Third (fourth, actually) ERCP for post liver transplant anastomotic biliary stricture (Case J)

This 56 year old gentleman had undergone biliary stenting previously http://ercp365.blogspot.com/2015/04/post-transplant-anastomotic-biliary.html. Following this he developed pruritus and disturbed transaminases and a repeat ERCP with stent removal and extension of sphincterotomy was done last month. The CBD was clean and free of any stones/sludge (A: White arrow). His liver enzymes became disturbed again and he developed pruritus. Contrast injection showed poor filling of the right ductal system (B: White arrow). No attempts at dilatation were made as our papillotome had easily traversed the strictured site and we placed a thicker 10 French stent of 12 cm length (C: White arrows) as opposed to the 7 French stent placed in the ERCP before last (see link above).

Follow up CBD clearance after initial clearing of pancreatic duct

This 18 year old lady underwent ERCP with pancreatic duct clearance a few days ago http://www.ercp365.blogspot.com/2014/03/managing-pancreatitis-with-blocked.html
At that time we hadn't been able to access the CBD. Going in now, the swelling had greatly subsided and we were bale to identify the bile duct clearly (A: black arrow indicates the CBD and white arrow shows the wide open pancreatic duct ). The CBD was cannulated (B: black arrow) followed by contrast injection (C) which outlined a normal calibre CBD with no negative shadows. We decided to do a sphincterotomy (D: white arrow) and swept the CBD with biliary balloon (E: white arrow shows the balloon inflated in the CBD). As suspected, it was a clean sweep and no stones or sludge was extruded.

A balloon for every stone

This 50 year old lady had undergone cholecystectomy twenty years earlier. She had now been having recurrent bouts of right hypochondrial pain. An ultrasound scan showed a 12mm stone impacted in the distal CBD. We were greeted by a big fat papilla with the orifice at its lower end (A: white arrow). Multiple attempts to cannulate the CBD were unsuccessful. We decided to do a precut with a needle knife (B). It was a textbook precut and the CBD opening was nicely exposed (C: white arrow shows the CBD opening - somehow appearing suspiciously similar to the Superman insignia). Contrast injection showed two stones, one below the scope and another just above it (D: white arrows). The papillotomy was extended (E) , however the size was insufficient considering the size of the stones. Our next step was to do a sphincteroplasty using an 18mm diameter TTS balloon (F: white arrow shows the waist of the inflated balloon at the ampulla). Following this, two stones were successfully extracted (G1 & G2). A final cholangiogram with an inflated balloon just above the ampulla showed a duct clear of stones (H).