Distal common bile duct impaction is common during management of large choledocholithiasis.
Despite lithotripsy, impaction of the stone fragments, ampullary edema, and the presence
of a periampullary diverticulum can limit balloon extraction [1]. We present a case where water irrigation of the common bile duct proved to be a
useful adjunct in the atraumatic removal of impacted distal biliary stone fragments,
allowing for successful completion of the procedure ([Video 1]).
Video 1 Video demonstrating the technique of water irrigation disimpaction endoscopic retrograde
cholangiopancreatography.
An 80-year-old woman was admitted with acute cholangitis. Contrast-enhanced computed
tomography revealed choledocholithiasis within a dilated biliary tree, with the common
bile duct measuring up to 2 cm.
An endoscopic retrograde cholangiopancreatography (ERCP) was performed, which showed
the ampulla on the edge of a large duodenal diverticulum. There was difficulty with
the initial biliary cannulation because of axis distortion, and a pancreatic duct
stent was inserted to facilitate biliary access. Initial cholangiogram ([Fig. 1]) showed a 2-cm common bile duct with a large 2-cm stone within. Balloon dilatation
of the biliary orifice to 10 mm was performed to match the size of the distal duct.
Larger dilatation was not carried out in view of the patient’s age, frailty, and the
periampullary diverticulum.
Fig. 1 Initial cholangiogram showed a 2-cm common bile duct with a large 2-cm stone within.
Spyglass cholangioscopy-guided electrohydraulic lithotripsy ([Fig. 2]) was followed by attempts at balloon trawling of the fragmented stones with an extraction
balloon. However, there was difficulty in extraction owing to impaction of distal
biliary stone fragments as well as edema. Water irrigation of the bile duct ([Fig. 3]) led to atraumatic removal of the impacted stones and subsequent successful clearance
of all ductal stones ([Fig. 4]).
Fig. 2 Electrohydraulic lithotripsy via direct peroral cholangioscopy.
Fig. 3 Large stone removed via water irrigation.
Fig. 4 Final cholangiogram after stone removal.
Water irrigation has previously been shown to be useful in reducing the risk of residual
common bile duct stones [2]. Here, we demonstrate its utility as an adjunct in the removal of impacted biliary
stones with minimal trauma.
Endoscopy_UCTN_Code_TTT_1AR_2AH
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
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