Clin Endosc.  2019 Jan;52(1):83-86. 10.5946/ce.2018.060.

Papillary Cannulation Facilitated by Submucosal Saline Injection into an Intradiverticular Papilla

• Lee K
• Choi JW
• Lee Y
• Han JH
• Park SM

• KMID: 2438151
• DOI: http://doi.org/10.5946/ce.2018.060

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) of the intradiverticular papilla with its invisible orifice remains challenging. Several techniques have been introduced to evert the papillary opening to facilitate cannulation. A 79-year-old woman with bile duct stones underwent ERCP, which revealed that the papilla was located inside a large diverticulum and tended to rotate inward with a trial of papillary cannulation. Submucosal papillary injection of 3 cc of normal saline was performed at 3 and 9 o'clock. Eversion and fixation of a papilla in the diverticulum with this technique allowed selective cannulation of the biliary tree. Stones were retrieved after endoscopic papillary balloon dilation without complications. She had an uneventful post-procedural course. Our findings suggest that submucosal saline injection technique is safe and effective for selective cannulation and can be recommended when cannulation is very difficult because of an intradiverticular papilla.

Keyword

Cholangiopancreatography, endoscopic retrograde; Gallstones; Ampulla of Vater; Intradiverticular papilla; Submucosal injection

MeSH Terms

Aged
Ampulla of Vater
Bile Ducts
Biliary Tract
Catheterization*
Cholangiopancreatography, Endoscopic Retrograde
Diverticulum
Female
Gallstones
Humans

Figure

• 

  Fig. 1. Abdominal computed tomography. (A) Pre-contrast axial scan showed a hyperdense lesion inside the dilated common bile duct. (B, C) Post-contrast axial scan and coronal view revealed the presence of a periampullary diverticulum (arrowheads).

• 

  Fig. 2. Duodenoscopic findings during endoscopic retrograde cholangiopancreatography. (A) The major duodenal papilla (arrow) is positioned inside the diverticulum. (B) Saline injection was performed at 3 and 9 o’clock (stars) for eversion and fixation of the papilla (arrow). (C) Endoscopic papillary balloon dilation preceded stone extraction.

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