Managing pancreatitis with a blocked pancreatic duct and ascites

This 18 year girl had developed pancreatitis, most likely biliary in origin and followed by the development of ascites. She was in a a lot of pain and her MRCP showed a significantly dilated pancreatic duct (A: red arrows) with a stone or sludge collection near the terminal end (A: white arrow). The duct was also quite tortuous about a third of the way up (A: blue arrow). Her CT findings also showed the same with a dilated CBD of over 10mm diameter in its terminal portion (B1: black arrow) with an impacted stone/debris collection in its distal end (B2: black arrow). This ERCP was done under propofol sedation due to significant pain reported by the patient. CBD cannulation was quick and contrast injection confirmed the MRCP report with impacted terminal end debris (C: white arrow), dilated pancreatic duct (C: red arrows) and tortuosity (C: blue arrow). We did a pancreatic papillotomy (D1) and the constituency of the impacted material was evident as a white gooey material (D2: white arrow shows debris on the cutting element of papillotome). Further contrast was injected to online the tail region of the pancreatic duct and to rule out any leakage (E)-none was seen.   The papillotomy was extended and further debris was extruded by the extended papillotome (F: white arrow). The pancreatic duct was then swept with balloon (G: white arrow shows the inflated balloon in the pancreatic duct). A large amount of this white gooey debris was removed with repeated balloon sweeps (H1 & H2). Final contrast injection showed a clear pancreatic duct. We decided not to place a stent keeping in mind the large papillotomy done.