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. 

Metastatic ampullary carcinoma

A 55 year old lady had presented with metastatic ampullary tumor causing obstructive jaundice. Endoscopy showed an infiltrated ampulla with a visible bile duct opening (A: white arrow). Ampullary tumors are usually soft and friable and hence offer little hindrance to cannulation. Contrast injection outlined a grossly dilated bile duct (B: white arrows) with a  distal stricture. A 10cm long 10 French plastic stent was placed (C1 & C2: white arrows).

Multiple biliary strictures in a patient with lymphoproliferative disorder

This 38 year old patient had extensive abdominal lymphadenopathy with obstructive jaundice. The oncologist had referred him to our institution for biliary stenting. Contrast injection on ERCP showed a dilated biliary tree (A & B: red arrows) with strictures seen in the distal CBD and below the confluence (A & B: blue arrows). A 10cm long 10 French plastic stent was placed (C: blue arrows).

Tumor of the pancreatic head causing obstructive jaundice

A mass of approximately 21cm size in the region of pancreatic head was cashing obstructive symptoms in this 78 year old gentleman. He had also developed fever. His CT scan showed a dilated pancreatic duct (A1: green arrow)  with abrupt obliteration of its lumen (A2: green arrow) with an adjacent mass in the pancreatic head (A2: red arrow). On ERCP, his cholangiogram showed significant intrahepatic biliary dilatation (B: white arrows) with a stricture involving the distal CHD and proximal CBD (B: green arrows). He was in good physical shape and the remaining CT films didn't show any contraindications to resection. We placed a 10cm long plastic stent of 10 French diameter to drain the biliary system and resolve the infection (C: white arrows). He is due to undergo surgery soon after.

Periampullary tumor causing obstructive jaundice

This patient was a 52 year old lady with jaundice secondary to a periampullary tumor. The CT films showed a dilated CBD (A: green arrow) with abrupt narrowing of lumen (B: green arrow). Contrast injection during ERCP showed a markedly dilated biliary tree (C: green arrows). A 10 French plastic stent of 12 cm length was placed (D: green arrows).

Ampullary tumor with hepatic and vascular invasion

This patient was a 50 year old gentleman who had obstructive jaundice secondary to an ampullary tumor with hepatic metastatic deposits and thrombosis of his right portal vein. On ERCP, the ampulla was swollen. Contrast injection showed a dilated CBD and intrahepatic biliary tree (A: green arrows). We passed a 10 French 10cm long  plastic stent (B: green arrows).

Adenocarcinoma of gallbladder infiltrating into common hepatic duct and right hepatic lobe

A 50 year old lady who had developed jaundice a few weeks earlier. She was a diabetic and hypertensive and also had ischemic heart disease.
The CT scan showed a gallbladder mass infiltrating into the right hepatic lobe and common hepatic duct (A: green arrows & B: red arrows). Cannulation of the CBD was difficult and we kept going into the pancreatic duct. We decided to place a guidewire in the pancreatic duct and keep it there till the CBD was cannulated (C: green arrow). The image shows the papillotome engaging the ampulla with the pancreatic duct guidewire adjacent to it (D: green arrow). This technique helped and the CBD was cannulated (E: red arrow shows the guidewire in the CBD anf green arrow shows the first guidewire in the pancreatic duct). The cholangiogram showed involvement of the common hepatic duct and markedly dilated left ductal system with a poorly outlined right system (F: red arrows & G: green arrows). Only a few peripheral ducts of the right system were seen (G: green arrows). This was in accordance with the CT findings ( A & B). A self expanding metallic stent of 10mm diameter and 100mm length was placed (G: red arrows).

Obstructive jaundice secondary to gallbladder tumor invading the common hepatic duct

This 80 year old gentleman had a CBD stricture secondary to a gallbladder tumor which was involving the distal common hepatic duct. His ampulla had classic openings of the bile duct (A:green arrow) and pancreatic duct (A: red arrow) so I decided to include its photo. These openings aren't always that clearly defined. There was also a small diverticulum supwrior to the ampulla (B: green arrow). Contrast injection outlined a stricture of the common hepatic duct (C: green arrow). The stricture was dilated with a 9 French dilator (D: green arrow) followed by placement of a self expanding metallic stent of 10mm diameter and 100mm length (E: green arrow & F: green arrow).

Note: You can have a detailed 3D view of the gallbladder and associated structure anatomy by clicking on this link http://www.healthline.com/human-body-maps/gallbladder

Gall bladder mass causing obstructive jaundice with possible fistulous tract

A locally infiltrating gall bladder mass had caused obstructive jaundice in this 50 year old lady. Contrast injection outlined a stricture at the level of the cystic duct (A: green arrow) and dilated intrahepatic ducts. Further contrast injection also outlined what appeared to be a fistulous tract adjacent to the CBD (B: green arrow). A 10F x 12 cm plastic stent was placed.

Obstructive jaundice secondary to hilar mass

This was a middle aged lady with a large right ovarian mass and obstructive jaundice caused by a mass lesion in the hilar region. She was extremely obese and couldn't lie prone. We did the procedure in the left lateral position. Initial contrast injection showed a sharp cutoff at tue levelcof cystic duct (A: green arrow). The guidewire was passed beyond the stricture followed by contrast injection which outlined a dilated left system with no contrast going into the right system (B: green arrow). We dilated the stricture with a 9F dilatation catheter followed by placement of a 10F x 12cm plastic stent (C & D: green arrow).

Malignant biliary stricture secondary to infiltration by gallbladder tumor

This was a locally infiltrating gallbladder tumor. The images show the structured segment with sharp cutoff of contrast (A: Green arrow).  Dye injection after crossing the strictured segment showed dilated intrahepatic biliary channels (B). A 10F x 12cm plastic stent was passed.