However, if it has been necessary to perform a choledochotorny to remove calculi in the common bile duct, an instrumental exploration of the papilla is com monly performed in spite of rhc normal anatomy and function shown hy the operauve cholangiogram. If examination of the papilla by means of cholangiograrn reveals an anatomic or functional abnormality of the sphincter of Oddi or the presence of an impacted calculus, instrumental exploration of the papilla is mandatory.
To perform an exploration of the papilla it is safest to explorers wirh tapering olive shaped explorers made of rubber, plastic, or silk.
These plastic and silk tissue explorers arc considered semirigid in relation to those made of rubber which are soft, and metallic ones which are rigid. Metallic explorers should be used only occasionally, since they may traurnauze the common bile duct and the papilla.
If metallic Bakes dilators are used in spite of their name since they were originally designed to dilate the papilla, they should not be used for chis purpose and only should be used as explorers.
It is sufficient that the Bakes 3 mm dilator pass through the papilla to consider that the papilla is not srrictured. It is completely unnecessary co dilate the papilla, since recurrencc in a short period of time is the rule and because of the possibility that trauma of the papilla produces spasm, edema, hernatomas, and even lacerations of the same. On the other hand, attempts to dilate the papilla, at times forced, may lead to dangerous false tracts.
It is also not advisable that the explorer that has passed easily into the duodenum be passed several times unnecessarily through the papilla with the object of reconfirming the papilla's permeability. This is enough to traumatize the papilla, giving rise to spasm, edema, and congestion of the same.
At the moment of instrumental exploration of the papilla it is necessary to establish if the exploring insrru mcnt passed through the lumen of the papilla or if the papilla was pushed by the exploring instrument.
To perform this distinction these elements of judgment arc involved:
- If the explorer has passed through the lumen of papilla, it makes the duodenal wall opposite the papilla prominent. giving the impression that it is about lo perforate it. If the explorer us metallic, it produces a shiny metallic color which is characteristic and was described by Walzd in the year 1919 walzel's sign will not appear if the explorer is pushing the papilla forward.
- If the explorer passes through the papilla, its end moves freely in the duodenal lumen, something that docs not occur fit pushes the papilla.
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If the explorer passes rhrough the papilla it generally descends 4 to 5 cm below the level at which the papilla is found.
- Palpation of the explorer reveals that it is not surrounded by tissue but lies free in the duodenum.