfully cannulated, and sphincterotomy was performed with stone clearance achieved using a balloon extraction catheter. Subsequent MRCP demonstrated variant pancreas divisum anatomy with the dominant continuation of the main pancreatic duct extending to the expected location of the minor papilla. A smaller branch of the main pancreatic duct extended to the vicinity of the ampulla, but terminated inferior to the distal common bile duct without a confluence of the 2 structures. Endoscopic image demonstrating double ampulla anatomy. To our knowledge, this is the first case of concurrent double ampulla and pancreas divisum anatomic variants described in the literature. Double ampulla anatomy occurs when non-union of the common bile duct and pancreatic duct leads to 2 distinct ampullae in the duodenum.1 This is a rare anatomic variant, occurring in approximately 0.18% of patients undergoing ERCP.2 A previous study found that common bile duct stones were more common in patients with double ampulla anatomy and hypothesized that associated sharp angulation and bile stasis may contribute to this.3 The presence of double ampulla anatomy may also lead to greater manipulation and cannulation of the duct of Wirsung, raising the risk of post-ERCP pancreatitis.4 While rare, proper identification and awareness of double ampulla anatomy are important to limit procedural risks of ERCP. Scott MacKay was involved in study design, literature review, and manuscript drafting. Rachel Sullivan, Jan-Erick Nilsson, and Gurpal Sandha were all involved in direct patient care for this case and were involved in manuscript preparation. Supplementary material is available at Journal of the Canadian Association of Gastroenterology online. None declared. Conflict of interest disclosure forms (ICMJE) have been collected for all co-authors and can be accessed as supplementary material here. There are no data associated with this manuscript.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.004 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.004 | 0.002 |
| Science and technology studies | 0.001 | 0.002 |
| Scholarly communication | 0.002 | 0.003 |
| Open science | 0.001 | 0.002 |
| Research integrity | 0.004 | 0.003 |
| Insufficient payload (model declined to judge) | 0.003 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".