This is a young woman who presented to the Emergency Department with new onset acute abdominal pain. Blood tests showed an elevation in her liver enzymes. An abdominal sonogram test found that her gallbladder was full of gallstones. She was scheduled for urgent gallbladder surgery. But, there was a problem. The sonogram also showed that the bile ducts that normally drain the liver were blocked by a cluster of many small stones. This is a serious condition which can cause damage to the liver and pancreas. This blockage also makes surgical removal of the gallbladder more difficult and dangerous. Her surgeon requested that an ERCP examination first be done to clear out the stones in the bile duct. Here is a photo taken in the duodenum during the ERCP. You can see the opening of the bile duct in the duodenum - called the Ampulla of Vater.
	During the ERCP, a small catheter was introduced into the Ampulla and up into the bile duct. X-ray contrast dye was injected into the ducts to make them visible on the X-ray machine. This confirmed the presence of many gallstones lodged in the bile duct blocking the flow of bile. A special wire loop was used to cut and enlarge the opening of the Ampulla. This allowed the stones to drain out of the bile duct and relieve the blockage. In this photo take just after the "cut," you can see one small yellow stone emerging from the new opening.
	The large stone in the foreground was removed using a small basket. Once this was accomplished,a flood of many small gallstones (arrow) followed through the newly enlarged opening and flooded the duodenum. In this photo you can see numerous small gallstones in the duodenum. This relieved the blockage of the bile ducts and the patient was able to safely undergo sugical removal of the gallbladder. She did well afterward and was discharged from the hospital the following day. About 20 million Americans (twice as many women as men) suffer from gallstones, and more than 500,000 a year undergo surgical gallbladder removal. This is an example of how ERCP can be used to help some of those patients.

Text & Images Courtesy of Three Rivers Endoscopy Center
© Dr. Robert Fusco, Three Rivers Endoscopy Center, All Rights Reserved