PAPILLARY CANNULATION FACILITATED BY SUBMUCOSAL SALINE INJECTION INTO THE INTRADIVERTICULAR PAPILLA

Aims:

Endoscopic retrograde cholangiopancreatography (ERCP) of the intradiverticular papilla with an invisible orifice remains challenging. Several techniques have been introduced for everting the papillary opening to facilitate cannulation.

Methods:

The submucosal injection of 2 – 4 mL of normal saline at single or multiple points enables intradiverticular papillary eversion. The important step is selecting the best inflation point to preserve the bile duct opening and to keep papillary eversion.

Results:

A 79-year-old woman received ERCP for bile duct stones, which revealed that the papilla was located inside a large diverticulum and it tended to rotate inward on a trial of papillary cannulation. The submucosal injection of 3 cc of normal saline was done on 3 and 9 o'clock of the papilla. Eversion and fixation of a papilla in the diverticulum by this technique allowed selective cannulation of the biliary tree. After cannulation into biliary tree, stones were retrieved after endoscopic papillary balloon dilation without complications. She had an uneventful post procedural course.

Conclusions:

Our findings suggest that submucosal saline injection technique is safe and effective for selective cannulation and could be recommended in the condition, which cannulation is very difficult because of intradiverticular papilla.