An unusual cause of failed selective biliary cannulation

Abstract

A 40-year-old man underwent ERCP because of a 4-mm bile duct (BD) calculus. The longitudinal fold in the second part of the duodenum was seen oriented in the 11 to 5 o’clock axis. Initial attempts at selective biliary cannulation accessed the pancreatic duct (PD). Precut papillotomy using a needle-knife exposed a clear opening toward 11 o’clock (A, thick arrow), which surprisingly accessed the PD. A faintly visible opening toward 3 o’clock (A, slim arrow) led to the BD (B). The stone was extracted after sphincterotomy at this opening (C).