Tips 'n tricks: successful ERCP in the presence of periampullary diverticula

  • Abstract
    Duodenal diverticula are found in approximately 10-20% of patients undergoing Endoscopic Retrograde Cholangio-Pancreatography (ERCP). Usually, these diverticula lie within 2cm of the major duodenal papilla and are called juxtapapillary diverticula. They are mostly acquired and their incidence increases with age. Juxtapapillary diverticula have often been associated with mechanical compression and they are also involved in Oddi’s sphincter dysfunction. The presence of juxtapapillary diverticula is known to influence the outcome of ERCP procedure by making it more difficult and causing some complications like bleeding. Various techniques have been advised for a more successful ERCP outcome In this video, four cases of duodenal diverticula are presented to provide tips and tricks for the successful cannulation of the CBD and management of periampullary bleeding in case they occur.
  • 00'19" Case No. 1
    This is a case of a 77-year-old woman referred to our unit for elevation of Gamma Glutamyl Transferase (GGT) and alkaline phosphatase, without elevation of bilirubin. MRCP confirmed a significant dilation of the common bile duct. In view of the persistently elevated liver enzymes, we decided to perform an ERCP. On entering the duodenum, the duodenal diverticulum was visualized and the papilla could not be reached initially. On exploration of the diverticulum’s edge, the papilla was found on the right edge. With the diverticulum, the direction of the CBD was presumed to be on the right side arising at 1 o\'clock position as against the normal 11 o\'clock position. Keeping the head of the scope to the right, the sphincterotome was pushed approximately across the papilla, but without any success. We gently turned the right-left wheel to the right and pushed the catheter. The probing tip of the catheter found the papilla and then we slowly pushed the guide wire in. Under fluoroscopic control, the position of the guide wire was confirmed. It also revealed significant dilation of the extrahepatic duct without any visible obstacle. These fluoroscopic pictures suggested the diagnosis of Lemmel syndrome consisting of distal compression of the CBD by the diverticula with concomitant high level of biliary parameters. The sphincterotomy was performed using auto cut effect 2. It caused some bleeding. The coagulation was attempted with the blade of the catheter at the sphincterotomy’s site. Although there were no visible stones in the CBD, multiple passages were done with the stone balloon extractor and some sludge came out. Dilute adrenaline 1:20 000 was injected to the four angles of the sphincterotomy to lift the mucosa and ensure hemostasis. Post-procedure recovery was uneventful.
  • 03'24" Case No. 2
    This 82-year-old woman was referred to our unit for symptomatic common bile duct stone diagnosed on MRCP. At endoscopy, the papilla was found between two diverticula, one bigger on the left side and smaller one on the right side. The papilla was visible easily thanks to the oozing of bile and to the sphincter’s spontaneous opening. But the overlying mucosa was very floppy. With the tip of the sphincterotome, we tried to stretch it. We turned the scope to the right side to follow the direction of the common bile duct at the spur between the two diverticula and pushed the sphincterotome gently, keeping the elevator wheel of the scope a little up so that it slides up in the CBD without puckering of the papilla. A sphincterotomy of a sufficient size was then performed to permit the extraction of a 5mm biliary stone. The direction of the cut was along the spur between the diverticula, trying to keep along the direction of the CBD and avoiding perforation. The stone was retrieved with a biliary balloon extractor without any difficulty.
  • 04'38" Case No. 3
    This is the case of a 73-year-old woman admitted to the emergency room for acute pancreatitis with more than 8000 IU/L lipase and elevation of SGOT / SGPT and GGT, and normal alkaline phosphatase and bilirubin levels. MRCP was carried out and a duodenal diverticulum with extrinsic compression of the distal part of the common bile duct with some microcalculi was diagnosed. The pancreatitis resolved in a few days but because of the persistence of cholestasis without jaundice, the decision was made to go in with ERCP and a sphincterotomy was performed. The papilla was found on the left edge of the juxtapapillary diverticula. Because of its peristalsis with the tip of the sphincterotome, we teased the edge of the diverticulum and the papilla was more visible then. This time, the direction was on the left of the diverticulum and for that, with the scope turned to the left, we pushed the sphincterotome but we were a bit far to achieve the successful cannulation. We bent the blade of the catheter and in that way we had more power and better direction to push the guide wire. Fluoroscopic control showed that, in the first attempt, we cannulated the duct of Wirsung. We withdrew the catheter and the guide wire. We turned the scope more to the left and bent the catheter more —this can be seen on the fluoroscopy picture— and we gently pushed the guide wire. The CBD was successfully cannulated, as confirmed by the X-ray picture. A dilation of the CBD was detected and a sphincterotomy in standard position (11 o\'clock position) was carried out close to the edge of the diverticulum. Soon, oozing of blood was seen, but the sphincterotomy was a little more enlarged to the optimal size. The hemorrhage spontaneously stopped and a catheter extractor was passed multiple times through in the CBD and one stone of a few millimetres was extracted along with some small pigment stones. After the passage of the extractor balloon, maybe due to the trauma, the bleeding re-appeared. We decided to inject adrenaline and saline (1:20 000) at the site of the sphincterotomy and the lift of the mucosa was well obtained in order to do a compressive hemostasis. The patient was kept fasting until the next day, and then discharged.
  • 07'45" Case No. 4
    We present this last case of a 54-year-old man who underwent cholecystectomy 5 days before in some other private hospital. During the intraoperative cholangiography, the surgeon discovered a 5mm stone in a non-dilated CBD. The ERCP attempted in the same hospital failed because CBD could not be cannulated. The patient was referred to us. MRCP confirmed the juxtapapillary diverticula along with the small stone in the distal non-dilated CBD. During ERCP, we visualized a small duodenal diverticulum with the papilla on its right edge. With the same technique: scope turned to the right, pushing the sphincterotome and bending it, the papilla was probed and pushing the guide wire, we were in the CBD. The sphincterotomy was performed and a small stone was extracted using a standard technique. In conclusion, we would like to emphasize that small modifications of the routine techniques of the ERCP and some tricks such as turning the scope in the direction of the CBD and bending the tip of the catheter to come in line with the CBD help in successful cannulation of the CBD and positive ERCP outcome. For beginners and in such difficult cases, we recommend to get assistance from more experienced endoscopists.
  • Related medias
    Duodenal diverticula are found in approximately 10-20% of patients undergoing Endoscopic Retrograde Cholangio-Pancreatography (ERCP). Usually, these diverticula lie within 2cm of the major duodenal papilla and are called juxtapapillary diverticula. They are mostly acquired and their incidence increases with age. Juxtapapillary diverticula have often been associated with mechanical compression and they are also involved in Oddi’s sphincter dysfunction. The presence of juxtapapillary diverticula is known to influence the outcome of ERCP procedure by making it more difficult and causing some complications like bleeding. Various techniques have been advised for a more successful ERCP outcome In this video, four cases of duodenal diverticula are presented to provide tips and tricks for the successful cannulation of the CBD and management of periampullary bleeding in case they occur.