PMC8286368_01
(A) ERCP illustration of a diffusely dilated common bile duct up to 20 mm with a concentric indeterminate stricture at the hilum after papillotomy and extraction of some bile duct stones. (B) Extensive drainage of sludge and debris after endoscopic papillary large-balloon dilation up to 12 mm. (C) Direct cholangioscopic visualization of a concentric impression with a smooth mucosal surface in the proximal bile duct. (D) Fluoroscopic correlation corresponding to (C) with the tip of the ultra-slim upper endoscope in the middle-to-high common bile duct (note air cholangiogram)
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F1
A 69-year-old patient presented with signs of cholangitis and underwent urgent endoscopic retrograde cholangiopancreatography (ERCP), revealing stone material in a diffusely dilated common bile duct with an indeterminate proximal bile duct stricture, although the intrahepatic ducts appeared not to be significantly dilated (Fig. 1A). Of note, extensive amounts of sludge and debris spontaneously drained after EPLBD up to 12 mm, potentially contributing to the initial cholangiographic presentation after upward mobilization during contrast injection (Fig. 1B). High-quality DC revealed unremarkable mucosal findings with a linear semi-concentric constriction with well reproducible arterial pulsation, highly suggestive of an overriding right hepatic artery (RHA) (Fig. 1C).