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A 91-year-old woman was admitted for cholangitis secondary to common bile duct (CBD) stones. She had previously undergone an unsuccessful ERCP because of a prominent Kerckring's fold in the duodenum covering the major papilla.
During this hospitalization, ERCP was attempted again. The major papilla was completely hooded under a duodenal fold, with only the frenulum visible. A sphincterotome was used to evert the fold, exposing the papilla (Fig. 1). However, once it was removed, the fold would slip back. Clipping the fold superiorly was unsuccessful. Instead of tackling the fold, a pediatric biopsy forceps (Maxum reusable Forceps; Wilson-Cook Medical Inc., Winston-Salem, NC) was used to grab the frenulum of the papilla and pull it inferiorly. This enabled the papillary orifice to be exposed. A sphincterotome was inserted beside the forceps for cannulation. The initial guidewire cannulation was into the pancreatic duct, and a 5F 4-cm single pigtail stent was inserted. Next, biliary cannulation was performed over the pancreatic stent (Figure 2, Figure 3). After biliary sphincterotomy, the stones were partially cleared with a mechanical lithotripter, and a CBD stent was inserted.
Figure 1A, Initial endoscopic view of the concealed major papilla beside a small duodenal diverticulum. B, Manipulation of the mucosa with the sphincterotome reveals only the frenulum. C, Major papilla revealed after the duodenal fold has been lifted.
Figure 2A, Cannulation of the pancreatic duct with a sphincterotome while forceps are used to apply traction inferiorly. B, Biliary cannulation over the pancreatic stent with forceps maintaining traction to keep the papilla visible. C, Major papilla after biliary sphincterotomy.
Figure 3A, Fluoroscopic image showing successful biliary guidewire cannulation over the pancreatic stent while the forceps is anchoring the papilla. B, Cholangiogram showing multiple large common bile duct stones.
The presence of a redundant Kerckring's fold is a known cause of a failed ERCP. Endoscopic strategies include everting the fold with a sphincterotome or a clip, approaching the papilla from an inferior angle in a long-loop position, and performing EUS-guided rendezvous ERCP.
This is the first report to illustrate that forceps can also be used to expose a papilla hooded under a duodenal fold. However, engagement is challenging because movements of the duodenoscope would alter the angle of the pulled papilla. With minor adjustments, cannulation can be achieved. In conclusion, when a hooded major papilla is encountered at ERCP, traction of the papilla by the use of forceps may be useful.
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