This 66 year old gentleman took the cake for multiple coexisting diseases in addition to his biliary pathology. He had diabetes, hypertension, ischemic heart disease, epilepsy and depression. He also had cholelithiasis and choledocholithiasis. We engaged the papilla (A:green arrow) but couldn't cannulate the CBD. We resorted to a precut with a needle knife (B:green arrow) which clearly identified the CBD opening (C: green arrow). Contrast injection showed stones in the distal CBD (D: green arrow). Our patient became distressed and felt pain during extension of papillotomy (which was quite unusual) by this time and we quickly ended the procedure by cancelling stone extraction and placing a plastic stent of 10 French diameter and 10cm length (E: green arrows). In our opinion, the papilla seemed unhealthy. This, plus the transaminase and ALP levels in the high hundreds prompted us to advise a CA 19-9 and abdominal CT scan before a repeat ERCP for stone extraction (to be done under propofol sedation)
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