Optimizing Cholangiography When Performing Endoscopic Retrograde Cholangiopancreatography  Timothy B. Gardner, Todd H. Baron  Clinical Gastroenterology and Hepatology  Volume 6, Issue 7, Pages 734-740 (July 2008) DOI: 10.1016/j.cgh.2008.04.015 Copyright © 2008 AGA Institute Terms and Conditions

Figure 1 (A) Schematic representation of the biliary system, emphasizing pertinent anatomy. (B) Normal cholangiogram. The intrahepatics are well-filled, small in caliber, and regular. Clinical Gastroenterology and Hepatology 2008 6, 734-740DOI: (10.1016/j.cgh.2008.04.015) Copyright © 2008 AGA Institute Terms and Conditions

Figure 2 (A) Scout radiograph taken before cholangiography. Note rib calcifications (arrows). (B) After injection of contrast. The rib calcifications are again seen and could have been misinterpreted as part of the cholangiogram. Clinical Gastroenterology and Hepatology 2008 6, 734-740DOI: (10.1016/j.cgh.2008.04.015) Copyright © 2008 AGA Institute Terms and Conditions

Figure 3 (A) Hilar cholangiocarcinoma. The bifurcation strictures are not well-visualized with the C-arm in the direct anterior-posterior direction. (B) After rotation, the bifurcation strictures are defined (arrows). Clinical Gastroenterology and Hepatology 2008 6, 734-740DOI: (10.1016/j.cgh.2008.04.015) Copyright © 2008 AGA Institute Terms and Conditions

Figure 4 (A) Early injection with a sphincterotome shows limited intrahepatic filling, with contrast preferentially entering the cystic duct. In this patient with a liver biopsy suggestive of primary sclerosing cholangitis (PSC), the intrahepatics are not adequately filled. (B) After inflation of an occlusion balloon above the level of the cystic duct and below the bifurcation, the intrahepatics are filled adequately to exclude large duct PSC. Clinical Gastroenterology and Hepatology 2008 6, 734-740DOI: (10.1016/j.cgh.2008.04.015) Copyright © 2008 AGA Institute Terms and Conditions

Figure 5 (A) Cholangiogram obtained several days after open cholecystectomy for persistent abnormal liver enzymes and suspicion of choledocholithiasis. (B) After advancing the endoscope into the long position, a stricture is identified (arrow). Tissue sampling showed carcinoma. Clinical Gastroenterology and Hepatology 2008 6, 734-740DOI: (10.1016/j.cgh.2008.04.015) Copyright © 2008 AGA Institute Terms and Conditions

Figure 6 (A) Filling of the intrahepatic system, with the catheter near the bifurcation. A leak is not seen. (B) With the catheter advanced more peripherally into the right system, a leak is identified adjacent to the catheter (arrow). Clinical Gastroenterology and Hepatology 2008 6, 734-740DOI: (10.1016/j.cgh.2008.04.015) Copyright © 2008 AGA Institute Terms and Conditions

Figure 7 (A) Scout radiograph before cholangiography shows extensive pneumobilia (arrows) in a patient with prior pancreaticoduodenectomy and intermittent cholangitis. (B) An occlusion balloon is seen inflated below the bifurcation. As much air as possible was evacuated before contrast injection. Minimal residual air is present on filling the intrahepatic system. Clinical Gastroenterology and Hepatology 2008 6, 734-740DOI: (10.1016/j.cgh.2008.04.015) Copyright © 2008 AGA Institute Terms and Conditions

Figure 8 (A) Large liver mass (M) caused by metastatic, unresectable rectal cancer. Note bilateral intrahepatic ductal dilation (arrows). (B) Minimal to no contrast was injected until the wire and catheter had passed into the right intrahepatic system. (C) Additional contrast was injected through the inner guiding catheter of the stent delivery system just before final deployment. No contrast is seen in the left system. Cholangitis did not occur, and excellent palliation of jaundice was achieved. Clinical Gastroenterology and Hepatology 2008 6, 734-740DOI: (10.1016/j.cgh.2008.04.015) Copyright © 2008 AGA Institute Terms and Conditions

Figure 9 After sampling a subtotal stricture at the bifurcation, contrast was injected into an area where excessive length of guidewire was noted, demonstrating extravasation (arrow). A biliary stent was placed and prevented clinical manifestations of a bile leak. Clinical Gastroenterology and Hepatology 2008 6, 734-740DOI: (10.1016/j.cgh.2008.04.015) Copyright © 2008 AGA Institute Terms and Conditions