This paper presents a review of the clinical significance of juxtapapillary duodenal diverticula in man. The incidence of such diverticula varies considerably in the literature, and possibly depends on the methods of investigation used. Studies show that the incidence of biliary calculi is significantly higher in patients with juxtapapillary diverticula as compared with patients without such diverticula. The assumed higher rate of diverticula in patients with pancreatitis is probably due to the presence of biliary calculi in these patients. Studies have shown that there is an insufficient choledochoduodenal sphincter in patients with diverticula, and also a higher rate of bacterial contamination of the duodenum and bile ducts in these patients. Fecal type flora has been found in most patients with juxtapapillary duodenal diverticula. Further, pigment gallstones have been found in most patients with diverticula, and analyses of these calculi showed that calcium bilirubinate was the main component. Further studies in our laboratory have shown that bacterial cultures produced beta-glucuronidase, a fact which may be connected with the increased frequency of pigment gallstones. Other studies have shown that there is a higher rate of diverticula in patients with recurrent biliary calculi who had undergone cholecystectomy. Recent data have also shown that there is a higher rate of common bile duct calculi in patients with diverticula, than in those without diverticula and without prior cholecystectomy--a fact supporting the theory on the pathogenesis of biliary calculi in patients with juxtapapillary diverticula. Other, and rare complications due to such diverticula are also mentioned.

The results suggest that probiotics primarily act superficially, with change of gross appearance of the mucosa at endoscopy, but without significant effect on histological picture, mucosal perfusion or faecal calprotectin, during a relatively short period of 4 weeks.

The function of the choledocho-duodenal sphincter was studied in 16 patients, 8 with juxta-papillary duodenal diverticula. All patients had calculi in the gallbladder. The common bile duct was normal. At cholecystectomy two catheters were introduced into the common bile duct through the stump of the cystic duct and fixed in place. The examinations were performed when the patients had recovered from the operation. One catheter was connected to a pressure transducer, the other was used for saline infusions. Pressure in the common duct was recorded before infusion and at constant infusion rates of 3,6, and 12 ml/min. The muscular tone, the contractile activity, and the total rhythmic variations of the sphincter during infusions were all significantly less in patients with diverticula than in the controls without diverticula. The findings indicate that there is a dysfunction of the choledochoduodenal sphincter in patients with juxta-papillary duodenal diverticula. This may in part be responsible for the high incidence of biliary calculi in patients with duodenal diverticula.

Several studies indicate a causal relationship between duodenal diverticula and gallstone disease. The diverticula persist after biliary tract surgery, and it is therefore presumed that patients with diverticula have an increased disposition to develop new calculi in the bile ducts after cholecystectomy. To test this hypothesis, the occurrence of recurrent biliary calculi was studied in 101 patients who had cholecystectomy, all with an asymptomatic period of two years or more following the primary biliary surgery. All patients had symptoms, that indicated biliary tract or pancreatic diseases. The incidence of recurrent calculi in patients with diverticula was 87.5% (95% confidence interval, 66.9-95.8). In patients without diverticula, the incidence was 31.9% (95% confidence interval, 21.5-44.3). The difference is highly significant, and the results support the assumption tht diverticula in the area of the papilla of Vater dispose to gallstone disease.

In a consecutive series of 174 patients the biliary and pancreatic ducts were demonstrated by endoscopic retrograde cholangio-pancreatography (ERCP). In 84 patients with normal duct systems, juxtapapillary diverticula were found in 5 patients (6%). In 90 cases with ductal abnormalities due to biliary concrements, dilated common bile duct and pancreatitis, diverticula were found in 35 patients (39%). In patients with abnormalities in both duct systems, diverticula were found in 52%, and in patients with changes in one duct system diverticula were found in 33%. The difference in occurrence of diverticula in patients with normal duct systems and pathological duct systems was statistically significant (p less than 0.02). The findings indicate a correlation between juxtapapillary diverticula and pathological changes due to biliary concrements, dilated common bile duct without concrements and pancreatitis.