Tumor of the pancreatic head causing an unusually long biliary stricture

A 55 year old patient with metastatic tumor of the head of pancreas. The ampulla seemed normal. Contrast injection outlined dilated intrahepatic bile ducts (A: white arrows) and a dilated upper CBD. The mid and lower CBD was strictured and narrow (A: green arrows). We did a small papillotomy to allow the stent assembly to pass with ease and deployed a self expanding metallic stent of 8mm diameter and 80mm length (B: white arrows. C: white arrows show the deployed stent and washout of contrast from the biliary tree) . The longer stent was required due to a longer stricture, unexpected in tumors of the head of pancreas where usually 6 cm long stents suffice.

Tumor of the pancreatic head

This 48 year old patient had a metastatic tumor of the pancreatic head. On physical examination, his gallbladder was palpable and he was jaundiced (Courvoisier 's sign).  His CT film showed the classical "double duct" sign, with dilated pancreatic and biliary ducts within the pancreatic head (A: red arrow points to the bile duct and yellow arrow points to the pancreatic duct. White arrow: gallbladder). He had liver and lung metastases. Going in during ERCP, the area around the papilla was infiltrated and was oozing blood (B1 & B2: red arrows). The cholangiogram showed a grossly dilated CBD (C: green arrow) with distal tapering (C: white arrow). We did a small papillotomy (D: white arrow) and passed a partially covered self expanding metallic stent of 10mm diameter and 60mm length (E: white arrows marking the extent of deployed stent and green arrow marks the "waist" at the affected strictured area. F: green arrow shows the lower end of the deployed stent in the duodenal lumen).

Cholangiocarcinoma and cholangitis

A 50 year old lady had developed obstructive jaundice over the past few months and had been admitted with recent onset of fever. She was found to have a mass lesion near the area of confluence. She had no co-morbids. On ERCP, our guidewire couldn't initially go beyond the proximal CHD. The cholangiogram showed the CBD and CHD, along with the sharp cutoff at the proximal CHD (A: white arrow). The cystic duct was also outlined (A: green arrow). The guidewire was finally placed across the strictured part after a few attempts and contrast injection outlined the full biliary tree. The right and left ductal systems were dilated and a stricture was seen just below the confluence (B: white arrow. This would seem to be a Bismuth Type I lesion). After dilatation with a 9 French graduated dilator, we passed a 12 cm long plastic stent of 10 French diameter to drain the biliary system. She will continue to recieve antibiotics and will be placed in our weekly multidisciplinary meeting for review and eventual surgery.