A 91-year old woman was admitted with painless jaundice, weight loss and Cholestatic symptoms. Imaging revealed dilated intra and extra-hepatic bile ducts down to the level of the ampulla. We were unable to initially obtain selective deep cannulation of the bile duct using a sphincterotome and wire in a standard technique as the ampulla was very floppy. Moreover, the duodenum was distorted resulting in suboptimal positioning of the duodenoscope in relation to the ampulla. We then proceeded to pre-cut the ampulla in order to achieve biliary cannulation. Before proceeding to a pre-cut, it is always important to reassess the indication for ERCP. In this elderly lady with deep jaundice, there was a clear indication for ERCP. However, we were mindful that there could be a distal biliary stricture making access difficult. For the pre-cut, we use a triple-lumen papillotome and probe with a wire. The direction of the pre-cut is cephalad and requires careful adjustment of the duodenoscope for position. We attempt practice strokes prior to initiating the papillotomy. The needle-knife is positioned at the apex of the ampulla and the ampullary mucosa is laid open in a systematic manner. Cutting may also be achieved in a downward direction by hooking the tip of the needle knife on the ampullary mucosa and cutting downwards. Tissue folds are moved away gently using the needle knife and washing may be required to obtain a good view of deeper structures. Close inspection is essential and we use a wire to probe for a potential orifice for the bile duct. Further cutting may be required for exposure. We use contrast injection cautiously to avoid sub-mucosal injection which may impair further cutting into likely sites. A further cut is made into the deeper structures and cannulation is achieved with a sudden passage of the wire.
A cholangiogram demonstrates a significant distal biliary stricture down to the level of the ampulla with upstream biliary dilatation. An uncovered metal stent is placed across the stricture in order to achieve effective biliary drainage. Following biliary decompression, there is rapid improvement in jaundice and given our patient's age, no other treatment is planned. The key learning points from this procedure are that it is important to identify the ?line' of papillotomy and practice moves are required to establish what manipulation of the duodenoscope and needle-knife are needed to produce the desired result. Sequential ?un-roofing' of the ampullary mucosa is important to try and expose the bile duct. In cases of distal biliary strictures such as ours, laying open the ampulla only serves to expose the mouth of the stricture. Wire guided probing is necessary in order to try and achieve access.
Shyam Menon, MRCP, University Hospital Aintree
Richard Sturgess, MD, University Hospital Aintree