First ERCP for post liver transplant anastomotic biliary stricture (CASE N)

This 54 year old gentleman had recently undergone living donor liver transplant at our centre. He had presented with fever, chills, pruritus and a raised ALP level. His MRCP showed a short stricture at the anastomotic site (A: white arrow). We were greeted with a bulging ampulla on ERCP (B). Contrast injection highlighted the stricture ( C & D: white arrow). We dilated the track with a 7 French graduated dilatation catheter (D: black arrow) followed by placement of a 7 French plastic stent of 12 cm length (E:black arrows. White arrow shows the upper end of the stent assembly). This was rewarded with a gush (F: white arrow) of white (hence infected) bile.

Third follow up ERCP for post transplant anastomotic biliary stricture (CASE K)

This 22 year old lady had undergone her second ERCP for an anastomotic biliary stricture less than month earlier http://ercp365.blogspot.com/2015/09/second-follow-up-ercp-for-post-liver.html when we had placed a 7 French 12 cm plastic biliary stent. She had developed cholangitis and pruritus soon after and her ultrasound did not show any pneumobilia. We suspected the sludge ball proximal to the previously deployed stent to be the culprit (Refer to images in the link above). We removed her blocked stent (A). Contrast injection again highlighted the narrowed anastomotic segment (B: Black arrow). A stent assembly was then manoeuvred across this site (C: Black arrow) and a wider 10 French plastic stent of 12 cm length was deployed (D1 & D2: Black arrows).

Second time lucky-Managing metastatic peri-ampullary tumor with cholangitis

This 65 year old lady had been admitted with obstructive jaundice and cholangitis secondary to a metastatic peri-ampullary tumor. We encountered a swollen ampulla on duodenal intubation (A). Cannulation and contrast injection outlined a significantly dilated pancreatic duct (B: Black arrows) and what appeared to be the accessory duct (B: White arrow). We did a pancreatic papillotomy (C: White arrow). Further attempts here were unsuccessful and slight scope with-drawl showed an opening at the upper surface of the ampulla seen in image A (D: Black arrow), which was cannulated (E: Black arrow). This was the proper route as evidenced by wire cannulation (F: Black arrows). Contrast injection in this area outlined a dilated proximal bile duct and intrahepatic channels (G: White arrows) with no distal or mid duct delineation. A 10 mm diameter and 8 cm long partially uncovered metallic stent was prepped (I. We used a Micro-Tech stent. These come with an internal stiffening wire with a ring for removal prior to insertion: Red arrow). The stent assembly was placed across the strictured segment unto the dilated duct (J: Black arrows). The stent was then deployed (K1: The stent being deployed. Red arrow marks the gold reference mark which is kept visible just at the edge of field of view. K2: The deployed stent. A gush of contrast and white pus was seen. L1 & L2: White arrows show the fully deployed stent with black arrows indicating the proximal and distal radiographic markers).

Diverticula Galore!

This 84 year old lady had been admitted with cholangitis. Her ultrasound scan indicated a dilated CBD with a distal stricture. Her CA 19-9 level was also normal. The MRCP film confirmed the ultrasound findings of a dilated CBD with a distal narrowing (A: white arrow). Starting our ERCP, we were greeted with a duodenum full of diverticulae. Fortunately, the papilla was not at the bottom of one of these (B: white arrows indicating two adjacent diverticulae, with food residue in the left one. Blue arrow indicating the papilla. Black arrow indicating the duodenal lumen). Thankfully it didn't take too long to cannulate the papilla (C). Contrast injection showed the same findings as the MRCP (D) and we suspect that the lower narrowing in the CBD could be attributed to the diverticulae. We passed a 10 French 7cm long plastic stent (E1 & E2: white arrows).

Cholangiocarcinoma and cholangitis

A 50 year old lady had developed obstructive jaundice over the past few months and had been admitted with recent onset of fever. She was found to have a mass lesion near the area of confluence. She had no co-morbids. On ERCP, our guidewire couldn't initially go beyond the proximal CHD. The cholangiogram showed the CBD and CHD, along with the sharp cutoff at the proximal CHD (A: white arrow). The cystic duct was also outlined (A: green arrow). The guidewire was finally placed across the strictured part after a few attempts and contrast injection outlined the full biliary tree. The right and left ductal systems were dilated and a stricture was seen just below the confluence (B: white arrow. This would seem to be a Bismuth Type I lesion). After dilatation with a 9 French graduated dilator, we passed a 12 cm long plastic stent of 10 French diameter to drain the biliary system. She will continue to recieve antibiotics and will be placed in our weekly multidisciplinary meeting for review and eventual surgery.

Metastatic ampullary tumor

A 38 year old lady with an ampullary tumor which had metastasized to the liver and duodenum (A: green arrows). On endoscopy, the ampulla was heavily infiltrated (B: green arrow). Cannulation was unexpectedly swift. Dye injection showed a grossly dilated CBD with a distal stricture (C: green arrows showing dilated CBD with red arrow showing the strictured segment). The guidewire was placed across the stricture (D: green arrows) and a self expanding metallic stent of 10mm diameter and 60cm length was placed (E: green arrows showing the stent and red arrow showing constricted part of the stent in the area of the malignant stricture). A gush of pus and bile was seen (F: green arrow) after stent deployment. The patient had developed cholangitis prior to the procedure. Hopefully this stent will help in resolution of the acute condition.