Fifth follow up ERCP for post cholecystectomy biliary stricture.

This was this 40 year old lady's fifth ERCP. Somehow her stricture didn't seem to respond to conventional methods. This time around we removed the two stents that were placed in her last visit http://ercp365.blogspot.com/2014/02/fourth-follow-up-ercp-for-post.html (A). Contrast injection showed the strictured area (B: Red arrow) and dilated biliary channels proximal to the stricture (B: White arrow). A 10 French plastic stent of 12 cm length was placed first (C: White arrows), crossing the affected area (C: Red arrowhead). This was followed by a longer 15 cm plastic stent, also of 10 French diameter (D: Blue arrows. White arrows mark the first stent).

Bile duct calculi in a patient with multiple co-morbids

This 66 year old gentleman took the cake for multiple coexisting diseases in addition to his biliary pathology. He had diabetes, hypertension, ischemic heart disease, epilepsy and depression. He also had cholelithiasis and choledocholithiasis. We engaged the papilla (A:green arrow) but couldn't cannulate the CBD. We resorted to a precut with a needle knife (B:green arrow) which clearly identified the CBD opening (C: green arrow). Contrast injection showed stones in the distal CBD (D: green arrow). Our patient became distressed and felt pain during extension of papillotomy (which was quite unusual) by this time and we quickly ended the procedure by cancelling stone extraction and placing a plastic stent of 10 French diameter and 10cm length (E: green arrows). In our opinion, the papilla seemed unhealthy. This, plus the transaminase and ALP levels in the high hundreds prompted us to advise a CA 19-9 and abdominal CT scan before a repeat ERCP for stone extraction (to be done under propofol sedation)

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.