This 72 year old lady had been referred for a stone extraction. Our typical biliary stone patients are usually much younger females. Going in, we were greeted by an infra-diverticular ampulla (A: white arrow). The ampulla was at the edge of the diverticulum. Such ampullas are difficult to cannulate and have a tendency to keep sliding over the edge of the diverticulum. Once cannulation was achieved, contrast injection showed a large stone in a very prominent CHD (B: white arrow) and a prominent CBD (B: blue arrow) with a tapered lower end. The position of the ampulla restricted the extent of our papillotomy (C: white arrow). One can easily end with an intestinal perforation if too "courageous" with papillae that lie on the borders of diverticuli. Keeping in mind the size of the stone, the patient's age, the narrowed lower CBD and limited papillotomy, we decided to pass a plastic stent of 10 French diameter and 12 cm length (D: white arrows).
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