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).
I am a gastroenterologist. This is a blog of the ERCPs and related endoscopic procedures carried out at my department. Dr Adnan Salim.
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