Case 2

A 85 year old female patient arrives in the emergency department with an elevated temperature. Urinanalysis reveals an urinary tract infection. The patient is hospitalized and after a week of antibiotics has persistently elevated inflammatory parameters.  Laboratory tests at initial presentation showed discretely elevated GGT and AP. 

EUS confirms the suspicion of  choledocholithiasis. Two gallstones (yellow) can be visualized in the common bile duct (green). Also note the acoustic shadowing caused by the gallstones (blue).

To fully examine the common bile duct in its entirety, the endoscope is slowly retracted. The EUS-Image will move in a counterclockwise fashion (i.e. left to right). Rotating the shaft of the scope left and right will help visualize all areas.  Here we should see the common bile duct (green) run parallel to the portal vene (blue). Usually the hepatic artery can also be seen. Since the artery typically has a winding path, its presentation varies from circular ("o") to linear ("===").

TIP: use the Duplex/color Doppler Mode to differentiate between bile duct (no sign), portal vene and artery (pulsating).

The diameter of the common bile duct is normally <7mm (after cholecystectomy ≤10mm). 

Inspection of the body and tail of the pancreas is possible trans-gastrically. The pancreatic parenchyma (blue) lies "on top" of the splenic vene (see "Learn Endosono" to learn more about anatomical landmarks). The unremarkable pancreatic duct (i.e. duct of Wirsung) is nicely depicted in the image above (yellow). 

How does a pathological pancreatic duct look like? 

What happened next?

Three gallstones were extracted in the endoscopic retrograde cholangiopancreatography (ERCP). A plastic stent was placed with the intention of removing it in 3-6 weeks. The antibiotic regime was altered due to the likelihood of cholangitis.  

Video of the procedure

coming soon....