Preoperative Investigations and Preparation for Procedure

Clinical:

Physical examination: Laboratory evaluation:

Imaging:

Other:

Psychologic/psychiatric consultation:

Episodic, mid-epigastric pain, often young women, 25-40years old, usually after cholecystectomy Lack of jaundice or epigastric tenderness, essentially normal abdominal examination

Hemoglobin, amylase/lipase; one-third of patients with papillary stenosis will have transient increase in biliary or pancreatic enzymes but only during the episode of pain; cardiorespi-ratory evaluation as indicated

Ultrasonography to exclude cholecystolithiasis and choledo-cholithiasis; ERCP probably should be attempted in all patients; deformity of papilla or dilation of bile or pancreatic ducts is present in 25 %; cannulation of pancreatic duct is possible only in 50 %

Transpapillary manometry, when performed, shows high resting pressures in the pancreatic and biliary ducts All candidates for operative approach, a viable attempt preopeatively at narcotic detoxification should be entertained (almost never successful)

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