Endoscopic classification of the papilla of Vater. Results of an inter- and intraobserver agreement study

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Background: Many endoscopists acknowledge that the appearance of the papilla of Vater seems to affect biliary cannulation. To assess the association between the macroscopic appearance of the papilla and biliary cannulation and other related clinical issues, a system is needed to define the appearance of the papilla. Objective: The purpose of this study was to validate an endoscopic classification of the papilla of Vater by assessing the interobserver and intraobserver agreements among endoscopist with varying experience. Methods: An endoscopic classification, based on pictures captured from 140 different papillae, containing four types of papillae was proposed. The four types are (a) Type 1: regular papilla, no distinctive features, ‘classic appearance’; (b) Type 2: small papilla, often flat, with a diameter ≤ 3 mm (approximately 9 Fr); (c) Type 3: protruding or pendulous papilla, a papilla that is standing out, protruding or bulging into the duodenal lumen or sometimes hanging down, pendulous with the orifice oriented caudally; and (d) Type 4: creased or ridged papilla, where the ductal mucosa seems to extend distally, rather out of the papillary orifice, either on a ridge or in a crease. To assess the level of interobserver agreement, a web-based survey was sent out to 18 endoscopists, containing 50 sets of still images of the papilla, distributed between the four different types. Three months later a follow-up survey, with images from the first survey was sent to the same endoscopists. Results: Interobserver agreement was substantial (κ = 0.62, 95% confidence interval (CI) 0.58–0.65) and were similar for both experts and non-experts. The intraobserver agreement assessed with the second survey was also substantial (κ = 0.66, 95% CI 0.59–0.72). Conclusion: The proposed endoscopic classification of the papilla of Vater seems to be easy to use, irrespective of the level of experience of the endoscopist. It carries a substantial inter- and intraobserver agreement and now the clinical relevance of the four different papilla types awaits to be determined.


  • E Haraldsson
  • Lars Lundell
  • F. Swahn
  • L Enochsson
  • J. M. Löhr
  • U Arnelo
  • Lars Aabakken
  • Juha Grönroos
  • Jorma Halttunen
  • Truls Hauge
  • Björn Lindkvist
  • Marja Leena Kylänpää
  • Palle N Schmidt
  • Arto Saarela
  • Ervin Toth
  • Scandinavian Association for Digestive Endoscopy (SADE) Study Group of Endoscopic Retrograde Cholangio-Pancreaticography
External organisations
  • Karolinska Institute
  • Skaraborg Hospital
  • Karolinska University Hospital
  • Oslo university hospital
  • Turku University Hospital
  • Helsinki University Central Hospital
  • Sahlgrenska Academy
  • Hvidovre Hospital
  • Oulu University Hospital
  • Skåne University Hospital
Research areas and keywords

Subject classification (UKÄ) – MANDATORY

  • Gastroenterology and Hepatology


  • Duodenoscopy, endoscopic classification, endoscopic retrograde cholangio-pancreaticography, interobserver agreement, intraobserver agreement, papilla of Vater
Original languageEnglish
Pages (from-to)504-510
JournalUnited European Gastroenterology Journal
Issue number4
StatePublished - 2017 Jun 1