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CPC sample question # 7


Procedure: ERCP with sphincterotomy and removal of common duct stone

Indication for Procedure: The patient is a 62-year-old women with documented obstructing common duct stone. She is status post T-tube insertion for creation of a biliary drainage tract. She now present for sphincterotomy and stone removal.

Description of Procedure: The patient was brough to the endoscopy suite and sedated with IV Versed and Fentanyl. After the pharynx was anesthetized with Xylocaine spray, a guidewire and snare were advenced through the external biliary drain site into the duodenum.

Next the side-viewing duodenoscope was inserted per os and advanced into the esophagus, stomach, and duodenum. Esophageal, gastric, and duodenal mucosa were all noted to be unremarkble. The scope was positioned in place and a guidewire was grasped by the external snare and pulled up into the bile duct and out through the skin.

The sphincterotome was then advanced over the guidewire up into the bile duct and positioned across the papilla of Vater. The papilla was noted to be lying in the base of a large duodenal diverticulum. The sphincterotomy was then performed to a total of 1.0 cm. There was a moderate amount of bleeding that resolved spontaneously. Estimated blood loss was less than 25 cc. Next a 1.1 mm. balloon was advanced over a guidewire up into the bile duct and pulled out clearing the duct of all gravel and small stone material.

Before concluding the procedure, a follow-up cholangiogram was performed and revealed no further evidence of stones within the duct. Ther was free flow of contrast out to the T-tube site, revealing a well-established drainage tract. A mild stricture of the right hepatic duct was observed, but no residual stones were seen. During the procedure the pancreatic duct was also visualized and appeared to be patent and of normal caliber. It is anticipated that excellent drainage has been established. The procedure was thus terminated and all instruments were withdrawn. The patient tolerated the procedure well. She will be discharged after recovery from sedation.

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