Achalasia or pseudoachalasia?

This 45 year old patient had been referred from another institution for balloon dilatation for achalasia of cardia. He had undergone an upper GI endoscopy and nothing unusual had been discovered. A barium swallow showed the classic bird beak lower esophagus (A: green arrow). The manometric findings also suggested classic achalasia. When we went in to dilate and retroflexed to view the fundus prior to wire insertion, the esophago-gastric junction was seen to be ulcerated and indurated (B:green arrow). We took biopsies (C: green arrow) and cancelled the dilatation till the biopsy report and a CT scan of the lower chest and abdomen.

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)

Pancreatitis with pancreatic and bile duct calculi

This 48 year old gentleman had a history of recurrent pancreatitis. MRCP showed calculi in the distal and middle pancreatic duct (A: green arrows) and calcification in the region of pancreatic head (A: red arrows). The ultrasound report indicated the presence of small calculi in the distal CBD in addition to the pancreatic duct calculi. On ERCP, the CBD was cannulated, followed by contrast injection which did not show any stones. The CBD showed distal tapering (B: green arrows - which may be due to pressure from the calcified pancreatic head). We did a papillotomy followed by sweep with balloon which also didn't result in any stone or sludge. Despite repeated attempts, we couldn't cannulate the pancreatic duct. The case has now been rescheduled to a later date. 

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. 

Cholangiocarcinoma below the confluence

This 48 year old gentleman had a cholangiocarcinoma just below the level of confluence. The MRCP showed abrupt cutoff of the common duct just below the hilum (A: green arrow). Contrast injection during ERCP confirmed the MRCP findings of stricture below the confluence, visible just above the endoscope (B: green arrow) and dilated intrahepatic ducts (B: red arrows). We passed a partially covered self expanding metallic stent of 10mm diameter and 80mm length (C: green arrows). The part of the stent crossing the strictured area was apparent (C: red arrow). The covered (D: green arrows) and uncovered (D: red arrows) portions of the stent were visible.

A very large bile duct stone

Out patient was a 65 year old lady who had Addison's disease and diabetes. She had developed obstructive jaundice and the cause was a very large bile duct stone. During ERCP, contrast injection outlined the stone and a particularly dilated CBD (A: green arrow). The stone couldn't be extracted so we passed a 10 French plastic stent of 10cm length (B: green arrows). There's a possibility of a choledochal cyst in this case. We will be reviewing this case in our joint meeting with the hepatobiliary surgical team.

Periampullary tumor causing obstructive jaundice

This patient was a 52 year old lady with jaundice secondary to a periampullary tumor. The CT films showed a dilated CBD (A: green arrow) with abrupt narrowing of lumen (B: green arrow). Contrast injection during ERCP showed a markedly dilated biliary tree (C: green arrows). A 10 French plastic stent of 12 cm length was placed (D: green arrows).