An unusual cause of acute obstructive suppurative cholangitis

Kohei Iribe; Koji Sawada; Koji Kubo; Mikihiro Fujiya

doi:10.5946/ce.2025.108

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Boost Your Learning with Quiz An unusual cause of acute obstructive suppurative cholangitis: Kohei Iribe¹, Koji Sawada², Koji Kubo¹, Mikihiro Fujiya²; Clinical Endoscopy 2025;58(4):628-629.
DOI: https://doi.org/10.5946/ce.2025.108
Published online: July 2, 2025

¹Department of Internal Medicine, Municipal Nakashibetsu Hospital, Nakashibetsu, Japan

²Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, Asahikawa, Japan

Correspondence: Koji Sawada Division of Gastroenterology, Department of Internal Medicine, Asahikawa Medical University, 2-1 Midorigaoka-higashi, Asahikawa, Hokkaido 078-8510, Japan E-mail: k-sawada@asahikawa-med.ac.jp

• Received: April 6, 2025 • Revised: April 26, 2025 • Accepted: April 27, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Quiz

A 74-year-old man with a history of partial hepatectomy and cholecystectomy due to hepatic echinococcosis presented with sudden-onset epigastric pain, nausea, and vomiting. Physical examination indicated tenderness in the epigastria and jaundice, and the results of blood tests were as follows: white blood cell count, 16,860/mm³; aspartate aminotransferase, 1,410 U/L; alanine aminotransferase, 532 U/L; alkaline phosphatase, 185 U/L; gamma-glutamyl peptidase, 514 U/L; total bilirubin 2.6 mg/dL, and direct bilirubin 1.2 mg/dL. Computed tomography (CT) imaging revealed dilation of both the common and intrahepatic bile ducts. Magnetic resonance cholangiopancreatography imaging revealed unusual dilatation of the common bile duct (Fig. 1A). These findings suggested acute obstructive suppurative cholangitis (AOSC). Subsequently, endoscopic retrograde cholangiopancreatography (ERCP) was performed for biliary drainage. Although CT imaging revealed a small periampullary diverticulum (PAD) three years before (Fig. 1B), endoscopic findings did not confirm its presence (Fig. 1C), and it was difficult to insert a cannulation catheter into the common bile duct.

What is the most likely diagnosis?

Answer

Based on the findings from the endoscopic and previous CT images, we speculated that the oral protrusion of the papilla of Vater was completely incarcerated within the small PAD.

ERCP was performed for biliary drainage; however, the guidewire formed a loop in the bile duct, complicating catheter insertion. To resolve the incarceration, we carefully advanced the cannulation catheter using a wire-guided technique (Fig. 2A). Subsequently, pulling the catheter into the duodenal lumen at a downward angle partially corrected the oral protrusion from the PAD. However, this method alone was insufficient (Fig. 2B). Although traction device-associated techniques¹ and biopsy forceps technique² were considered for correcting the incarceration, these methods are difficult to implement effectively because of the narrow opening of the PAD and complete incarceration. Therefore, a sphincterotome (CleverCut3V; Olympus) was used to reposition the incarcerated papillae. After fully extending the wire to flex the tip of the sphincterotome within the oral protrusion of the papilla of Vater, we pulled out the sphincterotome by hooking its tip inside the papilla of Vater, successfully repositioning the incarceration of the large oral protrusion (Fig. 2C, D) and facilitating the deep insertion of the cannulation catheter (Fig. 2E). Subsequently, temporary biliary stenting was performed after endoscopic sphincterotomy, which contributed to improvement in the AOSC. During the 15-month follow-up period, there was no recurrence of cholangitis.

The usefulness of traction device-associated techniques¹ and the biopsy forceps technique for correcting the intradiverticular papilla has been reported.² To our knowledge, this is the first case of complete oral protrusion incarceration in PAD successfully corrected using the sphincterotome. This procedure is simple and effective for resolving incarceration.

Conflicts of Interest

The authors have no potential conflicts of interest.

Funding

None.

Acknowledgments

Written informed consent was obtained from the patient to publish these images.

Author Contributions

Conceptualization: all authors; Writing–original draft: KI, KS; Writing–review & editing: KK, MF.

Fig. 1.

(A) Magnetic resonance cholangiopancreatography imaging revealed an uncommon dilated common bile duct. (B) Computed tomography imaging three years before indicated the presence of a small periampullary diverticulum (arrow). (C) Endoscopic findings did not confirm the presence of the periampullary diverticulum.

Fig. 2.

(A) Endoscopic retrograde cholangiopancreatography revealed the guidewire forming a loop in the bile duct. (B) After the cannulation catheter was pulled into the duodenal lumen at the endoscopic downward angle, the oral protrusion of the papilla of Vater was partially extruded from the periampullary diverticulum (PAD). (C) Endoscopic findings indicated the successful correction of the incarceration of the large oral protrusion of the papilla of Vater within the PAD by using the sphincterotome. (D) Endoscopic findings revealed the presence of PAD (arrow). (E) Following the correction of the papillary incarceration, biliary tract cannulation became feasible.

REFERENCES

1. Ishii T, Kin T, Katanuma A. Successful intervention using multiloop traction for cases with difficult biliary cannulation due to periampullary diverticula. Dig Endosc 2021;33:e111–e113.Article PubMed PDF
2. Takenaka M, Minaga K, Kudo M. Cannulation method for intradiverticular papilla with long oral protrusion using biopsy forceps for axis alignment. Dig Endosc 2018;30:700–701.Article PubMed PDF

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An unusual cause of acute obstructive suppurative cholangitis

Clin Endosc. 2025;58(4):628-629. Published online July 2, 2025

DOI: https://doi.org/10.5946/ce.2025.108

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Figure

An unusual cause of acute obstructive suppurative cholangitis

Fig. 1. (A) Magnetic resonance cholangiopancreatography imaging revealed an uncommon dilated common bile duct. (B) Computed tomography imaging three years before indicated the presence of a small periampullary diverticulum (arrow). (C) Endoscopic findings did not confirm the presence of the periampullary diverticulum.

Fig. 2. (A) Endoscopic retrograde cholangiopancreatography revealed the guidewire forming a loop in the bile duct. (B) After the cannulation catheter was pulled into the duodenal lumen at the endoscopic downward angle, the oral protrusion of the papilla of Vater was partially extruded from the periampullary diverticulum (PAD). (C) Endoscopic findings indicated the successful correction of the incarceration of the large oral protrusion of the papilla of Vater within the PAD by using the sphincterotome. (D) Endoscopic findings revealed the presence of PAD (arrow). (E) Following the correction of the papillary incarceration, biliary tract cannulation became feasible.

Fig. 1.

Fig. 2.

An unusual cause of acute obstructive suppurative cholangitis