This is a 58-year-old woman, post-liver transplantation, who presented to hospital with low-grade fever, jaundice, cholestasis, and mild elevation of transaminases. An abdominal ultrasound revealed common bile duct stones, so an ERCP was performed. Despite multiple attempts, a deep cannulation of the bile duct with two different sphincteratomes and guide wires could not be performed. Therefore, a guide wire was advanced in the pancreatic duct, and a 5-french by 3-centimeter stent was placed in order to perform a pre-cut of the papilla. A needle knife can be seen, and the direction of the cut is assessed by carefully placing the needle at the orifice of the papilla over the pancreatic stent. The pancreatic stent not only helps as a guide to perform the cut, but also protects the pancreas from needle injury and maintains pancreatic drainage during and after the procedure. After assessing the papilla, the best location at the 11 o'clock position is chosen for the pre-cut. An incision is performed by placing the needle at the orifice and over the stent and extending cephalad. The needle is slowly advanced upwards with minimal pressure over the mucosa. As shown here, this is the first cut. The incision site is inspected and no bile or blood comes out. At this point, the area previously cut is probed with the needle and closely examined. After this step, a second cut can be performed. The incision is slowly performed in the same direction, but this time deeper, in order to expose the bile duct. After this incision, the area is examined again, and a dark yellow area is seen at the apex of the cut. This indicates the bile duct, so at this point the needle knife is removed and a sphincteratome with a guide wire can be used to cannulate. A triple lumen sphincteratome with a 0.035 guide wire is advanced and pointed towards the apex of the pre-cut at the 11 o'clock position. It is gently probed and then advanced. Here it pops in the duct and afterwards the guide wire is advanced without any resistance. At this point, the guide wire is in the bile duct and is confirmed with fluoroscopy. The tip of the guide wire is in the right intrahepatic duct and injection of contrast confirms filling of the common bile duct. The sphincteratome is pulled back into the duodenum in order to expose the guide wire and expand the pre-cut. As shown, the sphincteratome is pulled back and forth in order to get into position for sphincterotomy. A sphincterotomy is successfully performed and bile gushes out afterwards.

liver transplant

case study

symptoms

endoscopic retrograde cholangiopancreatography

common bile duct stones