case_images: PMC10965233_01
case_images: CT images on admission. a Coronal view. b Axial view. a A calcified stone (arrow) measuring 6 mm is observed in the papilla of Vater. Dilation of the common bile duct is observed (arrowhead). b Diffuse swelling of the pancreas and peripancreatic inflammation are observed. No dilation of the MPD is observed.
case_images: crg-2024-0018-0001-538009_F01.jpg
case_images: PMC10965233_01_crg-2024-0018-0001-538009_F01.jpg
case_images: F1
case_images: A CT scan revealed a stone measuring 6 mm in the papilla of Vater, dilation of the common bile duct, the disappearance of the stone from the gallbladder, acute pancreatitis, and absence of chronic pancreatitis and MPD dilation (Fig. 1).
case_images: Endoscopic and fluoroscopic images obtained during the first ERCP. a An endoscopic image showing the swollen and reddish papilla of Vater. The edge of the stone is visible (arrow). b A fluoroscopic image obtained during biliary cannulation. A calcified stone (arrow) measuring 5 mm is observed in the papilla of Vater. c A cholangiogram showing no filling defects. A calcified stone (arrow) measuring 5 mm is observed in the MPD. d An endoscopic image showing the papilla of Vater after biliary cannulation. The guidewire inserted into the bile duct is observed, and the edge of the stone is invisible. e An endoscopic image showing a well-opened biliary orifice in the papilla after an endoscopic sphincterotomy.
case_images: crg-2024-0018-0001-538009_F02.jpg
case_images: PMC10965233_01_crg-2024-0018-0001-538009_F02.jpg
case_images: F2
case_images: At ERCP, the papilla was swollen and red owing to CBDS impaction at the orifice of the papilla (Fig. 2a, b). Although the edge of the CBDS was endoscopically invisible in the papilla after biliary cannulation, cholangiography revealed no filling defects in the bile duct (Fig. 2c, d). A retrospective comparison of the fluoroscopic images before and after cannulation revealed that a calcified stone measuring 5 mm had moved into the MPD from the papilla of Vater (Fig. 2b, c).
case_images: Contrast-enhanced CT images obtained in the evening on post-admission day 1. a Coronal view. b Axial view. a A calcified stone (arrow) measuring 6 mm is observed in the MPD with upstream dilation (white arrowhead). No dilation of the common bile duct is observed (black arrowhead). b Diffuse swelling of the pancreas and peripancreatic inflammation are observed.
case_images: crg-2024-0018-0001-538009_F03.jpg
case_images: PMC10965233_01_crg-2024-0018-0001-538009_F03.jpg
case_images: F3
case_images: The CT scan revealed a stone measuring 6 mm in the MPD with upstream dilation, no dilation of the bile duct, and evidence of deterioration of pancreatitis compared with the findings of the previous day (Fig. 3).
case_images: Endoscopic and fluoroscopic images obtained during the second ERCP 2 days after the first procedure. a An endoscopic image showing the papilla of Vater. Stones were not visible in the papilla of Vater. The biliary orifice is opened. b A cholangiogram showing no filling defect. c A pancreatogram showing a filling defect measuring 5 mm (arrow). d A fluoroscopic image after successful pancreatic stent placement (arrow). e An endoscopic image showing the pancreatic stent.
case_images: crg-2024-0018-0001-538009_F04.jpg
case_images: PMC10965233_01_crg-2024-0018-0001-538009_F04.jpg
case_images: F4
case_images: Pancreatography revealed a stone measuring 5 mm in the MPD, whereas cholangiography showed no filling defects in the bile duct (Fig. 4b, c). Pancreatic sphincterotomy was performed, followed by the placement of a pancreatic stent with an internal flap (Geenen, 5 Frx7 cm; Cook Medical Japan, Tokyo, Japan) to relieve the MPD obstruction (Fig. 4d, e).