ERCP, sphincterotomy, and balloon sweep

PROCEDURES PERFORMED:  ERCP, sphincterotomy, and balloon sweep.

INDICATION:  High liver enzymes with gallstones and central abdominal pain, possible common bile duct stones.

POSTPROCEDURE DIAGNOSES:

1.  Patent cystic duct.

2.  Bile duct evaluated with small sphincterotomy and balloon sweeping.  No obvious stones emerging.  Initial small filling defects noted; however, without materializing stone.

MEDICATIONS:  Per anesthesia with intubation.

PROCEDURE IN DETAIL:  The risks of perforation, bleeding, infection, sedation, pancreatitis, the consequences of gallstones, and possible common bile duct stones including pancreatitis reviewed and informed consent obtained.  Once intubated in the prone position, the duodenoscope easily advanced in second portion of the duodenum where the major ampulla was identified.  This appeared endoscopically normal.  Small slivers of bile noted coming out.  The Hydratome was placed direct in the 11 o'clock position.  Gentle wire protrusion resulted in pancreatic cannulation.  The wire was then removed, catheter manipulated, and again pancreatic cannulation was noted.  There was no injections undertaken.  The catheter was then manipulated more to the left of the 11 o'clock position, which allowed wire-guided common bile duct cannulation.  Careful cholangiogram was obtained, initially it was not clear with the filling defect in the distal ducts.  Further images were attempted to be obtained to identify this.  The cystic duct filled.  Caution was taken not to overfill the gallbladder.  The intrahepatic ducts appeared normal.  Decided to do small sphincterotomy, which was undertaken without complications.  A small balloon 9 through 12 was then inflated to fill the caliber of the proximal ducts and gently sweep out with filling defects identified with these that appeared to be bubbles.  Subsequent repeat _____ cholangiogram appeared to be negative and there were no stones visualized in the duodenum at the completion of the procedure.  The patient appeared to tolerate this well.  She will be observed, placed on liquids if stable and there is no increasing symptoms.  She has received a dose of Levaquin today.  She will probably be observed overnight with consideration given to cholecystectomy in the a.m.  If she is symptom free and elects to be discharged, she should have subsequent elective cholecystectomy.