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.

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. 

Managing choledocholithiasis and a damaged pancreatic duct in a patient with surgical complications following a history of biliary pancreatitis and pseudocyst formation

This 50 year old patient was himself a physician. He had an episode of biliary pancreatitis which resulted in pseudocyst formation. A percutaneous drainage catheter was placed to drain the cyst during cholecystectomy a few weeks after his pancreatitis had settled. A few days later, significant hemorrhage occurred from the catheter. He underwent repeat surgery during which the affected portion of the pancreas was "packed". He was then referred to our center. His MRCP showed bile duct calculi (A: green arrow) and a disruption in the pancreatic duct continuity (A: white arrows marking the absent portion of the pancreatic duct). Contrast injection on ERCP outlined stones in the mid CBD (B: white arrow). We did a wide papillotomy during which a significant amount of sludge extruded from the CBD (C: green arrows showing sludge around the papilla). The CBD was swept with an extraction balloon (D1: white arrow shows the inflated balloon in the CBD) and a single stone was removed (D2: green arrow shows the stone and red arrow marks the inflated balloon in the duodenal lumen). We then cannulated the pancreatic duct (E: green arrow shows the papilla and the red arrow shows the papillotome engaging the pancreatic duct opening). Initially our guidewire went in along an abnormal path, downwards where the duct disruption began (F1: white arrows show the guidewire in an abnormal position). After repeated attempts, we were able to place the guidewire across the disrupted segment and into the intact distal pancreatic duct (F2:white arrows marking the guidewire). A 10cm long plastic stent of 7 French diameter was placed (G1: white arrows showing the stent placed in the pancreatic duct, bridging the damaged portion. G2: shows the stent draining in the duodenal lumen).