The brothers diverticulae

This 35 year old lady had been referred after a history of biliary type pain and an ultrasound which reported gallbladder sludge and a dilated CBD with a distal stricture. The MRCP report confirmed the ultrasound findings of CBD dilatation (A: red arrows) and a distal stricture (A: white arrow). Going in,  we were greeted with two diverticulae (B: red arrows) sitting on top of the papilla (B: white arrow). Contrast injection showed a picture similar to the MRCP of a dilated bile duct (C: red arrows) with distal narrowing (C: white arrow). We did a papillotomy which was limited by the close proximity of the lower edge of the diverticulae (D: red arrow). The CBD was swept with a biliary balloon (E: white arrow). The limited papillotomy necessitated a sphincteroplasty. We used a TTS balloon of 15-18mm expansion range (F1 & F2) and dilated the papilla to 15 mm (G1 & G2 showing the balloon expanding at the papilla) which was maintained for 30 seconds (G3: black arrows mark the balloon. Red arrow shows the waist forming at the papilla). The end result was a wide open papilla (H). 

A tricky ampullary tumor at the edge of a diverticulum

This 80 year old lady had a metastatic ampullary tumor. We were greeted by an infiltrated ampulla (A: green arrow) lying at the edge of a diverticulum (A: white arrow). This made cannulation extremely tricky. Repeated attempts were rewarded with success. Cannulation showed a significantly dilated CBD (B: white arrow) with distal narrowing (B: red arrow). A stent assembly was placed (C: white arrow) followed by deployment of a 7 cm long self expanding metallic stent (Micro-Tech Nanjing) of 10mm diameter (D: white arrows. E: white arrow shows the distal end of the stent in the duodenum.