Bile duct clearance with an intra-diverticular ampulla

Have a close look at the first image (A1: green arrow). The ampulla is inside a seemingly small diverticulum. However, these diverticuli change their shape considerably with bowel movements. Since this was a pre-cholecystectomy CBD clearance, when we saw the ampulla, we were skeptical about attempting stone extraction (the patient's bilirubin was normal) and thought to advise the surgeon to clear the CBD as well. In the second image (A2: green arrow), the ampulla seems to be pouting out. The diverticulum was invaginating and evaginating with bowel movements. Contrast injection showed a single large stone (B: green arrow). We did a papillotomy (A2) and removed the stone with extraction balloon. Repeat contrast injection showed a clear CBD (C & D).

Bile duct clearance prior to cholecystectomy

The ultrasound report said this lady had gallstones and a 1.5 cm calculus in the distal CBD. The story inside was different. The ampulla didn't look like a bus had gone through it. The CBD had no negative shadows signifying stones either(A) . We did a papillotomy followed by sweeping the CBD with extraction balloon. This was followed by an occlusion cholangiogram (B) showing a clear CBD. An unexpected incident was the breaking of the guidewire sheath and being lodged in the right system (B:red arrow). It couldn't be retrieved. Maybe the surgeon will get it when she goes for a cholecystectomy.