Biliary pain in an 80 year old patient

This gentleman had a history of biliary pain for the past month. The MRCP suggested the presence of a stone in the distal CBD (A green arrow) and gall bladder calculi (A: red arrow). ERCP showed a diverticulum superior to the papilla (B: green arrow). We kept cannulating the pancreatic duct. Even after a transpancreatic papillotomy, the CBD could not be accessed so we placed one guidewire in the pancreatic duct and went after the CBD again. The technique worked. Contrast injection showed a markedly dilated CBD (C: red arrow) with distal tapering (C: green arrow) without any negative shadows signifying calculi. We did a wide papillotomy and swept the CBD multiple times with a biliary balloon( D1: green arrow showing the inflated balloon at the upper end of CBD &  D2 green arrow showing the inflated balloon at the lower end of CBD) . Clean sweep every time. The negative shadow at the lower end of CBD in the MRCP could have been caused by the diverticulum. This still doesn't completely explain the dilated CBD and distal tapering. Sphincter of Oddi dysfunction is a possibility. 

Procedure related complication: Pre cholecystectomy CBD clearance

This patient was an obese 35 year old lady with systemic hypertension and heart disease. She had been referred from another facility for ERCP and removal of CBD stones prior to undergoing a cholecystectomy. The case turned out to be a tough one. We were able to cannulate the pancreatic duct and went for a transpancreatic papillotomy. CBD cannulation followed. Surprisingly, there weren't any stones inside (A: green arrow & B) neither did the ampulla look like a stone had passed through it.
The CBD showed a short stricture in its terminal part. We passed a plastic stent (C: green arrow)and admitted her for overnight monitoring as she had gotten quite restless (the procedure wasn't being done under propofol sedation) and her blood pressures had shot up. The patient was underwent an abdominal x ray which was normal. A CT scan however showed free air in the retroperitoneal space (D: red arrows). She was afebrile and bowel movements were normal. It was decided to manage her conservatively. She was improving 96 hours later.