Morphology of the major papilla predicts ERCP procedural outcomes and adverse events

Rachid Mohamed, B. Cord Lethebe, Emmanuel Gonzalez-Moreno, Ahmed Kayal, Sydney Bass, Martin Cole, Christian Turbide, Millie Chau, Hannah F. Koury, Darren R. Brenner, Robert J. Hilsden, B. Joseph Elmunzer, Rajesh N. Keswani, Sachin Wani, Steven J. Heitman, Nauzer Forbes*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

7 Scopus citations


Background: The morphology of the major papilla affects the difficulty of endoscopic retrograde cholangiopancreatography (ERCP), but no associations with adverse events have previously been established. We aimed to assess whether papillary morphology predicts ERCP adverse events. Methods: A retrospective analysis was performed of a prospective registry of patients undergoing ERCP for biliary indications. The primary outcome was post-ERCP pancreatitis (PEP), with secondary outcomes including other adverse events and procedural outcomes such as inadvertent pancreatic duct cannulation, cannulation time, and attempts. Papillae were classified as normal (Type I), small or flat (Type II), bulging (Type IIIa), pendulous (Type IIIb), creased (Type IV), or peri-diverticular (Type D). Outcomes were ascertained prospectively at 30 days from index procedures. Results: A total of 637 patients with native papillae were included. Compared to Type I papillae, Type II and Type IIIb papillae were associated with PEP, with adjusted odds ratios (AOR) of 7.28 (95% confidence intervals, CI, 1.84–28.74) and 4.25 (95% CI 1.26–14.32), respectively. Type II and IIIb papillae were associated with significantly longer cannulation times by 5.37 (95% CI 2.39–8.35) and 4.01 (95% CI 1.72–6.30) minutes, respectively. Type IIIb papillae were associated with lower deep cannulation success (AOR 0.17, 95% CI 0.06–0.48). Conclusion: Papillary morphology is an important factor influencing both ERCP success and outcomes. Understanding this is key for managing intraprocedural approaches and minimizing adverse events. Prospective registry registration: identifier NCT04259580.

Original languageEnglish (US)
Pages (from-to)6455-6465
Number of pages11
JournalSurgical endoscopy
Issue number12
StatePublished - Dec 2021


  • Bile ducts
  • ERCP
  • Pancreatitis

ASJC Scopus subject areas

  • Surgery


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