ERCP inpatient with Zinker's diverticulum. Primary author, Mateus Pereira Funari. Authors, Guilherme Oliveira, Maurício Minata, Spencer Schenk and Eduardo Moura. These are our disclosures. Case presentation, 62-year-old male patient with one month jaundice. Abdominal ultrasound show coladocorritiasis. He was then referred for an ERCP and at the beginning of the procedure there was resistance to the duodenoscope introduction. We opted to visualize with the gastroscope which show a Zinker's diverticulum. Now we have the assessment with the front view scope. As we pull the scope we see a small Zinker's diverticulum. What calls our attention is the intense abrasive of the geosphinter spas which probably collaborated with the difficulty to pass the duodenoscope. We placed the overtube over the gastroscope as we can see in the little upper left screen and accessed the stomach with the gastroscope. Once the scope was on the stomach we pushed the overtube to the stomach and once that is in place we removed the scope. The next step is to access the duodenum with the duodenoscope. As we can see the shaking is to slide the scope and the gastroscope is to slide the scope over the overtube. We also used mineral oil for such purpose. We confirmed the overtube position on fluoroscopy and Cholangiography evidenced multiple stones up to 11 mm. Then we performed biliary sphincterotomy using endocut eye. The incision was limited due to the peripapillary diverticulum, so we dilated the papilla up to 12 mm. Colonial control revealed radiological waste lost of the balloon. We swept the CBD with an extraction balloon, removing all stones, which are seen in the duodenum. Control occlusion cholangiography confirmed the absence of residual stones. After the ERCP, a key step is to reassess the Zanker's diverticulum and discard any adverse event in that area and in the esophagus. In our case, front view scope revision showed no signs of complication. gastroscope. After positioning the overtube, no resistance was found for the introduction of the duodenoscope. ERCP was successfully performed. Clinical implication. While a relatively prevalent Zankers diverticulum is a potential cause for resistance of the duodenoscope introduction and complication during ERCP. We recommend cautions evaluating with the gastroscope in all cases that there is resistance in introduce the duodenoscope especially in old male patients. Conclusion. Positioning an overtube is a creative strategy to minimize complications when performing ERCP in patients with Zankers diverticulum.

ERCP procedure

Zanker's diverticulum

overtube placement

biliary sphincterotomy

stone removal