Second follow up ERCP for post liver transplant anastomotic biliary stricture (Case K)

This 22 year old lady had undergone living donor liver transplant at our centre for hepatitis B related liver disease. She developed an anastomotic stricture shortly after her surgery and underwent an ERCP in April of this year (A 7 French stent of 15 cm length was initially placed after dilatation of stricture with graduated dilatation catheters but she developed GI bleeding the same day. On endoscopy done the next day, the distal end of the stent was seen to erode the opposite duodenal wall and cause ulceration. This was removed and a shorter stent of the same diameter but shorter 12 cm length was placed). Now, she had developed pruritus and fever. Her stent was removed (A). The next image shows her MRCP which was done prior to her first ERCP (B: White arrow shows the anastomotic stricture site and red arrow shows a collection next to the biliary tree). Contrast injection after stent removal showed the narrowed stricture area (C: Black arrow) and what appears to be a sludge ball above the stricture (C: White arrow). A stricture dilatation balloon of 40 mm length and 6 mm diameter was used to dilate the stricture ( D: Black arrow). A stent assembly was placed across the affected area (E: Black arrow) and a 7 French plastic stent of 12 cm length was deployed (F: Black arrows).

Chronic pancreatitis post abdominal trauma leading to pancreatic duct strictures

This patient was a 20 year old gentleman who had suffered blunt abdominal trauma during motorcycle accident. He developed a pancreatic abscess which was managed conservatively. Over the past one year he had repeated episodes of pancreatitis. His MRCP showed two pancreatic duct strictures at the junction of head and body and in the body (A: White arrows). The same were seen during contrast injection during ERCP (B: Black arrows). We did a pancreatic papillotomy (C: Black arrow), following which the pancreatic duct was dilated along its length using an 8mm x 30 mm biliary stricture dilatation balloon (D1 -D3: Black arrows). A stent assembly was then placed into the pancreatic duct (E: Black arrows). A 7 French plastic stent of 10 cm length was then placed (F: Black arrows).

Fifth ERCP for post transplant anastomotic biliary stricture (CASE A)

This gentleman had come after about four months after his last ERCP http://www.ercp365.blogspot.com/2015/02/fourth-follow-up-ercp-for-post-lover.html?m=1. We had placed a single plastic stent at that time. His labs showed a normal bilirubin but  constantly rising ALP and GGT. His ultrasound showed no pneumobilia with the proximal tip of the stent slightly distal to the anastomotic site. We removed his stent and manoeuvred the guidewire across the stricture (A: Black arrow shows the guidewire curling back across the site of the stricture. B: The wire finally across the strictured segment, indicated by the black arrow. Contrast injection shows dilated ducts in the implanted liver indicated by white arrows) . A pneumatic balloon rated to 8 atm/10 mm was used. It was placed across the stricture (D: black arrows show the balloon assembly and blue arrows show its proximal and distal radio opaque markers). The balloon was then inflated (E: black arrows mark the fully inflated balloon with an obliterated "waist"). Repeat contrast injection showed a fully dilated stricture (F: blue arrows). No stent was placed this time and the patient was discharged. We expect to see him in the OPD with a fresh ultrasound and LFTs in a few weeks.