Description:
An 81-year old male presented to his local hospital with multiple episodes of biliary colic and two episodes of cholangitis. Cross-sectional imaging revealed a 20mm common bile duct stone with dilated extra and intra-hepatic bile ducts. Attempted ERCP failed twice due to the presence of a large duodenal diverticulum.
At ERCP, we found a large peri-ampullary diverticulum with a considerable amount of food debris. On exposing the ampulla, it was found to be located deep within the inner lip of the diverticulum and attempts to cannulate it initially were unsuccessful. We cleared the debris from within the diverticulum by using a Roth net followed by a snare. With removal of debris, the fine detail of the ampulla could be appreciated. After removing the debris, we proceeded to wash the diverticulum to ensure a clear working field. It was clear that cannulation could only be achieved if redundant folds at the edge of the diverticulum could be retracted. We therefore applied a clip to draw out the redundant folds. We inserted a second clip in similar fashion. The arm of the clip is first hooked onto the mucosa, which is then drawn downwards into the duodenum and once a stable position is achieved, the clip is released. After clip application, we find that the ampulla is at a much more ‘everted' and accessible angle. We then proceed to use a sphincterotome to engage the ampulla. After having engaged the ampulla, pulling the sphincterotome back slightly and using the bridge, enables us to straighten out the ampulla. Further traction on the sphincterotome allows further straightening out of the ampulla. This enables biliary cannulation with a sudden passage of the wire as in this instance. An initial cholangiogram outlines a large stone in the distal bile duct adjacent to the clips. This stone may have caused further distortion of the ampulla, making cannulation difficult. A sphincterotomy is subsequently performed and stone extraction is carried out with a clear duct at the end of the procedure.
Biliary cannulation in the presence of a peri-ampullary diverticulum can be challenging. It is important to adequately visualise the peri-ampullary area and remove as much debris as possible. Specific manoeuvres that serve to aid biliary cannulation are adjusting the scope position and clip application to draw out the duodenal folds. These measures depend on the position of the ampulla and should be applied depending on the actual situation. Finally, a rendezvous approach with wire exchange via PTC should be considered if necessary.
Contributed By:
Shyam Menon, MRCP, University Hospital Aintree
Richard Sturgess, MD, University Hospital Aintree
