Video endoscopic technology has simplified the mechanics of endoscopic retrograde cholangiopancreatography (ERCP). Identification of anatomic landmarks such as the entrance into the stomach, the incisura angularis (gastric notch), and pylorus, as well as the papilla itself, is now simpler. The refined optics can also assist in identifying subtle abnormalities of the papilla caused by inflammatory or neoplastic disorders. In contrast with endoscopy in other organs, where the action is on the screen, ERCP primarily identifies abnormalities in the ductal structures radiographically. With continued advancements in the technology of smaller endoscopes (mother–daughter scopes), endoscopic identification of intraductal disease may become more widespread. The ability to watch the procedure on a monitor is nowhere more advantageous than during a therapeutic case in which all personnel have a firsthand look. This teamwork undoubtedly improves success and safety.
Typical view of the mid and distal stomach, with the duodenoscope tipped down and the patient prone. The lesser curvature is at the top (posterior) and the greater curvature is at the bottom (anterior;
top left). With advancement of the duodenoscope to the antrum, the angularis is directly above, with the pylorus in the 6 o’clock position in the distance (top right). To advance the endoscope into the duodenum, the pylorus should be in the 6 o’clock position (bottom left). On entering the duodenal bulb, the endoscope is deflected to the right, advanced, and then withdrawn, revealing the normal position of the major papilla. In this patient, the papilla cannot be directly visualized, but its normal position can be ascertained by the presence of the longitudinal fold, which leads proximally to the papilla, as well as by the presence of bile. The papilla appears to sit on a ledge (bottom right).
Bile can be seen draining from the middle of this longitudinal structure, with no ampullary orifice identified
(A). The hooded fold is lifted by the diagnostic catheter, demonstrating the pinkish color of the ampullary orifice (B). The longitudinal fold is a landmark to the papilla.
The Many Faces of The Major Papilla
A, Small papilla in a jaundiced patient. B, The papilla is more bulbous with exudate and erythema at the papilla. This patient had gallstone pancreatitis. C1, More pronounced major papilla. When the hooded fold is moved with the catheter, the intraduodenal segment with protruding epithelium is appreciated (C2). D1, The papilla is situated under duodenal folds with ampullary tissue visible. When viewed in the appropriate position, the biliary sphincter can be seen in the ampullary orifice (D2). E, A guidewire is present in the biliary sphincter, and the opening to the pancreatic sphincter is shown inferiorly. The septum between the two ducts is also apparent. F, The major papilla is normal, and the biliary sphincter relaxes with flow of bile (F1, F2). G, Variable length of the longitudinal fold leading to the ampulla (G1, G2). H, The minor papilla is often visible in a lateral superior orientation. I1, I2, Major papilla is in a small diverticulum and is flat, but with cannulation the papilla becomes more pronounced. J1-J3, The papilla is situated in a diverticulum but is seen to prolapse out.
Separate Openings for The Bile and Pancreatic Ducts
A1, Major papilla alongside a diverticulum with fleshy tissue both above and below a fold. A2, The bile duct is selectively cannulated. A3, The fleshy tissue inferiorly is cannulated confirming the pancreatic segment. B1, A structure resembling the ampulla is seen above a longitudinal fold with ampullary tissue. Underneath the fold, typical ampullary epithelium is also shown. B2, A sphincterotome is used to selectively cannulate the bile duct. C, Bile exits from an opening on the superior surface of the ampulla. A slitlike area in the middle of the papilla represents the pancreatic segment. The patient has previously undergone biliary sphincterotomy. D, A manometry catheter is in the pancreatic sphincter (D1). The manometry catheter is in the biliary sphincter (D2). D3, D4, A pancreatic stent is deployed in the pancreatic duct. E1, The patient has previously undergone pancreatic sphincterotomy, and a pancreatic stent is visible. The biliary sphincter is at the 11 o’clock position. E2, The bile duct is selectively accessed. E3, Biliary sphincterotomy is performed. E4, A bile duct stent is now present. F1, Two distinct papillary structures. The bile duct has been cannulated (F2) and sphincterotomy performed. Note the opening to the bile duct and the papillary structure inferiorly representing the pancreatic sphincter (F3).
Both biliary and pancreatic sphincterotomies were performed with a pancreatic stent in place. Note the thick septum dividing the two openings.
Position of Major Papilla with Billroth II Anatomy
Note the inverse relation of the longitudinal fold to the hooded fold over the major papilla
Intraduodenal Segment of Common Bile Duct
A, Note the long intraduodenal segment. The length of the intraduodenal segment dictates the length of the sphincterotomy incision. B, Catheter in bile duct. C, Intraduodenal segment easy to identify as it appears separate from the duodenal wall. D, Very small segment.
Position of Ampulla on Diverticulum
A1, Ampulla residing on the diverticular ridge. A2, Close-up shows the small ampullary structure. B, Ampullary structure at the 5 o’clock position. C, Ampullary structure at the 6 o’clock position. D, Large intraduodenal segment occupying the center of the diverticulum. E1, Diverticulum with no ampullary structure visible. E2, View of the diverticulum from a distance shows a small area compatible with the papilla on the inside lip at the 5 o’clock position. E3, A sphincterotome has been used to move the ampullary tissue toward the lumen. F, Bulbous ampulla occupying the inferior lip of a diverticulum. Cannulation confirmed an impacted stone. G1, The ampulla is located in a small diverticulum inferior to a larger diverticulum. G2, After selective biliary cannulation, the ampulla appears to be withdrawn from the diverticulum. H1, The ampullary orifice is on the 3 o’clock position deep inside a large diverticulum. H2, The diverticulum had to be entered for selective cannulation. H3, The diverticulum is gently entered and sphincterotome used for selective bile duct access. H4, Biliary sphincterotomy performed and a solitary stone removed (H5).
Diverticulum with Debris
A, Large duodenal diverticulum with amorphous debris and air. This patient had a bile duct obstruction. B, Mass of debris obscures the ampulla. C, The debris was ultimately removed, exposing a large periampullary diverticulum. Bile duct obstruction in this setting has been termed Lemmel syndrome. In this patient, jaundice resolved after removal of the debris.
Biliary Cannulation Techniques
A, The bile duct was selectively cannulated from a distance that takes advantage of the curve in the catheter. Note the direction toward the 11 o’clock position. A tortuous longitudinal fold leads to the ampulla. B1, The major papilla is bulbous, and overlying duodenal mucosa hides the ampullary orifice. B2, A sphincterotome is used to push away duodenal mucosa, exposing the ampullary structure. B3, Given the more en face position and need for biliary cannulation, a bowed sphincterotome was used for selective cannulation. C1, Exudate covers the ampullary tissue resulting from recent previously failed cannulation. C2, A sphincterotome is placed just inside the ampullary structure toward the 11 o’clock position. C3, C4, The sphincterotome is slowly bowed, the elevator dropped, and the sphincterotome slowly advanced, which helps orient to the 11 o’clock position.
Rendezvous for Biliary Cannulation
A, This patient has a T-tube in place. A wire is passed through the T-tube and out of the ampulla. B, A diagnostic catheter is placed toward the wire. C, The wire is fed into the catheter, and the catheter is then advanced into the bile duct.
Intramucosal Contrast Injection
A, Purplish hue to the ampullary structure. B, After biliary sphincterotomy, the underlying mucosa is hemorrhagic. A biliary stent was inserted.
Biliary Opening after Whipple Procedure
A1, Biliary anastomosis after Whipple procedure. Note the small subtle opening to the bile duct. A2, A biliary catheter has been placed into the duct. B, Distinct orifice draining bile. C, Large anastomosis with the bile duct easily visible.
Termination of Afferent Limb after Whipple Procedure
A, Termination of the afferent limb. B, The ECRP catheter is pointing to the entrance to the pancreatic duct. The pancreatic duct is anastomosed in variable positions (see below). C1, In this patient, the pancreatic duct was anastomosed more distally. A stent is present. C2, The stent is grasped with forceps. Note a small suture is present superiorly.
Position of Pancreatic Duct after Biliary Sphincterotomy
A1, Note the opening of the biliary duct in relation to the pancreatic sphincter. A2, The diagnostic catheter is placed in the biliary tree. A3, The catheter is placed in the pancreatic duct. B1, Patulous biliary opening. Note the small defect immediately inferior representing the pancreatic duct. B2, The catheter is entering the pancreatic duct.
Papilla after Passage of a Stone
A, The periampullary area is hemorrhagic, and the ampulla itself appears open. B, Hemorrhagic edematous papilla from stone passage.
A-E, In each case, a bilirubinate stone is impacted at the ampulla. D1, Stone impacted in ampulla. D2, Endoscopic ultrasonography (EUS) image shows dilated bile duct with large impacted stone. Note the shadowing. D3, E2, After cannulation, a large amount of pus spontaneously passed. E1, Bilirubinate stone seen in ampullary orifice. F, Ulceration from impacted stone with impending fistula. G, Small stone in the ampullary orifice.
Obstruction from Pus
A, Yellow material obstructs the ampulla. B, With sphincterotomy, only pus passes from the obstructed duct. C, At laparoscopic cholecystectomy, thick yellow pus exudes from the gallbladder.
Passage of Sludge
A, Bile filled with sludge was seen to spontaneously pass. This patient had acute pancreatitis. B1, Characteristic gallbladder sludge by EUS. B2, Mildly dilated common bile duct with scant debris that does not shadow typical for common bile duct sludge. B3, Large amount of sludge removed with balloon catheter. C1-C3, After biliary sphincterotomy, a large amount of sludge is seen to pass. C4, Bile aspirate shows debris.
Spontaneous Passage of Large Impacted Stone
A, Markedly enlarged ampulla. B, With observation, a large stone was seen to spontaneously pass, leaving a tear (C). Bile and pus now spontaneously pass from this large opening (D).
A1, The ampulla is open, and on close-up (A2) a stone is visible. B, After sphincterotomy, a balloon is being withdrawn delivering a calculus.
A, The bile duct has been selectively cannulated with a sphincterotome. B, The wire is slightly bowed. Note the length of the intraduodenal segment proximal to the large duodenal fold. C, The incision is slowly made. D, The incision is extended close to the overlying fold. E, The fold is now being incised again, noting the length of the intraduodenal segment. F, The fold is being incised. G, A small incision is made just proximal to the fold, which is the full extent of the intraduodenal segment. H1, Small papilla and intraduodenal segment. H2, A sphincterotome is bowed in the papilla. H3, Complete biliary sphincterotomy performed. Note the incision was made to the most proximal portion of the bulge in the duodenum. I1, Sphincterotome in the ampulla with selective biliary cannulation. I2, Note the incision was made over the duodenal fold and to the duodenal wall (I3). I4 Dilated bile duct with multiple stones. Contrast fills a normal distal pancreatic duct. , I5, A balloon catheter is removing a large number of stones. I6, The bile duct is easily seen through the wide sphincterotomy. I7, At fluoroscopy air was now seen to outline the biliary tree, suggesting complete incision. J1, Normal major papilla. J2, Biliary sphincterotomy is carried out to the duodenal wall just distal to the overlying fold. J3, The duodenal wall itself is now visible overlying the exposed common bile duct (CBD). K1, Long intraduodenal bile duct segment. The sphincterotome is in the bile duct. K2, Biliary sphincterotomy performed. K3, A small portion of the duodenal wall is shown.
Suture Alongside Biliary Sphincterotomy
Suture material is present at the site of prior sphincterotomy. This patient had duodenal oversew after duodenal perforation at the time of biliary sphincterotomy and stone removal.
Biliary Sphincterotomy with Stone Removal
A, Common bile duct stone with shadowing on EUS. B, Bulbous-appearing ampulla. C1, Solitary stone on cholangiography. C2, The more proximal biliary tree is normal. Note the large number of filling defects representing gallbladder stones. D, The biliary sphincter is incised. E, The incision is performed to the duodenal wall. F, A balloon catheter is placed in the bile duct. Note the pancreatic sphincter is easily seen inferiorly. G, The balloon catheter is slowly removed, delivering a cholesterol mulberry-like stone. H, The stone is now completely removed and resides in the duodenum. I, The surgical specimen shows a large number of similar-appearing stones with debris.
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