Post transplant anastomotic stricture. This patient also had an intra-diverticular papilla.

This was a long drawn out affair. The first ERCP attempt at cannulation of CBD was unsuccessful due to the intra-diverticular position of papilla (1A: red arrow). We then planned a railroad technique, whereby the radiologist would do a percutaneous cannulation. That attempt was also unsuccessful (1B), due to a very tight stricture so the radiologist placed an external drain. In the second ERCP attempt, we were able to cannulate the Pancreatic duct but the CBD could still not be accessed. Our 3rd attempt was rewarded with success. The guidewire can be seen in the initial film curling up near the stricture (B: yellow arrow) with the external drain seen right above the stricture (B: green arrow). To the right (B: red arrow) a collection can be seen. Despite the external drain and stricture, the CBD was unusual in being dilated. We did a sphincterotomy (C: red arrow. Yellow arrow points to the diverticular lumen). A 10F x 12cm plastic stent was then placed across the stricture (D: red arrow & E).