Physical examination: Laboratory evaluation:
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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