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. 

A 48 year old woman with biliary pain

This lady had been having biliary type pain for the past two years. Her bilirubin levels were normal and alkaline phosphatase was mildly raised. The ultrasound suggested possibility of distal CBD sludge. The MRCP also suggested presence of sludge in the distal CBD (A: green arrow). There was an anomaly which appeared to be a stricture at the level of confluence. The radiologist reported that it was due to the hepatic artery crossing over the CBD (A red arrow). During ERCP, CBD access was very difficult and required an extensive papillotomy. The reason for posting the image (B) is because we encountered a problem faced by many when papillotomy is done. There was a fold of intestine above the ampulla (B: green arrows). This fold kept coming down with every peristaltic intestinal movement and kept touching the cutting wire (and hence getting cut in the process). The cholangiogram showed no negative shadows in the distal CBD (C1 &  C2: green arrow). The anomaly seen in the upper CBD in the MRCP was not present in the cholangiogram (C1& C2: red arrow). A very extensive papillotomy was required. There was no sludge or stone in the CBD. A clean sweep with biliary balloon was done. A diagnosis of sphincter of Oddi dysfunction was made.