ERCP. El Salvador Atlas of Gastrointestinal VideoEndoscopy. A Large Database of Images and Video Clips with Cases Reported.
El Salvador Atlas of Gastrointestinal VideoEndoscopy

 

Acute suppurative cholangitis caused by choledocolithiasis.  96 year-old female, 20 years previously underwent a cholecystectomy, patient was hospitalized with abdominal pain in the right upper quadrant pain, tenderness and jaundice, elevated alkaline phosphatase more than 800 units, the total billirubins more than 18, direct billirubin: 16.9.. Physical examination showed generalized jaundice.

Video Endoscopy Sequence 1 of 12.

Acute suppurative cholangitis caused by choledocolithiasis

 96 year-old female, 20 years previously underwent a
 cholecystectomy, patient was hospitalized with abdominal
 pain in the right upper quadrant, tenderness and
 jaundice, elevated alkaline phosphatase more than 800
 units, the total billirubins more than 18, direct billirubin:
 16.9. Physical examination showed generalized jaundice.

 Patient underwent an endoscopic Needle-knife precut
 sphincterotomy draining great amount of suppurative
 material
successfully treated endoscopically and with
 
course of two broad-spectrum antibiotics during four ten
 days.

 CBD stones are either primary or secondary. Primary
 stones arise within the biliary duct system, while secondary
 stones develop in the gallbladder and migrate to the CBD.

 Endoscopic biliary drainage is a safe and effective measure
 for the initial control of severe acute cholangitis due to
 choledocholithiasis and to reduce the mortality associated
 with the condition.

 Older age has been considered a risk factor for increased
 morbidity and mortality rates in the treatment of acute
 cholangitis.

 For more endoscopic details download the video clips by
 clicking on the endoscopic images, wait to be downloaded
 complete then press Alt and Enter; thus you can observe
 the video in full screen.

 All endoscopic images shown in this Atlas contain
 video clips.

Magnetic resonance cholangiopancreatography (MRCP) is a noninvasive method for imaging the biliary and pancreatic ducts using magnetic resonance imaging. These techniques do not require intravenous contrast material and use specialized MRI sequences (i.e., heavily T2-weighted) to make the fluid in the ducts appear bright while the surrounding organs and tissues are suppressed and appear dark. Additional technical factors include fast imaging to reduce motion artifact and sufficient resolution to detect small ductal structures and pathology. When imaging pediatric subjects, a very small field of view and high pixel matrix provide better spatial resolution for small structures. Modifications of the MRCP protocol to include secretin infusion and functional evaluation have also been explored.

Video Endoscopy Sequence 2 of 12.

Magnetic Cholangioresonance 3D reconstruction

 Magnetic resonance cholangiopancreatography (MRCP) is
 a noninvasive method for imaging the biliary and pancreatic
 ducts using magnetic resonance imaging. These techniques
 do not require intravenous contrast material and use
 specialized MRI sequences (i.e., heavily T2-weighted) to
 make the fluid in the ducts appear bright while the
 surrounding organs and tissues are suppressed and appear
 dark. Additional technical factors include fast imaging to
 reduce motion artifact and sufficient resolution to detect
 small ductal structures and pathology. When imaging
 pediatric subjects, a very small field of view and high pixel
 matrix provide better spatial resolution for small
 structures. Modifications of the MRCP protocol to include
 secretin infusion and functional evaluation have also been
 explored.

 

Click here to enlarge the image

Needle-knife precut sphincterotomy .  The  sphincterotomy is iniciates with pre-cut needle emerging abundant purulent secretion (Colangitis).

Video Endoscopy Sequence 3 of 12.

Needle-knife precut sphincterotomy Endoscopic biliary drainage for severe acute cholangitis.

 The sphincterotomy is iniciates with pre-cut needle
 emerging abundant purulent secretion (Colangitis).

  • Charcot triad of fever, RUQ pain, and jaundice is found in 50-70% of patients presenting with cholangitis.
  • Fever is present in approximately 90% of cases. Abdominal pain and jaundice is thought to occur in 70% and 60% of patients, respectively.
  • Patients present with altered mental status 10-20% of the time and hypotension approximately 30% of the time. These signs combined with Charcot triad constitute Reynolds pentad.
  •  Most patients complain of RUQ pain; however, some patients (ie, elderly persons) are too ill to localize the source of infection.
  •  Other symptoms include the following:
    •  Jaundice
    •  Fever, chills, and rigors
    •  Pruritus
    •  Acholic or hypocholic stools
  •  The patient's past medical history may be helpful. For example, a history of the following increases the risk of cholangitis:
    •  Gallstones, CBD stones
    •  Recent cholecystectomy
    •  Endoscopic manipulation or ERCP, cholangiogram
    •  History of cholangitis
    •  History of HIV or AIDS: AIDS-related cholangitis is characterized by extrahepatic biliary edema, ulceration, and obstruction. Etiology is uncertain but may be related to cytomegalovirus or cryptosporidium infections. Manage cholangitis as described below, although decompression usually is not necessary.
Cholangitis can be life-threatening, and is regarded as a medical emergency. Characteristic symptoms include jaundice, fever, abdominal pain, and in severe cases, low blood pressure and confusion. Initial treatment is with intravenous fluids and antibiotics, but there is often an underlying problem (such as gallstones or narrowing in the bile duct) for which further tests and treatments may be necessary, usually in the form of endoscopy to relieve obstruction of the bile duct.  Acute cholangitis is a bacterial infection superimposed on an obstruction of the biliary tree most commonly from a gallstone, but it may be associated with neoplasm or stricture.  Mortality of cholangitis is high due to the predisposition in people with underlying disease. Historically, mortality was 100%. Currently, mortality ranges from 7-40%.

Video Endoscopy Sequence 4 of 12.

 The Needle-knife precut extending the incision.

 Cholangitis can be life-threatening, and is regarded as a
 medical emergency. Characteristic symptoms include
 jaundice, fever, abdominal pain, and in severe cases, low
 blood pressure and confusion. Initial treatment is with
 intravenous fluids and antibiotics, but there is often an
 underlying problem (such as gallstones or narrowing in the
 bile duct) for which further tests and treatments may be
 necessary, usually in the form of endoscopy to relieve
 obstruction of the bile duct.

 Acute cholangitis is a bacterial infection superimposed on
 an obstruction of the biliary tree most commonly from a
 gallstone, but it may be associated with neoplasm or
 stricture.
 Mortality of cholangitis is high due to the predisposition in
 people with underlying disease. Historically, mortality was
 100%. Currently, mortality ranges from 7-40%.

MRI Portal System. As a imaging of a Magnetic Cholangioresonance Reconstruction the portal system is useful for adecuate diagnosis, in this image is observed the calculi, the choledoco, the aorta and the inferior cava vein.

Video Endoscopy Sequence 5 of 12.

MRI Portal System

 As a imaging of a Magnetic Cholangioresonance
 Reconstruction the portal system is useful for adecuate
 diagnosis, in this image is observed the calculi, the
 choledoco, the aorta and the inferior cava vein.

 MRCP has been proposed as a noninvasive alternative to
 more invasive imaging procedures such as endoscopic
 retrograde cholangiopancreatography (ERCP),
 percutaneous cholangiography, or intravenous
 cholangiography (IVC). ERCP is an invasive procedure
 using a long specialized endoscope that can cannulate the
 biliary tree. This procedure is associated with a risk of
 complications such as pancreatitis, bleeding, bowel
 perforation, infection, and rarely death, and it requires
 anesthesia, which is also associated with potential
 complications. Percutaneous transhepatic cholangiography
 (PTC) is also invasive and requires placement of a needle
 through the liver into an intrahepatic duct. ERCP and PTC
 obtain diagnostic images by direct ductal injection of
 radiographic contrast while IVC uses radiographic contrast
 that is injected into the bloodstream and later excreted into
 the bile ducts. ERCP or PTC may also be used to perform
 therapeutic interventions such as stent placement for
 obstruction, stone removal or sphincterotomy. In addition,
 ERCP may not be technically successful in approximately
 3 to 10% of cases depending on operator skill and/or
 complex anatomy. Finally, MRCP is able to demonstrate
 the ducts beyond an obstructing lesion whereas this may be
 difficult with ERCP or PTC.

 Click here to enlarge the image

Magnetic resonance cholangiopancreatography

Video Endoscopy Sequence 6 of 12.

 Another projection of the Magnetic resonance
 cholangiopancreatography of the patient, It is observed the
 liver, choledoco which is dilated and distal the calculi.

 This technique provides images derived from different
 magnetic properties of various tissues. Gadolinium is used
 as a contrast for this test
.

  • It is a noninvasive tool with 97% accuracy, 92% sensitivity, and 100% specificity. It is improving with the advent of new sequences in imaging of the CBD.
  • Cost, inconvenience, and limitations (eg, obesity, presence of metal objects, eg, pacemakers) are some of its disadvantages.

 It is a noninvasive tool with 97% accuracy, 92% sensitivity, and
 100% specificity. It is improving with the advent of new
 sequences in imaging of the CBD.

Click here to enlarge the image

Magnetic resonance cholangiopancreatography (MRCP) depicting  colelithiasis.    In Western countries CBDS typically originate in the gallbladder and migrate. Such secondary stones should be differentiated from primary CBDS that develop de novo in the biliary system. Primary stones are more common in south-east Asian populations, have a different composition to secondary stones, and may be a consequence of biliary infection and stasis.

Video Endoscopy Sequence 7 of 12.

 Magnetic resonance cholangiopancreatography (MRCP)
 depicting colelithiasis.

 In Western countries CBDS typically originate in the
 gallbladder and migrate. Such secondary stones should be
 differentiated from primary CBDS that develop
de novo in
 the biliary system.
Primary stones are more common in
 south-east Asian populations,
have a different composition
 to secondary stones, and may be a consequence of biliary
 infection and stasis.

Click here to enlarge the image

 

Emerging Purulent Secretion.  In 1877, Charcot described cholangitis as a triad of findings of right upper quadrant (RUQ) pain, fever, and jaundice. The Reynolds pentad adds mental status changes and sepsis to the triad. A spectrum of cholangitis exists, ranging from mild symptoms to fulminant overwhelming sepsis. With septic shock, diagnosis can be missed in up to 25% of patients. Consider cholangitis in any patient who appears septic, especially with patients who are elderly, jaundiced, or who have abdominal pain. History of abdominal pain or past symptoms of gallbladder colic helps make the diagnosis.

Video Endoscopy Sequence 8 of 12.

Emerging Purulent Secretion

 In 1877, Charcot described cholangitis as a triad of findings
 of right upper quadrant (RUQ) pain, fever, and jaundice.
 The Reynolds pentad adds mental status changes and
 sepsis to the triad. A spectrum of cholangitis exists,
 ranging from mild symptoms to fulminant overwhelming
 sepsis. With septic shock, diagnosis can be missed in up to
 25% of patients. Consider cholangitis in any patient who
 appears septic, especially with patients who are elderly,
 jaundiced, or who have abdominal pain. History of
 abdominal pain or past symptoms of gallbladder colic helps
 make the diagnosis.

Dormia basket is used to removal the calculi . Emergency surgery for patients with severe acute cholangitis due to choledocholithiasis is associated with substantial morbidity and mortality. Emergency endoscopic drainage could improve the outcome of such patients,

Video Endoscopy Sequence 9 of 12.

 Dormia basket is used to removal the calculi

 Emergency surgery for patients with severe acute
 cholangitis due to choledocholithiasis is associated with
 substantial morbidity and mortality. Emergency endoscopic
 drainage could improve the outcome of such patients.

 Elderly patients with acute cholangitis have a high
 incidence of severe cholangitis, concomitant medical
 illnesses, hypotension, altered sensorium, peritonism,
 renal failure and higher mortality even after successful
 biliary drainage.

 

Endoscopic retrograde cholangiopancreatography (ERCP) has become a widely available and routine procedure, whilst open cholecystectomy has largely been replaced by a laparoscopic approach, which may or may not include laparoscopic exploration of the common bile duct (LCBDE). In addition, new imaging techniques such as magnetic resonance cholangiography (MR) and endoscopic ultrasound (EUS) offer the opportunity to accurately visualise the biliary system without instrumentation of the ducts. As a consequence clinicians are now faced with a number of potentially valid options for managing patients with suspected CBDS.

Video Endoscopy Sequence 10 of 12.

 Endoscopic retrograde cholangiopancreatography (ERCP)
 has become a widely available and routine procedure,
 whilst open cholecystectomy has largely been replaced by
 a laparoscopic approach, which may or may not include
 laparoscopic exploration of the common bile duct
 (LCBDE). In addition, new imaging techniques such as
 magnetic resonance cholangiography (MR) and endoscopic
 ultrasound (EUS) offer the opportunity to accurately
 visualise the biliary system without instrumentation of the
 ducts. As a consequence clinicians are now faced with a
 number of potentially valid options for managing patients
 with suspected CBDS.

 

Obstruction causes an increase in ductal pressure. The bacteria proliferate and escape into the systemic circulation via the hepatic sinusoids. The manifestations of sepsis may overshadow those of hepato-biliary disease causing acute suppurative cholangitis.

Video Endoscopy Sequence 11 of 12.

 Obstruction causes an increase in ductal pressure. The
 bacteria proliferate and escape into the systemic
 circulation via the hepatic sinusoids. The manifestations of
 sepsis may overshadow those of hepato-biliary disease
 causing acute suppurative cholangitis.

 Without prompt diagnosis and treatment, acute cholangitis
 can lead rapidly to septicaemia, shock and death.

Video Endoscopy Sequence 12 of 12.

The calculi responsible for the cholangitis is observed.

 

Larynx with ictericia (yellowish color). Patient with cholangitis and choledocholithiasis. This 83-year-old male was admitted with abdominal pain and increasing jaundice. Common bile duct stones were diagnosed on abdominal ultrasound.

Video Endoscopy Sequence 1 of 6.

Larynx with ictericia (yellowish color).

Patient with cholangitis and choledocholithiasis.

 This 83-year-old male was admitted with abdominal pain
 and increasing jaundice. Common bile duct stones were
 diagnosed on abdominal ultrasound.

 

Hard Palate.

Video Endoscopy Sequence 2 of 6.

Hard Palate.

 

White bilis is emerging from the Vater papila (cholangitis). This picture was taken through a forward-viewing  gastroscope.

Video Endoscopy Sequence 3 of 6.

 White bilis is emerging from the Vater papila (cholangitis).

 This picture was taken through a forward-viewing
 gastroscope.

Vaterīs papilla is observed protrued . Acute cholangitis is a difficult diagnostic and therapeutic problem. Classically, Charcot's triad of jaundice, abdominal pain and fever have been the main basis of diagnosis however 30%-45% of the patients with acute cholangitis do not satisfy the criteria of Charcot's triad

Video Endoscopy Sequence 4 of 6.

Vaterīs papilla is observed protrued

 Acute cholangitis is a difficult diagnostic and therapeutic
 problem. Classically, Charcot’s triad of jaundice, abdominal
 pain and fever have been the main basis of diagnosis
 however 30%-45% of the patients with acute cholangitis do
 not satisfy the criteria of Charcot’s triad.

The principal indications for sphincterotomy include removal of common bile duct stones, treatment of papillary stenosis, and facilitation of endotherapy (ie, stent placement, tissue sampling, and stricture dilation).

Video Endoscopy Sequence 5 of 6.

 The principal indications for sphincterotomy include
 removal of common bile duct stones, treatment of papillary
 stenosis, and facilitation of endotherapy (ie, stent
 placement, tissue sampling, and stricture dilation).

 Altered sensorium, hypotension and renal failure can often
 be seen in patients with suppurative cholangitis.

 In many cases, bile duct infection is latent and does not
 cause symptoms. Cholangitis varies in severity from a mild
 form which responds to parenteral antibiotics alone
to
 severe or suppurative cholangitis which requires early
 drainage of biliary system to reduce the incidence of
 systemic complications.

 

ERCP.  Endoscopic Sphincterotomy and Stone Extraction. Although most stones <1cm in diameter will pass spontaneously in days or weeks following an adequate sphinterectomy, most experts prefer to extract them directly. This immediately clarifies the situation and reduces the risk of impactiona nd cholangitis.

Video Endoscopy Sequence 6 of 6.

ERCP.

Endoscopic Sphincterotomy and Stone Extraction.

 Although most stones <1cm in diameter will pass
 spontaneously in days or weeks following an adequate
 sphinterectomy, most experts prefer to extract them
 directly. This immediately clarifies the situation and
 reduces the risk of impaction and cholangitis.

Adenocarcinoma of the head of the Pancreas that infiltrates the wall of duodenum. A 58 year-old male with heavy drinking habits, presented with jaudince and weigh loss of 30 pounds, the ultrasound examinations reveled dilatation of the biliary tree and a mass of the pancreatic head.

Video Endoscopy Sequence 1 of 10.

 Adenocarcinoma of the head of the Pancreas that infiltrates
 the wall of duodenum.

 A 58 year-old male with heavy drinking habits, presented
 with jaudince and weigh loss of 30 pounds, the ultrasound
 examinations reveled dilatation of the biliary tree and
 a mass of the pancreatic head.

The image and the video clip display an irregular and nodular patterns of the periampullary region.

Video Endoscopy Sequence 2 of 10.

 The image and the video clip display an irregular and
 nodular patterns of the periampullary region.

A biopsy was taken with an Endoscopic snare excision.

Video Endoscopy Sequence 3 of 10.

 A biopsy was taken with an endoscopic snare excision.

 

The Vater papilla is observed.

Video Endoscopy Sequence 4 of 10.

 The Vater papilla is observed.

An endoscopic sphincterotomy was attempted at standard common bile duct cannulation and sphincterotomy were unsuccessful, then precut sphincterotomy needle-nife sphincterotomy was performed.

Video Endoscopy Sequence 5 of 10.

 An endoscopic sphincterotomy was attempted at standard
 common bile duct cannulation and sphincterotomy were
 unsuccessful, then precut sphincterotomy needle-nife
 sphincterotomy was performed.

 

Precut sphincterotomy needle-nife sphincterotomy.

Video Endoscopy Sequence 6 of 10.

 Precut sphincterotomy needle-nife sphincterotomy.
 

.

 

 

 

Video Endoscopy Sequence 7 of 10.

 

A guide-wire placement to deploy a self-expanding stent used for drainage of malignant biliary stenosis.  Sphincterotomy is a technically complex procedure that is performed under visual and fluoroscopic guidance. Deep cannulation of the bile duct is followed by electrocautery to incise the sphincter of Oddi.

Video Endoscopy Sequence 8 of 10.

 A guide-wire placement to deploy a self-expanding stent
 used for drainage of malignant biliary stenosis.

 Sphincterotomy is a technically complex procedure that is
 performed under visual and fluoroscopic guidance. Deep
 cannulation of the bile duct is followed by electrocautery to
 incise the sphincter of Oddi.

 

A dilated biliar tree is observed with this ERCP image.

Video Endoscopy Sequence 9 of 10.

 A dilated biliar tree is observed with this ERCP image.

A dilated biliar tree is observed

Video Endoscopy Sequence 10 of 10.

A dilated biliar tree is observed.

 

Adenocarcinoma of the Vater Papilla and stent migration. A 62 year-old male with adenocarcinoma of Papilla of Vater, a biliar stent was placed in another clinic, the stent migrated one month after, patient present anorexia, nauseas and vomiting.  Endoprostheses are commonly used in the treatment of biliary and pancreatic disorders incidence rates of 4.% for proximal biliary stent migration.

Video Endoscopy Sequence 1 of 7.

Adenocarcinoma of the Vater Papilla and stent migration.

 A 62 year-old male with adenocarcinoma of Papilla of
 Vater, a biliar stent was placed in another clinic, the stent
 migrated one month after, patient presented anorexia,
 nauseas and vomiting. The stent caused contralateral wall
 ulceration with the danger of causing duodenal perforation.

 Endoprostheses are commonly used in the treatment of
 biliary and pancreatic disorders incidence rates of 4.% for
 proximal biliary stent migration.

 

 

This image displays the adenocarcinoma of papilla of Vater. Because of its location with respect to the biliary system, carcinoma of the ampulla of Vater is considered to manifest earlier in its course of development than carcinoma of the pancreas. The most common physical finding is jaundice, which occurs in 93-100% of cases.Endoprosthesis which was then inserted into malignant strictures of the ampulla .

Video Endoscopy Sequence 2 of 7.

This image displays the adenocarcinoma of papilla of Vater.

 Endoprosthesis which was inserted into malignant strictures
 of the ampulla.

 Because of its location with respect to the biliary system,
 carcinoma of the ampulla of Vater is considered to manifest
 earlier in its course of development than carcinoma of the
 pancreas. The most common physical finding is jaundice,
 which occurs in 93-100% of cases.

Carcinoma of the ampulla of Vater is a malignant tumor arising within 2 cm of the distal end of the common bile duct, where it passes through the wall of the duodenum and ampullary papilla. The common bile duct merges with the pancreatic duct of Wirsung at this point and exits through the ampulla into the duodenum. The most distal portion of the common bile duct is dilated.

Video Endoscopy Sequence 3 of 7.

 Periampullary Carcinoma.

 Carcinoma of the ampulla of Vater is a malignant tumor
 arising within 2 cm of the distal end of the common bile
 duct, where it passes through the wall of the duodenum and
 ampullary papilla. The common bile duct merges with the
 pancreatic duct of Wirsung at this point and exits through
 the ampulla into the duodenum. The most distal portion of
 the common bile duct is dilated.

 

Ampullary cancer accounts for approximately 0.2% of all gastrointestinal tract malignancies.   The Courvoisier sign, painless jaundice associated with a palpable gallbladder, may be present. Unlike that due to a neoplasm, obstructive jaundice due to a stone causes scarring of the gallbladder, precluding its distension.

Video Endoscopy Sequence 4 of 7.

 Ampullary cancer accounts for approximately 0.2% of all
 gastrointestinal tract malignancies.

 The Courvoisier sign, painless jaundice associated with a
 palpable gallbladder, may be present. Unlike that due to a
 neoplasm, obstructive jaundice due to a stone causes
 scarring of the gallbladder, precluding its distension.

 Although biopsy is not 100% accurate.

This image as well as the video clip display the tip of the stent that ulcerated the contralateral wall of the duodenum.

Video Endoscopy Sequence 5 of 7.

 This image as well as the video clip display the tip of the
 stent that ulcerated the contralateral wall of the duodenum.

This image Shows the tip of the stent causing a duodenal wall ulceration with the danger of perforation.

Video Endoscopy Sequence 6 of 7.

 This image Shows the tip of the stent causing a duodenal
 wall ulceration with the danger of perforation.

 

More images and video clip of this case.

Video Endoscopy Sequence 7 of 7.

More images and video clip of this case.

 

LARGE BULGING PAPILLA OF VATER.         A 87 year-old male, with 10 months after cholecystectomy due to gallstones, presented 20 days of fever, diarrhea,  jaundice and upper right quadrant pain. Abdominal sonography demonstrated the intrahepatic ducts, comom hepatic duct, and choledocho were dilated. Total Bilirrubine was of 3.0 mg/dl with a direct bilirrubine of 2.6 mg/dl and Alkaline Fosfatase of 812. Duodenoscopic sphincterotomy of the papilla of Vater as performed using a standard side-viewing duodenoscope.

Video Endoscopic Sequence 1 of 2.

LARGE BULGING PAPILLA OF VATER.

 An 87 year-old male, with 10 months after cholecystectomy
 due to gallstones, presented 20 days of fever, diarrhea,
 jaundice and upper right quadrant pain. Abdominal
 sonography demonstrated the intrahepatic ducts, comom
 hepatic duct, and choledocho were dilated. Total Bilirrubine
 was of 3.0 mg/dl with a direct bilirrubine of 2.6 mg/dl and
 Alkaline Fosfatase of 812. Duodenoscopic sphincterotomy
 of the papilla of Vater was performed using a standard
 side-viewing duodenoscope.
 
 

A point diathermy incision was made with a precut papillotome (needle-knife). When the papillotome advanced sufficiently, gush of bile and small gallstone were observed. Slight bleeding was observed.  3 days later, the patient reduced total bilirrubine to 1mg/dl, abdominal sonography was normal.

Video Endoscopic Sequence 2 of 2.

 A point diathermy incision was made with a precut
 papillotome (needle-knife). When the papillotome
 advanced sufficiently, gush of bile and small gallstone were
 observed. Slight bleeding was observed. 3 days later, the
 patient reduced total bilirrubine to 1 mg/dl, abdominal
 sonography was normal.

Stent Migration.  This 73 year-old male underwent placement of a biliary stent due to Klatskin?s tumors in another clinic.  Endoscopic plastic biliary stenting is a common procedure in the management of benign biliary pathology. Complications from biliary stenting are rare, with stent occlusion being the most common. Another late complication of long-term biliary stenting is stent migration, which occasionally can result in bowel perforation and obstruction.

Stent Migration.

 This 73 year-old male underwent placement of a biliary
 stent due to Klatskin’s tumors in another clinic.

 Endoscopic plastic biliary stenting is a common procedure
 in the management of benign biliary pathology.
 Complications from biliary stenting are rare, with stent
 occlusion being the most common. Another late
 complication of long-term biliary stenting is stent migration,
 which occasionally can result in bowel perforation and
 obstruction.

Magnetic Cholangio Resonance.  This 31 year-old lady, 8 years previously had an open cholecystectomy due to acute calculous cholecystitis and a biliodigestive surgery; Roux-en-Y, after that, has been suffering of repeated episodes of cholangitis, the magnetic cholangio resonance shows  recurrent stones in the the biliar tree with stenosis of the anastomosis of the asa with the biliar tree, the patient underwent a new surgery.

Magnetic Cholangio Resonance

 This 31 year-old lady, 8 years previously had an open
 cholecystectomy due to acute calculous cholecystitis and
 a b
iliodigestive surgery; Roux-en-Y, after that, has been
 suffering of repeated episodes
of cholangitis, the magnetic
 cholangio resonance shows recurrent stones in the the
 biliar tree with stenosis of the anastomosis of the asa with
 the biliar tree, the patient underwent a new surgery.

 
 Magnetic resonance Cholangiopancreatography (MRCP) is a
 non-invasive imaging technique able to provide projectional
 images of the bile ducts without any contrast.

 Different sequences , using both breath-hold and
 non-breath-hold acquisition techniques, have been employed in
 order to obtain MRCP images.

 The main indication for MRCP study is represented by the
 evaluation of common bile duct obstruction, with the aim of
 assessing the presence of the obstruction (accuracy 85-100%)
 and, subsequently, its level (accuracy 91-100%) and its cause.
 The utility of associating conventional MR images to MRCP in
 malignant strictures, in order to characterize and stage the
 malignant lesion, is also discussed. Finally, data are presented
 regarding the indications and the utility of MR-pancreatography
 in the evaluation of patients with pancreatic duct anomalies and
 chronic pancreatitis.

 Click here to enlarge the image