Tackling a large stone in an old lady

his 80 year old lady had presented with a common bile duct stone (bit unusual in her age group if our past experience was anything to go by). The ampulla was quite swollen (A :white arrow). Contrast injection showed a stone in the upper CBD (B: white arrow). We did a large papillotomy (C: white arrow), keeping in mind the size of the stone. The first attempt at stone extraction was made using a balloon which was maneuvered

across the stone (D: white arrow & E: white arrow shows the balloon inflated behind the stone, marked by the red arrow). The balloon kept slipping past the stone (F: white arrow shows the balloon which has slipped below the stone, marked by the red arrow). We went for the basket next (G: white arrow points to the open basket next to the stone, indicated by red arrow). This was successful and the stone was finally extracted (H1 & H2). Quite large and almost a perfect cylinder (I). Shotgun slugs, anyone?

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).

Intra-diverticular papilla

Thought it would be a simple "Snatch and Grab"  bile duct stone. Turned out this patient had an intra-diverticular papilla (like one of our previous transplant patients). Cannulation took its sweet time. One truly appreciates a normal papilla in such cases.