Corrosive intake with extensive esophageal and gastric damage

This was a forty year old gentleman who had ingested corrosive (alkaline toilet cleaner). The barium study showed a thin streak of contrast outlining the esophagus (A: green arrows). The stomach was small and deformed,  especially the antral region (B: green arrows marking the fundus and body; red arrows marking the antral area). The case was referred to the surgeon but the surgical team insisted for us to have a go at esophageal dilatation. They had hoped the esophagus could be salvaged. Things were worse than expected on endoscopy with extensive scarring and fibrosis and friability (C). We partially dilated the upper esophagus with a 30 French Savary dilator but it was the same story lower down. Further dilatation was abandoned and the case was referred for esophagectomy and gastrectomy with possible colonic interposition.

A 48 year old woman with biliary pain

This lady had been having biliary type pain for the past two years. Her bilirubin levels were normal and alkaline phosphatase was mildly raised. The ultrasound suggested possibility of distal CBD sludge. The MRCP also suggested presence of sludge in the distal CBD (A: green arrow). There was an anomaly which appeared to be a stricture at the level of confluence. The radiologist reported that it was due to the hepatic artery crossing over the CBD (A red arrow). During ERCP, CBD access was very difficult and required an extensive papillotomy. The reason for posting the image (B) is because we encountered a problem faced by many when papillotomy is done. There was a fold of intestine above the ampulla (B: green arrows). This fold kept coming down with every peristaltic intestinal movement and kept touching the cutting wire (and hence getting cut in the process). The cholangiogram showed no negative shadows in the distal CBD (C1 &  C2: green arrow). The anomaly seen in the upper CBD in the MRCP was not present in the cholangiogram (C1& C2: red arrow). A very extensive papillotomy was required. There was no sludge or stone in the CBD. A clean sweep with biliary balloon was done. A diagnosis of sphincter of Oddi dysfunction was made.

Ampullary tumor with hepatic and vascular invasion

This patient was a 50 year old gentleman who had obstructive jaundice secondary to an ampullary tumor with hepatic metastatic deposits and thrombosis of his right portal vein. On ERCP, the ampulla was swollen. Contrast injection showed a dilated CBD and intrahepatic biliary tree (A: green arrows). We passed a 10 French 10cm long  plastic stent (B: green arrows).

Adenocarcinoma of gallbladder infiltrating into common hepatic duct and right hepatic lobe

A 50 year old lady who had developed jaundice a few weeks earlier. She was a diabetic and hypertensive and also had ischemic heart disease.
The CT scan showed a gallbladder mass infiltrating into the right hepatic lobe and common hepatic duct (A: green arrows & B: red arrows). Cannulation of the CBD was difficult and we kept going into the pancreatic duct. We decided to place a guidewire in the pancreatic duct and keep it there till the CBD was cannulated (C: green arrow). The image shows the papillotome engaging the ampulla with the pancreatic duct guidewire adjacent to it (D: green arrow). This technique helped and the CBD was cannulated (E: red arrow shows the guidewire in the CBD anf green arrow shows the first guidewire in the pancreatic duct). The cholangiogram showed involvement of the common hepatic duct and markedly dilated left ductal system with a poorly outlined right system (F: red arrows & G: green arrows). Only a few peripheral ducts of the right system were seen (G: green arrows). This was in accordance with the CT findings ( A & B). A self expanding metallic stent of 10mm diameter and 100mm length was placed (G: red arrows).

Ampullary tumor infiltrating into duodenum

Gastric outlet obstruction had resulted in this 70 year old gentleman due to his ampullary tumor infiltrating into his duodenum. He had earlier undergone stenting of the common bile duct for obstructive jaundice. First a plastic stent followed a few weeks later by a self expanding metallic stent. Unfortunately, only a couple of weeks later he developed symptoms of gastric outflow obstruction. The tumor had invaded the duodenal wall. On endoscopy, the previously placed metallic biliary stent was seen (A: red arrow) with the tumor tissue obstructing the duodenal lumen at the junction of bulb and descending duodenum (A: green arrow). It was decided to place a 22mm x 90mm self expanding metallic stent. The stent assembly was manoeuvred across the strictured area under flouroscopic guidance followed by contrast injection to confirm luminal patency beyond the strictured segment (B: red arrows). The stent was then deployed (C: green arrow. This is a classic picture of a patient with gastric outflow obstruction: a stent being placed on the right, stomach full of fluid due to obstruction on the left and the  obstructed duodenal lumen in top middle). The stent was deployed successfully (D). The final image showing the fully deployed stent (E: green arrow) with the previously placed metallic (E: red arrow) and plastic (E: yellow arrow) biliary stents.

Obstructive jaundice secondary to gallbladder tumor invading the common hepatic duct

This 80 year old gentleman had a CBD stricture secondary to a gallbladder tumor which was involving the distal common hepatic duct. His ampulla had classic openings of the bile duct (A:green arrow) and pancreatic duct (A: red arrow) so I decided to include its photo. These openings aren't always that clearly defined. There was also a small diverticulum supwrior to the ampulla (B: green arrow). Contrast injection outlined a stricture of the common hepatic duct (C: green arrow). The stricture was dilated with a 9 French dilator (D: green arrow) followed by placement of a self expanding metallic stent of 10mm diameter and 100mm length (E: green arrow & F: green arrow).

Note: You can have a detailed 3D view of the gallbladder and associated structure anatomy by clicking on this link http://www.healthline.com/human-body-maps/gallbladder

Gall bladder mass causing obstructive jaundice with possible fistulous tract

A locally infiltrating gall bladder mass had caused obstructive jaundice in this 50 year old lady. Contrast injection outlined a stricture at the level of the cystic duct (A: green arrow) and dilated intrahepatic ducts. Further contrast injection also outlined what appeared to be a fistulous tract adjacent to the CBD (B: green arrow). A 10F x 12 cm plastic stent was placed.

Bile duct clearance with an intra-diverticular ampulla

Have a close look at the first image (A1: green arrow). The ampulla is inside a seemingly small diverticulum. However, these diverticuli change their shape considerably with bowel movements. Since this was a pre-cholecystectomy CBD clearance, when we saw the ampulla, we were skeptical about attempting stone extraction (the patient's bilirubin was normal) and thought to advise the surgeon to clear the CBD as well. In the second image (A2: green arrow), the ampulla seems to be pouting out. The diverticulum was invaginating and evaginating with bowel movements. Contrast injection showed a single large stone (B: green arrow). We did a papillotomy (A2) and removed the stone with extraction balloon. Repeat contrast injection showed a clear CBD (C & D).

Post cholecystectomy CBD stricture

This 40 year old lady had presented with a stricture of the CBD at the level of the cystic duct following a cholecystectomy. We had passed a single plastic stent of 10F diameter two months ago. She currently had normal bilirubin levels. This was a follow up ERCP. We removed the previously placed stent with a snare. Dye injection showed a CBD stricture at the level of cystic duct (A: green arrow). We had planned to place two new 10F x 12 cm plastic stents. The first stent was placed across the stricture (B: green arrow). The guidewire was  then manoeuvred along the first stent (C: green arrow marks the guidewire red arrows mark the first stent). Unfortunately, the sheath on the tip of the guidewire broke off and couldn't be retrieved (D: red arrow). A new guidewire was then passed along the same route and the second stent was placed parallel to the first one ( E1 & E2: green arrows & F).

Carcinoma of pancreatic head causing obstructive jaundice

A 52 year old gentleman with jaundice secondary to a tumor of the pancreas (remember Courvoisier's law). The CT findings were of a dilated gallbladder (A: green arrow) and dilated CBD and pancreatic ducts (A: yellow arrow-the "double duct sign") with a pancreatic mass (A: red arrow). On ERCP,  contrast injection outlined a markedly dilated CBD and intrahepatic channels (B1 & B2: green arrows) with a sharp cutoff point near the level of cystic duct. A plastic 10F x10 cm stent was placed (C: red arrows)

Cirrhosis of liver with biliary stricture

The patient was a 50 year old lady who had a history of pruritus and liver disease. Viral serology, metabolic profile and autoimmune profiles were normal. Lately she developed recurring jaundice with raised ALP. MRCP showed a distal CBD stricture. On ERCP, intrahepatic channels were poorly outlined on dye injection-the "pruned biliary tree"(red arrow). The CBD showed distal tapering (red arrow). We did a sphincterotomy. That was sufficient to drain the biliary system. The negative shadows in the CBD were only air bubbles (green arrow).

Bile leak post hepatectomy

This was a 25 year old gentleman who suffered blunt abdominal trauma in a road traffic accident. A hemi-hepatectomy (Resection of segments 2, 6, 7 & 8) was done alongwith a right hemicolectomy and jejunojejunostomy. A drain was placed near the liver and the daily drain output was over 400ml, mostly bile. Contrast injection showed a normal calibre CBD (green arrow) with leakage (red arrows), mostly from the right system. The drain placed during surgery was visible adjacent to the site of leakage (blue arrow). We did a sphincterotomy which resulted in good bile flow (the patient's bilirubin was 2.4 mg/dL). The case will now be reviewed in our multidisciplinary team meeting for further treatment plan.

Obstructive jaundice secondary to hilar mass

This was a middle aged lady with a large right ovarian mass and obstructive jaundice caused by a mass lesion in the hilar region. She was extremely obese and couldn't lie prone. We did the procedure in the left lateral position. Initial contrast injection showed a sharp cutoff at tue levelcof cystic duct (A: green arrow). The guidewire was passed beyond the stricture followed by contrast injection which outlined a dilated left system with no contrast going into the right system (B: green arrow). We dilated the stricture with a 9F dilatation catheter followed by placement of a 10F x 12cm plastic stent (C & D: green arrow).

Esophageal tumor extending into stomach

This was a 52 year old lady with a tumor of the lower esophagus which was extending into the stomach along the lesser curvature (A). We attached external markers to dilate the extent of the tumor under flouroscopic guidance (B:green arrows). A partially covered self expanding metallic stent was passed (C: Total length 12cm with a 1.5cm uncovered area at either end. Flared diameter 23mm and shaft diameter 17mm). The stent was positioned along the markers (D: red arrows showing the stent). Repeat endoscopy was done after stent placement (E). Flouroscopic images showed a successful stent deployment (F1: green arrows showing stent with external markers in place. F2: green arrows show stent with external markers removed)

Corrosive injury with gastric outlet obstruction

This was a 25 year old lady who had ingested bathroom cleaner (alkali) with a suicidal intent. Barium studies showed a long esophageal stricture (A1) and gastric outlet obstruction (A2: green arrow). On endoscopy we couldn't get far due to the extensive damage (B) and used Savary dilators (C: green arrow) to dilate the esophagus. There was extensive damage in the fundus (D), body and antrum (E: green arrow marks the wide open pylorus). The duodenal bulb was scarred and tubular (F:green arrow) with a pinhole narrowing between the bulb and descending duodenum (G: green arrows). She's definitely going to need surgery for that outlet obstruction.