Pancreatobiliary cases

Overall Comment

This was a good example of using various imaging modes with an X1 processor and TJF‑Q190V. The patient, presenting with biliary obstruction and biliary-type pain, was shown by EUS to have multiple common bile duct stones and was referred for ERCP. During the procedure a periampullary diverticulum containing residual food was observed and partially cleared. The papilla was clearly identifiable and appeared enlarged with suprapapillary bulging, suggesting stones.

In my clinical practice I regularly use TXI to help identify the papilla. Once located, I assess it in WLI and TXI, and I always use NBI briefly to further exclude adenoma. In this series of images and video, TXI (here TXI2) precisely delineates the orifice. I often use TXI for cannulation because it emphasizes surface texture and gives a more “3D” appearance than WLI. Also, during aspiration, interference of bile is neglectable in TXI mode in comparison to reddish color of bile with NBI, impeding analysis and precise accessories insertion for canulation. Another useful mode is RDI, which in this case identified the exact site of post-sphincterotomy bleeding, allowing precise electrocoagulation with the sphincterotome targeted only to the bleeding site. Before RDI, it was often difficult to treat only the bleeding spot after post-sphincterotomy bleeding, and we frequently needed to coagulate both sides of the sphincterotomy line. With RDI we could target our treatment specifically to the bleeding point. Post-treatment inspection with WLI or TXI is necessary but can be challenging because of residual blood and coagulum; RDI helps detect active flow, even when subtle. After stone extraction a rebleed occurred, and again RDI-guided electrocoagulation with the sphincterotome successfully stopped the bleeding.