A 52 year old gentleman with metastatic ampullary tumor. His CT scan showed a grossly dilated CBD (A: white arrow). Ampullary infiltration was evident on ERCP (B: white arrow). Contrast injection outlined a markedly dilated CBD (C: white arrow). A 10cm long plastic stent of 10 French diameter was deployed (D1, D2 & D3: white arrows).
I am a gastroenterologist. This is a blog of the ERCPs and related endoscopic procedures carried out at my department. Dr Adnan Salim.
Tuesday, December 31, 2013
Monday, December 30, 2013
Bike leak following laparosocpic cholecystectomy
This 54 year old gentleman had been referred to our unit with bile leak following a laparosocpic cholecystectomy. His MRCP showed the leak and collection (A: white arrow). Contrast injection on ERCP confirmed the MRCP report and the leakage was clearly seen (B1 & B2: white arrows). A 10cm long 10 French plastic stent was passed to bridge the leak (C: white arrows show the stent. Red arrow marks the leaked contrast).
Blockage of biliary stent placed for post transplant anastomotic stricture
This gentleman had undergone a living donor liver transplant approximately a month ago. A plastic biliary stent had been placed for an anastomotic stricture about three weeks after transplant. This was eight days ago. His total bilirubin level dropped from 15 mg/dL to 10.5 mg/dL in the 72 hours following stent placement. He then experienced fever along with rising bilirubin levels. We expected that the stent was blocked ( we had noted a significant amount of sludge along with bile flowing from the stent the first time we had placed it). Sure enough, we were met with a choked stent on ERCP (A1). We grabbed it with a snare (A2 & A3) and removed it (A4). We then generously flushed the bile duct with saline to wash out all debris (B1). A small papillotomy was also done to assist in drainage of the sludge (B2). Repeat contrast injection was done to check the status of the stricture. Sure enough, the stricture was present just behind the endoscope (C: white arrow). Since it had been only four weeks since the transplant, we avoided balloon dilatation of the strictured area (We had already "stretched" protocol by placing stent larger than 7 French diameter just three weeks after transplant in this patient. We had placed a 10 French stent and vendors that had been blocked). A similar 10 French plastic stent of 10 cm length was placed (D1 & D2: white arrows). A gush of bile and sludge was seen (E). We're keeping our fingers crossed as there is a probability that this stent might become blocked as well over the next one to two weeks.
Wrestling with Klastkin
This 85 year old lady presented with obstructive jaundice secondary to a Klastkin tumor. These tumors represent some of our most time consuming cases. On contrast injection, a sharp cutoff was seen at the level of confluence (A: white arrow). We tried to negotiate it with a 0.035 inch guidewire but were unsuccessful. A thinner, 0.025 inch wore was able to cross it (B: white arrow). We then attempted to dilate the track with an 8.5 French dilatation catheter (C: white arrow). Despite significant twisting and turning on our part (some moves would make Christopher Walken proud), the catheter wouldn't go across. We opted for a thinner 7 French dilator which was successfully forced up to level of dilated intrahepatic ducts (D: white arrow). The plan was to dilate the track further using a 10 French TTS balloon (E: white arrow). This however couldn't pass fully beyond the upper end of the stricture and inflation caused to slip backwards repeatedly. Finally, with a thin track that just wouldn't allow anything fatter than 7 French and contrast ominously pooled in the upper system, we passed a 12 cm long plastic stent of 7 French diameter (F1:white arrows). The reward was a gush of our injected contrast (F2: white arrow).
Friday, December 27, 2013
Stone extraction impeded by infra-diverticular ampulla and narrow CBD
This 72 year old lady had been referred for a stone extraction. Our typical biliary stone patients are usually much younger females. Going in, we were greeted by an infra-diverticular ampulla (A: white arrow). The ampulla was at the edge of the diverticulum. Such ampullas are difficult to cannulate and have a tendency to keep sliding over the edge of the diverticulum. Once cannulation was achieved, contrast injection showed a large stone in a very prominent CHD (B: white arrow) and a prominent CBD (B: blue arrow) with a tapered lower end. The position of the ampulla restricted the extent of our papillotomy (C: white arrow). One can easily end with an intestinal perforation if too "courageous" with papillae that lie on the borders of diverticuli. Keeping in mind the size of the stone, the patient's age, the narrowed lower CBD and limited papillotomy, we decided to pass a plastic stent of 10 French diameter and 12 cm length (D: white arrows).
One for the Stonehenge: An unusually large CBD stone
This 35 year old lady was one of our staple cases: CBD clearance before undergoing cholecystectomy. The ultrasound report mentioned multiple CBD stones. Contrast injection on ERCP seemed to confirm the ultrasound report with a long line of negative shadows in the CBD (A: white arrow). Once we had done a papillotomy and proceeded to retrieve some of the stones with extraction balloon, we realized that we were dealing with one very large stone. It just kept coming and coming (B & C: white arrows. Blue arrow indicated the balloon). All that was left was a very wide open papilla (D: white arrow) and further balloon sweeps were clean. The calculus filled the duodenal lumen (E: white arrows). Reminds me of the menhirs from the quarry of a certain indomitable Gaul.
Sunday, December 22, 2013
Follow up case of post cholecystectomy biliary stricture
Follow up case of post liver transplant biliary stricture (CASE B)
Saturday, December 21, 2013
Anastomotic biliary stricture developing 3 weeks after living donor liver transplantation
A 54 year old gentleman with liver cirrhosis secondary to Hepatitis C. He received a right lobe graft from his nephew. This stricture was noted three weeks post transplant. The stricture was evident ton cholangiogram during ERCP (A: white arrow). A 12cm plastic stent of 10 French diameter was placed (B & C: white arrows). There was a lot of sludge coming out of the stent and we suspect that the stent may get blocked sooner rather than later.
Thursday, December 19, 2013
Post liver transplant anastomotic biliary stricture (CASE C)
Wednesday, December 11, 2013
And another unresectable ampullary tumor
This 55 year old lady had a plastic stent placed for an unresectable ampullary tumor a month back. It had gotten blocked with debris and she had developed cholangitis. We decided to remove the plastic stent and place a metallic stent. A significantly dilated CBD was seen on ERCP (A: white arrow). A partially covered self expanding metallic stent (Wallstent. Boston Scientific) of 6 cm length and 10mm diameter was deployed (B & C: white arrows. D1 & D2 show the duodenal end of the deployed stent).
Second (actually 3rd) ERCP for post transplant biliary leak
This 60 year old gentleman had earlier undergone ERCP and stenting for an anastomotic biliary leakage a few months earlier http://ercp365.bl...
-
This patient was a 20 year old gentleman who had suffered blunt abdominal trauma during motorcycle accident. He developed a pancreatic absce...
-
This 60 year old gentleman had earlier undergone ERCP and stenting for an anastomotic biliary leakage a few months earlier http://ercp365.bl...
-
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...