Endoscopic Nasobiliary Drainage Tube Research Articles

Use of preoperative contrast-enhanced computed tomography in damage control strategy for blunt liver injury: A case report

For patients with unstable abdominal trauma unresponsive to initial transfusion, the damage control strategy includes prompt hemostasis by open surgery and packing. Recently, a hybrid treatment that combines packing and transcatheter arterial embolization as a damage control strategy was reported to be effective; however, the indications and techniques are yet to be established. A 25-year-old male patient who was in shock due to severe liver injury after a traffic accident was brought to our emergency room by emergency services. After initial resuscitation, including resuscitative endovascular balloon occlusion of the aorta and blood transfusion, preoperative contrast-enhanced computed tomography indicated grade IV liver injury with active bleeding from the right hepatic artery. Damage control strategy with packing and subsequent transcatheter arterial embolization was determined to be useful. During treatment, bile leakage was observed. An endoscopic nasobiliary drainage tube was inserted, and the patient was treated conservatively. He was discharged on day 83 of hospitalization. Although using preoperative contrast-enhanced computed tomography before damage control surgery remains controversial, it can provide useful information to determine damage control strategy, including morphological evaluation of the injured area and the presence of active bleeding.

Successful retrieval of a fractured biliary guidewire using a newly developed endoscopic tapered sheath.

An 81-year-old man with Bismuth–Corlette type II perihilar cholangiocarcinoma ([Fig. 1]) underwent endoscopic retrograde cholangiopancreatography (ERCP). Cholangiography showed a hilar stricture that was so severe that the biopsy forceps could not be passed alongside the tumor ([Fig. 2 a]). During this ERCP, a guidewire was fractured. An endoscopic nasobiliary drainage tube was inserted into the right anterior duct, without removal of the fragment being attempted ([Fig. 2 b]).

Application of a novel M-NED in ENBD patients: A case series report.

The traditional methods for exchanging the endoscopic nasobiliary drainage (ENBD) tube from the mouth to the nose, such as the guidewire method, sponge holding forceps method, and finger method, have significant drawbacks including pharyngeal stimulation symptoms, high incidence of epistaxis, low success rate, and potential bite injuries to the operator. A case series of 9 patients who underwent ENBD at Shenzhen Second People's Hospital from January 2021 to December 2021 was collected. The study included 9 patients diagnosed with choledocholithiasis, with 3 males and 6 females, with an average age of (55 ± 9.798) years (range 43-71). The M-NED was used to exchange the ENBD tube, and the success rate, operation time, and complications were recorded. All patients successfully completed the operation in one go with an average mouth-nose exchange time of (44.67 ± 13.388) seconds (range 28-65). Two patients had mild adverse events, one of which was controllable bleeding caused by nasal mucosal injury with an estimated blood loss of 1 mL. The other patient had nausea during the operation, which improved after completion. The novel M-NED is an effective and safe method for exchanging the ENBD tube from the mouth to the nose with a high success rate and low incidence of complications. It is a device with potential clinical application value.

Endoscopic nasobiliary drainage tube placement through a periampullary perforation for management of intestinal leak and necrotizing pancreatitis.

Video 1Management of ampullary perforation by endoscopic nasobiliary drainage tube placement through the perforation for suctioning out leaked intestinal juice and indicating the presence of the hepatic portal vein.

Endoscopic nasobiliary drainage tube insertion for treatment of afferent loop obstruction in a pregnant woman after Kasai portoenterostomy

Afferent loop obstruction (ALO) is a rare complication of Kasai portoenterostomy (KPE) for biliary atresia. A 23-year-old Japanese woman who had undergone KPE with Roux-en-Y reconstruction for biliary atresia at age 42 days experienced intermittent abdominal pain during pregnancy. From computed tomography findings, she was diagnosed with ALO of the Roux-en-Y limb due to obstruction at the jejunojejunostomy. At 22 weeks of gestation, we inserted an endoscopic nasobiliary drainage (ENBD) tube into the dilated Roux-en-Y limb during double-balloon small-bowel endoscopy for treatment of the ALO. As no findings of jejunojejunostomy obstruction were evident during the endoscopy, we consider the obstruction was caused by flexion of the jejunojejunostomy associated with pregnancy. The ENBD tube afforded good drainage, and decompression of the Roux-en-Y limb was confirmed. We waited until 28 weeks of gestation to remove the ENBD tube, considering both the durability of ENBD tube and continued safety of the fetus. At 39 weeks of gestation, the patient delivered of a live baby boy (2,864 g) via vaginal delivery. ENBD tube insertion could be a minimally invasive option for treating ALO during pregnancy after KPE with Roux-en-Y reconstruction.

A Rare Complication of Barium Swallow Test

Question: A 70-year-old man with gastroenteropancreatic neuroendocrine tumor of the duodenum underwent robotic subtotal stomach-preserving pancreatoduodenectomy (PD). During the surgery, retrocolic reconstruction for pancreaticojejunostomy and hepaticojejunostomy, as well as antecolic reconstruction for gastrojejunostomy, were performed. Surgical anatomy following these reconstructions is illustrated in Figure A. The patient’s postoperative follow-up was uneventful. Six months later, the patient underwent a barium swallow test for a medical checkup at another hospital. The examination found no significant findings in the stomach, but revealed reflux of the barium sulfate into the intrahepatic biliary trees through the afferent loop (Figure B). After the barium swallow test on that day, the patient was referred to our hospital. He complained only of fever, but did not demonstrate other symptoms. The laboratory findings showed the following unremarkable changes: white blood cell, 6920/μL; total bilirubin, 0.89 mg/dL; direct bilirubin, 0.25 mg/dL; aspartate transaminase 23 U/L; alanine aminotransferase, 22 U/L; and C-reactive protein, 0.76 mg/dL. The abdominal computed tomography revealed retained barium sulfate in the bilateral biliary system (Figure C). What is the treatment strategy for this patient? Look on page 402 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. Retained barium sulfate in the biliary system may cause hepatolithiasis because of progressive water absorption, leading to complications such as obstructive jaundice, cholangitis, and sepsis.1Walsham A. Larsen J. Adverse effects of barium sulfate in the biliary tract.Diagn Interv Radiol. 2008; 14: 94-96PubMed Google Scholar Despite the absence of guidelines for the treatment of barium-induced choleliths, evidence-based guidelines for hepatolithiasis after biliary reconstruction propose peroral endoscopic treatment as the first-line option, or percutaneous transhepatic biliary drainage (PTBD) as an alternative.2Tazuma S. Unno M. Igarashi Y. et al.Evidence-based clinical practice guidelines for cholelithiasis 2016.J Gastroenterol. 2017; 52: 276-300Crossref PubMed Scopus (71) Google Scholar However, endoscopic approaches using a double-balloon endoscope (DBE) could be less invasive and have several advantages in bilateral drainage as well as in the accurate evaluation for residual choleliths with peroral direct cholangioscopy.3Ishihara Y. Matsumoto K. Kato H. et al.Treatment outcomes, including risk factors of stone recurrence, for hepatolithiasis using balloon-assisted endoscopy in patients with hepaticojejunostomy (with video).Surg Endosc. 2020; 34: 1895-1902Google Scholar Therefore, urgent endoscopic intervention was attempted in this case. In facilities where DBEs are not available, PTBD should be considered. Using DBE, saline was injected into the biliary trees via a catheter through the hepaticojejunostomy, and barium sulfate lodged at the main bile duct was washed out (Figure D). An endoscopic nasobiliary drainage tube was placed, and further irrigation was conducted for 3 days. After confirmation of duct clearance by a computed tomography scan, the patient was discharged. The reflux of orally administered barium sulfate into the intrahepatic biliary system is a rare but complicated adverse effect of a barium swallow test. To date, several conditions, including spontaneous or postoperative fistula and choledochoenterostomy, have been reported to be associated with reflux.1Walsham A. Larsen J. Adverse effects of barium sulfate in the biliary tract.Diagn Interv Radiol. 2008; 14: 94-96PubMed Google Scholar However, to our knowledge, this report is the first of barium sulfate reflux into the intrahepatic biliary trees in a patient undergoing PD. Urgent endoscopic intervention was safe and effective to prevent barium-induced biliary complications. In conclusion, the present case demonstrated a rare complication of barium sulfate in the biliary system following biliary reconstruction. It suggests that barium swallow test following PD should be contraindicated. Therefore, in similar patients experiencing this rare adverse effect, urgent intervention with DBE or PTBD should be performed to avoid complex biliary complications.

A case of hemobilia caused by pancreatic metastasis of renal cell carcinoma treated with a covered metallic stent

We present the case of an 86-year-old man who had undergone left nephrectomy for renal cell carcinoma (clear cell carcinoma) 22 years ago. He visited the emergency department complaining of right hypochondrial pain and fever. He was eventually diagnosed with acute cholangitis. Abdominal contrast-enhanced computed tomography showed multiple tumors in the pancreas. The tumor in the pancreatic head obstructed the distal bile duct. Endoscopic retrograde cholangiopancreatography detected bloody bile juice flowing from the papilla of Vater. Therefore, he was diagnosed with hemobilia. Cholangiography showed extrinsic compression of the distal bile duct; a 6 Fr endoscopic nasobiliary drainage tube was placed. Endoscopic ultrasound showed that the pancreas contained multiple well-defined hypoechoic masses. Endoscopic ultrasound-guided fine-needle aspiration was performed using a 22 G needle. Pathological examination revealed clear cell carcinoma, and the final diagnosis was pancreatic metastasis of renal cell carcinoma (RCC) causing hemobilia. A partially covered metallic stent was placed in the distal bile duct. Consequently, hemobilia and cholangitis were resolved.

Endoscopic pancreaticobiliary drainage with overlength stents to prevent delayed perforation after endoscopic papillectomy: A pilot study.

BACKGROUNDEndoscopic papillectomy (EP) is rapidly replacing traditional surgical resection and is a less invasive procedure for the treatment of duodenal papillary tumors in selected patients. With the expansion of indications, concerns regarding EP include not only technical difficulties, but also the risk of complications, especially delayed duodenal perforation. Delayed perforation after EP is a rare but fatal complication. Exposure of the artificial ulcer to bile and pancreatic juice is considered to be one of the causes of delayed perforation after EP. Draining bile and pancreatic juice away from the wound may help to prevent delayed perforation.AIMTo evaluate the feasibility and safety of placing overlength biliary and pancreatic stents after EP.METHODSThis is a single-center, retrospective study. Five patients with exposure or injury of the muscularis propria after EP were included. A 7-Fr overlength biliary stent and a 7-Fr overlength pancreatic stent, modified by an endoscopic nasobiliary drainage tube, were placed in the common bile duct and pancreatic duct, respectively, and the bile and pancreatic juice were drained to the proximal jejunum.RESULTSEP and overlength stents placement were technically feasible in all five patients (63 ± 12 years), with an average operative time of 63.0 ± 5.6 min. Of the five lesions (median size 20 mm, range 15-35 mm), four achieved en bloc excision and curative resection. The final histopathological diagnoses of the endoscopic specimen were one tubular adenoma with high-grade dysplasia (HGD), one tubulovillous adenoma with low-grade dysplasia, one hamartomatous polyp with HGD, one poorly differentiated adenocarcinoma and one atypical juvenile polyposis with tubulovillous adenoma, HGD and field cancerization invading the muscularis mucosae and submucosa. There were no stent-related complications, but one papillectomy-related complication (mild acute pancreatitis) occurred without any episodes of bleeding, perforation, cholangitis or late-onset duct stenosis.CONCLUSIONFor patients with exposure or injury of the muscularis propria after EP, the placement of overlength biliary and pancreatic stents is a feasible and useful technique to prevent delayed perforation.

New method for fixing an endoscopic nasobiliary drainage tube in the treatment of postoperative bile leakage

Watch a video of this article

Usefulness of half-covered metallic stent placement in preventing acute cholecystitis complication in pancreatic cancer-induced distal biliary stricture.

Background and AimA self‐expandable metallic stent (SEMS) is commonly used for biliary stricture caused by pancreatic cancer. Covered SEMS may obstruct the cystic duct, causing acute cholecystitis. This study aimed to determine the outcomes of using a half‐covered SEMS with an offset covered portion for preventing cystic duct obstruction.MethodsAmong 80 patients with half‐covered SEMS placement for the treatment of pancreatic cancer‐induced distal biliary stricture, 74 were followed up. The half‐covered SEMS has a total length of 6 or 7 cm, and the offset covered part was 0.5–4.5 or 0.5–5.5 cm, respectively. Intraductal ultrasonography (IDUS) and endoscopic nasobiliary drainage (ENBD) were performed during the initial endoscopic retrograde cholangiopancreatography (ERCP). IDUS findings and ENBD tube cholangiogram confirmed the cystic duct confluence. SEMS placement was performed on the second ERCP or several weeks after the initial tube stent placement.ResultsHalf‐covered SEMS placement was successful in all patients. However, four (5.4%) patients exhibited early complications, including acute cholecystitis in one patient and stent displacement in another. Over 30 days, cholangitis, tumor growth, and stent displacement occurred in nine (11.3%), five (6.3%), and two (2.5%) patients, respectively. The median stent patency was 71.1 weeks, and the median overall survival in patients with and without chemotherapy was 31.8 and 12.2 weeks, respectively.ConclusionsWith confirmation of the cystic duct confluence, half‐covered SEMS placement may become a treatment option for distal biliary stricture caused by pancreatic cancer to prevent acute cholecystitis. Half‐covered SEMS patency was comparable with that of covered SEMS.

The Value of Contrast-Enhanced Ultrasound-Guided Contrast Injection via the Endoscopic Nasobiliary Drainage Duct in Diagnosing Residual Common Bile Duct Stones.

Objectives To investigate the diagnostic value of contrast-enhanced ultrasound- (CEUS-) guided contrast injection via an endoscopic nasobiliary drainage (ENBD) tube on the evaluation for residual stones in common bile duct (CBD). Methods 116 patients with CBD stones were treated by endoscopic retrograde cholangiopancreatography and duodenoscopic sphincterotomy incision surgery and ENBD. The US group consisted of 54 patients who underwent US-guided saline injection via the ENBD tube to evaluate for residual CBD stones. The CEUS group consisted of 62 patients who underwent CEUS-guided contrast injection via the ENBD tube to evaluate for residual CBD stones. The length and width of CBD and the detection rate of residual stones before and after NS injection were compared. Results In both the US group and the CEUS group, the rate of complete demonstration and the average length and width of CBD before and after injection of NS were all increased significantly. In the US group, 6 patients had verified residual stones, 1 of which was detected by conventional US (detection rate, 1/6), 5 of which were detected by saline injection ultrasound (detection rate, 5/6), and 4 of which were detected by ENBD cholangiography (detection rate, 4/6). There was 1 false positive result on saline injection US and 2 false positives on ENBD cholangiography. In the CEUS group, 6 patients had verified residual stones, none of which were detected by conventional US (detection rate, 0/6), all of which were detected by saline injection CEUS (detection rate, 6/6), and 4 of which were detected by ENBD cholangiography (detection rate, 4/6). There was 1 false positive result on ENBD cholangiography. Conclusions CEUS-guided contrast injection via an ENBD tube helps to provide clear observation of residual stones in the CBD after ERCP with EST and provides comprehensive information for follow-up.

Incidence and risk factors for postoperative common bile duct stones in patients undergoing endoscopic extraction and subsequent cholecystectomy

In patients who undergo cholecystectomy after endoscopic common bile duct (CBD) stone extraction, CBD stones found postoperatively could be problematic. This study aimed to investigate the incidence and risk factors of postoperative CBD stones after cholecystectomy. A total of 278 patients (mean age, 59.2 years; 71 men [51.1%]) who underwent endoscopic removal of CBD stones followed by cholecystectomy from January 2013 to December 2017 were included. An endoscopic nasobiliary drainage (ENBD) tube was placed immediately after endoscopic clearance of the CBD stones in all patients until cholecystectomy. An ENBD tubogram was obtained in all patients to determine the presence of postoperative CBD stones. Postoperative CBD stones were detected in 20.1% (56/278). An ENBD tubogram was obtained after an average of 2.42 days postoperatively. Based on univariate analysis, the statistically significant risk factors for postoperative CBD stone were CBD stones >2, CBD stone size >10mm, cholesterol stone, maximum diameter of CBD >15mm, treatment with endoscopic sphincterotomy alone, and use of endoscopic mechanical lithotripsy (EML). In multivariate analysis, cholesterol stone, CBD stones >2, CBD stone size >10mm, and EML were related to postoperative CBD stones after cholecystectomy. Based on the relatively high rate of postoperative CBD stones after cholecystectomy, careful follow-up should be considered in patients with high-risk factors to detect CBD stones early.

Radiofrequency Ablation for Hepatocellular Carcinoma Adjacent to the Bile Duct Via Intraductal Cooling Through an Endoscopic Nasobiliary Drainage Tube

Radiofrequency Ablation for Hepatocellular Carcinoma Adjacent to the Bile Duct Via Intraductal Cooling Through an Endoscopic Nasobiliary Drainage Tube

Safety and efficacy of microwave ablation for periductal hepatocellular carcinoma with intraductal cooling of the central bile ducts through a percutaneous transhepatic cholangial drainage tube

Background and aimsBiliary thermal injury caused by microwave ablation (MWA) for a hepatocellular carcinoma (HCC) close to the central bile ducts always results in severe complications and leads to mortality. Some studies have demonstrated that intraductal cooling of the biliary tract with chilled saline during thermal ablation can successfully prevent these complications. In this study, we present a novel bile duct cooling technique through a percutaneous transhepatic cholangial drainage (PTCD) tube for preventing biliary thermal injury caused by MWA, and compare the feasibility and safety of the intraductal cooling technique when performed with a PTCD tube and with an endoscopic nasobiliary drainage (ENBD) tube. MethodsParticipants were randomly assigned to undergo MWA of HCC with intraductal chilled saline perfusion through a PTCD tube or an ENBD tube. The main study outcomes were bile duct complications related to MWA and local tumor recurrence. p value < 0.05 was considered to indicate a statistically significant difference. ResultsA total of 23 patients with an HCC (23 nodules) close to a central bile duct were enrolled in this study. Of these patients, 12 had a PTCD tube and 11 had an ENBD tube placed into the hepatic duct close to the lesions. There were no PTCD- and ENBD-related mortality cases. There was no complication related to the PTCD procedure; however, 3 patients (27.27%) developed acute pancreatitis and 1 patient (9.09%) had hemorrhage in the ENBD group (p = 0.037). One patient (8.33%) in the PTCD group had bile leakage and 2 patients (18.18%) in the ENBD group developed a biloma. Within 5 years, 1 patient in the PTCD group and 2 patients in the ENBD group had local recurrence. There was no significant difference in local recurrence, nonlocal hepatic recurrence, mortality rate, or median cumulative overall survival between the 2 groups. ConclusionsThe intraductal cooling technique using a PTCD tube is a feasible and effective method for preventing bile duct thermal injury caused by MWA for an HCC close to the central bile ducts. It does not increase local recurrence and may be safer than intraductal cooling through an ENBD tube.

Development of an external-to-internal convertible endoscopic biliary drainage device - a preliminary prospective feasibility study.

Background and study aims Endoscopic nasobiliary drainage (ENBD) for a malignant stricture in the bile duct has some advantages over endoscopic biliary stenting (EBS). However, ENBD may cause nasopharyngeal discomfort. We developed an external-to-internal convertible endoscopic biliary drainage (ETI-EBD) device that enables both internal and external drainage to occur during a single endoscopy. Patients and methods This device consists of three parts, comprising a 5-Fr ENBD tube (250 cm) (ENBD-t), an 8.5-Fr EBS tube (7 cm) (EBS-t), and an 8-Fr pusher tube for EBS (230 cm) (P-t). The EBS-t is mounted over the ENBD-t at the distal end of the ENBD-t. The P-t is also placed over the ENBD-t. After an endoscopic sphincterotomy, the EBS-t of the device is inserted into the papilla, then the duodenal endoscope is withdrawn, leaving the device in place. After ENBD, only the ENBD-t was withdrawn from the P-t. At this point, the EBS-t was isolated and left without endoscopy or radiography. Results ETI-EBD was successfully placed in all consecutive 21 patients (100 %). The release of EBS-t from ENBD-t wit was successfully completed in 19 patients (90.5 %). There were 4 patients with kink of P-t when exchanging this device from the mouth to the nose. It was difficult for 2 patients to withdraw the ENBD-t because of poor lubrication performance. There were no significant complications associated with the use of the device. Conclusion This device allows for both external and internal biliary drainage with a single endoscopy.

Conversion to endoscopic ultrasound-guided biliary drainage by temporary nasobiliary drainage placement in patients with prior biliary stenting

Background and Objectives:Endoscopic ultrasound-guided biliary drainage (EUS-BD), first reported as an alternative to percutaneous transhepatic BD in failed endoscopic retrograde cholangiography, is sometimes performed as reintervention for transpapillary stent dysfunction such as in patients with new onset gastric outlet obstruction, but direct conversion to EUS-BD can potentially have a risk of leakage of infected bile. The aim of this study is to evaluate the safety and efficacy of conversion to EUS-BD using a temporary endoscopic nasobiliary drainage (ENBD) tube placement as a reintervention for prior BD.Patients and Methods:Sixteen patients with prior BD for malignant biliary obstruction undergoing conversion to EUS-BD using a temporary ENBD tube placement were studied. Technical and clinical success rate and adverse events were evaluated.Results:The major reason for conversion to EUS-BD was recurrent cholangitis due to duodenobiliary reflux (n = 13). In 14 patients with an indwelling covered metal or plastic stent, the stents were removed before temporary ENBD placement. After a median duration of 6 days, subsequent conversion to EUS-BD using a covered metal stent was performed, which was technically and clinically successful in all 16 patients (14 hepaticogastrostomy and 2 choledochoduodenostomy). Adverse events were observed in 3 patients (19%): one bleeding, one cholecystitis, and one cholangitis. No bile leak, peritonitis, or sepsis was observed.Conclusions:Conversion to EUS-BD using temporary ENBD tube placement in patients with prior BD was technically feasible and relatively safe without infectious complications related to bile leakage.

A rare case of gangrene of cystic duct due to the insertion of endoscopic nasobiliary drainage (ENBD) tube into the cystic duct by mistake

This is the first case report of Gangrenous cholecystitis due to the insertion of endoscopic nasobiliary drainage (ENBD) tube into the cystic duct by mistake,The reason why it happened may be related to Inflammation and hypoimmunity.

Endoscopic Hands-Off Technique versus Conventional Technique for Conversion from an Orobiliary to a Nasobiliary Tube.

Background. The aim of this study was to compare the outcomes of the endoscopic hands-off technique and the conventional technique when repositioning an endoscopic nasobiliary drainage (ENBD) tube from the mouth to the nose. Methods. We conducted a retrospective cohort study of all endoscopic retrograde cholangiopancreatographies (ERCPs) performed between July 2013 and May 2015 at a single tertiary referral center. A total of 1187 ERCPs were performed during the study period. Among them, 114 patients who underwent ENBD were enrolled in this study. In those patients, we used the endoscopic hands-off technique between July 2013 and May 2014 (endoscopy group) and the conventional technique between June 2014 and May 2015 (conventional group). Results. Technical success was achieved in 100% (58/58) of the endoscopy group and 94.6% (53/56) of the conventional group (P = 0.115). In the 3 cases of failed conventional technique, the endoscopic hands-off technique was then performed, and conversion of the ENBD tube was successful in all of these patients. The procedure time was significantly shorter in the endoscopy group than in the conventional group (124 s versus 149 s, P = 0.001). Conclusion. The endoscopic hands-off technique was feasible and effective for oral-nasal conversion of an ENBD tube.

Bile Duct Drainage Using a Short Double-Balloon Endoscope for a Hematoma due to Hepatocellular Carcinoma After Roux-en-Y Reconstruction

An 84-year-old male status post Roux-en-Y anastomosis and cirrhosis presented with fever and jaundice. Double-balloon endoscopy showed bleeding from the papilla of Vater and endoscopic retrograde cholangiopancreatography was performed. Cholangiography revealed an intraductal filling defect due to blood clots probably caused by bleeding from the hepatocellular carcinoma. Placement of an endoscopic nasobiliary drainage tube relieved the jaundice and cholangitis. Subsequent transarterial chemoembolization for hepatocellular carcinoma was performed to control the bleeding. After removal of the tube, he was discharged. The patient developed obstructive jaundice caused by a hepatocellular carcinoma. A short double-balloon endoscope with a 2.8 mm working channel enabled metal stent placement. Double-balloon ERCP enabled biliary drainage in a patient with surgically altered anatomy and cirrhosis, and provided effective relief of symptoms.

総胆管カニュレーションに難渋した胆囊管低位合流の1例

An 81-year-old man was admitted to our hospital complaining of abdominal pain. Upon admission, blood analysis showed elevated levels of serum bilirubin and hepatobiliary enzymes, together with an elevated inflammatory reaction. Acute cholangitis due to a common bile duct stone was diagnosed on the basis of imaging results. Endoscopic retrograde cholangiopancreatography was performed to drain the bile duct. Cannulation of the common bile duct was attempted, but insertion of the guide wire proved difficult. An abnormality of the cystic duct junction─where the cystic duct joined the lower bile duct─was suspected on the basis of abdominal computed tomography findings. Cannulation was eventually successful, and an endoscopic nasobiliary drainage (ENBD) tube was placed. The common bile duct stone was removed the following day. Cholangiography through the ENBD tube and magnetic resonance cholangiopancreatography revealed that the cystic duct revolved around the posterior wall of the common bile duct, and that an abnormally low junction existed between the cystic duct and the left-hand side of the common bile duct at the head of the pancreas. The patient elected not to undergo cholecystectomy due to his advanced age, and he was discharged from hospital on day ten. This case demonstrated that it is important to assess the bile duct’s course using imaging studies before initiating treatment.