A Case of The Hidden Papilla

Abstract

Purpose: Difficult cannulation during ERCP can lead to prolonged procedure time, increased rate of complications, and inability to complete the intended procedure. Endoscopic techniques and devices have been developed in order to deal with difficult cannulation. Here, we present the case of a difficult cannulation due to a hidden ampulla, hooded by a large redundant fold of Kerckring. In order to selectively cannulate the CBD, endoclips were used to mobilize the fold, thus revealing the ampulla. A 73-year-old male presented to our institution with biliary-like pain, jaundice, and fever. The previous medical history included cholecystectomy 10 years prior, hypertension, and hypercholesterolemia. His bilirubin was 8.2, lipase >2,000, WBC 17.8, and CT scan revealed a dilated CBD (13 mm) with choledocholithiasis. Temperature was 103 F and vital signs were otherwise normal. Abdominal examination revealed epigastric and RUQ tenderness without rebound or guarding. He was admitted for treatment of cholangitis and biliary pancreatitis. Antibiotics were given along with aggressive IV fluid hydration and ERCP was planned. Upon examination of the duodenum the ampulla was not identified. An area the appeared to be the ampullary mound was probed with the sphinctertome. The ampulla was covered by a hood, secondary to a redundant fold of Kerckring. Upon lifting the hood, copious pus emanated from the ampullary orifice. Conventional cannulation was not possible to this altered anatomy. Next, two endoclips (Boston Scientific) were used to mobilize the redundant fold and subsequently attached it to the adjacent duodenal mucosa, allowing for usual visualization of the ampulla. The CBD was then selectively cannulated and cholangiogram revealed a dilated duct with a large filling defect. Given prolonged procedure time and cholangitis, two double pigtail stents were placed to allow to adequate decompression. The patient tolerated the procedure and rapidly improved. Staged ERCP with sphincterotomy was performed 5 days later, the stent was removed, and balloon sweeps retrieved a large stone; the endoclips were still in place allowing for visualization. Redundant Kerking folds of the duodenum often present a serious challenge to the endoscopist, commonly prolonging ERCP procedure time with an increased incidence of related complications. In this report we present such a case, managed by mechanical clipping of the folds, thereby revealing the ampullary orifice and allowing for effective endoscopic therapy. Although not indicated in all cases, this approach is innovative and should be considered in anatomically difficult cases.