This was a 50 year old gentleman who had been referred after an MRCP showed a stricture below the hilum (A: green arrows) and fine tapering in the lower end of CBD (A: red arrows). When we did a cholangiogram the CBD was dilated with no stricture below the hilum (B: green arrow), however the lower CBD stricture was as it had been reported in the MRCP (B: red arrow). We passed a 10F x 10cm plastic stent to drain the biliary system (C: green arrow).
A middle aged lady with gallbladder and bile duct stones. The ultrasound mentioned a single 12 mm calculus. An interesting thing was the presence of a biliary fistula superior to the papilla (A:green arrow). Contrast injection showed multiple calculi (B). We did a wide papillotomy (C). The stones were removed using an extraction balloon (D1 & D2). Post stone removal cholangiogram showed a clear CBD (E).
This patient was an obese 35 year old lady with systemic hypertension and heart disease. She had been referred from another facility for ERCP and removal of CBD stones prior to undergoing a cholecystectomy. The case turned out to be a tough one. We were able to cannulate the pancreatic duct and went for a transpancreatic papillotomy. CBD cannulation followed. Surprisingly, there weren't any stones inside (A: green arrow & B) neither did the ampulla look like a stone had passed through it.
The CBD showed a short stricture in its terminal part. We passed a plastic stent (C: green arrow)and admitted her for overnight monitoring as she had gotten quite restless (the procedure wasn't being done under propofol sedation) and her blood pressures had shot up. The patient was underwent an abdominal x ray which was normal. A CT scan however showed free air in the retroperitoneal space (D: red arrows). She was afebrile and bowel movements were normal. It was decided to manage her conservatively. She was improving 96 hours later.
This gentleman was referred from another hospital. Cholangiogram showed a distal CBD stricture (A:green arrow). We placed a 10Fx10cm plastic stent. The patient was advised to have a biphasic CT scan abdomen and CA-19-9 levels done and report to the hepatobiliary surgeon.
This lady had a cholecystectomy done a year ago. She had been having recurrent cholangitis since then. The latest ultrasound reported a distal biliary stricture and calculi in the proximal CBD. The CA 19-9 was 494 IU. Things got interesting when we got in. There was no bile output from the ampulla. The duodenal bulb had a lot of bile (A). The source was a fistulous biliary opening at the junction of the bulb and descending duodenum which we tried to cannulate (an attempt at CBD cannulation in this patient had been unsuccessful last week) but were unsuccessful (B). A reattempt at CBD cannulation via the papilla was successful (C). The cholangiogram showed cutoff of contrast at the upper end of CBD with the fistulous tract outlined and draining into the duodenum (D: green arrows showing the thin fistula tract. The inadequate diameter of the tract explained her recurrent cholangitis episodes). We got the guidewire through the stricture (E) followed by dilatation of the stricture with a Soehendra stent retriever (F). The subsequent cholangiogram showed dilated upper channels and the fistula tract again (G: green arrows show the stent, red arrows marking the fistula tract). We passed a 10F x 12cm plastic stent. She was advised to have a biphasic CT abdomen and review by the hepatobiliary surgeon.
The ultrasound report said this lady had gallstones and a 1.5 cm calculus in the distal CBD. The story inside was different. The ampulla didn't look like a bus had gone through it. The CBD had no negative shadows signifying stones either(A) . We did a papillotomy followed by sweeping the CBD with extraction balloon. This was followed by an occlusion cholangiogram (B) showing a clear CBD. An unexpected incident was the breaking of the guidewire sheath and being lodged in the right system (B:red arrow). It couldn't be retrieved. Maybe the surgeon will get it when she goes for a cholecystectomy.
This lady had a bile duct stent placed after a post cholecystectomy biliary leak. We had gone in to retrieve the stent. It had unexpectedly migrated into the CBD. Using the traditional snare to grab it was not possible. So we tried a dormia basket first (A: arrows showing the extent of the open basket), which didn't work. We tried a Soehendra stent retriever but couldn't screw the stent. We lastly tried a papillotomy to see if we could further expose the stent. That too didn't help. Finally grabbing the exposed bit by forceps was tried (B: green arrow showing the stent. Red arrow points to the forceps). Again, unsuccessful. We'll reattempt in a couple of weeks.
This 60 year old gentleman had earlier undergone ERCP and stenting for an anastomotic biliary leakage a few months earlier http://ercp365.bl...
