This video demonstrates standard ERCP in a patient with abdominal colics. While the duodenoscope is advanced, the pylorus comes into view. By virtue of it being a side viewer, the device will not pass through if the pylorus is in full view on the video monitor. Turning the tip up facilitates passage through the pylorus into the duodenal bulb. By rotating the control handle to the right and turning the small wheel rightward, the endoscope advances beyond the bulb into the descending duodenum. At this point, the small wheel should be completely turned right and then locked, followed by withdrawal of the endoscope with slight torque to the right. This shortening manoeuvre hooks the tip of the duodenoscope in the descending duodenum, straightens the endoscope and the papilla is brought into full view on the video screen. It is typically recognisable as a protuberance with a central opening and is limited by a horizontal fold. The key to successful cannulation is optimal positioning. The endoscope should be in the short and straight position and the axis of the catheter needs to be aligned with the axis of the bile duct or pancreatic duct. In a first step, cannulation of the pancreatic duct with a straight cannula is attempted. The pancreatic duct typically takes off from the floor of the common channel and follows a more horizontal course than the bile duct. In the present case it is pretty challenging to achieve an optimal position to approach the papilla from a distance and aim for the one o'clock position of the papilla. Therefore fluoroscopy is used to optimise the angle and the endoscope is gently advanced to achieve the proper position. This time cannulation with a straight cannula at the one o'clock position is successful. Pancreatography shows the pancreatic duct with a discrete dilation, but regular branched ducts within the pancreatic head. It is of utmost importance to limit injection of contrast medium to small amounts in order to minimize the filling pressure and decrease the risk of post-ERP pancreatitis. In a next step, cannulation of the common bile duct with a triple lumen sphincteratome is attempted. The device accommodates a hydrophilic tipped wire in one lumen and allows simultaneously injecting in another lumen. The duct is located in the upper corner at the 11 o'clock position and is always positioned higher up into this corner than you first think. The tip is gently introduced into the common channel. Bowing of the tip eases the tip into the mouth of the common duct. The sphincteratome allows movement of the tip in the desired direction for wire guided cannulation. The hydrophilic tipped wire moves very smoothly in the channel of the sphincteratome and allows the assistant to sense when the wire enters the duct. At fluoroscopic control, we affirm that the sphincteratome is already within the bile duct and the guide wire is used as a pathfinder to allow passage through a siphon at the pre-papillary duct. Now we achieved a stable position inside the duct, and contrast is gradually injected to fill the entire biliary tree. To avoid over-distension of the gallbladder with contrast, it is useful to advance the catheter above the level of the cystic duct take-off before injecting. Careful observation during early filling is important in outlining small stones. It is very important to avoid over-filling because it may cause patient discomfort and may lead to bacteremia in patients with cholangitis. Guided by the wire, the sphincteratome is advanced within the duct. The triple lumen allows for concomitant application of contrast medium. In the present case, a regular common bile duct and a normal intrahepatic duct are visualised. To rule out discrete pathologies and small stones, it is useful to obtain an occlusion cholangiography through an inflated balloon catheter. To this end, the sphincteratome is withdrawn and the guide wire is back-loaded with a balloon catheter. Exchanging accessories over the wire takes some time and it is crucial to synchronise with the speed of the assistant and keep the wire at a constant position with the tip of the wire just reaching beyond the right or left hepatic duct. Therefore, intermittent fluoroscopic control is performed simultaneously. The occlusion cholangiography reveals adequate filling without pathological findings. The inflated balloon catheter is moved back and forth to straighten the common bile duct and to detect mobile biliary stones. No pathology is found in this case. At the end of the procedure, accessories are removed from the CBD and spontaneous drainage of contrast media from the papilla is observed. This can be stimulated by suction through the endoscope. Regular spontaneous drainage strongly argues against a stricture or hidden stone in the pre-papillary position.

ERCP

endoscopic retrograde cholangiopancreatography

abdominal colics

duodenum

papilla