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).
