Korean J Gastroenterol.  2021 May;77(5):253-257. 10.4166/kjg.2021.030.

Cannulation of the Portal Vein during Endoscopic Retrograde Cholangiopancreatography in a Patient with Choledocholithiasis

• Lee WD
• Song JS
• Kim BS
• Yang MA
• Lee YJ
• Jung GM
• Cho YK
• Cho JW
• Kim JW

• KMID: 2516043
• DOI: http://doi.org/10.4166/kjg.2021.030

Abstract

Cannulation of the portal vein is a rare complication of ERCP. This paper reports a case of portal vein catheterization during ERCP in a patient with choledocholithiasis. A 62-year-old man was admitted to the Presbyterian Medical Center with right upper quadrant pain and jaundice. ERCP was performed under the suspicion of obstructive jaundice caused by a radiolucent stone. Bile duct cannulation using a pull-type papillotome was attempted, but it failed. After needle-knife fistulotomy, wire-guided cannulation was performed successfully, and 10 mL contrast was injected. On the other hand, the fluoroscopy image showed that the contrast medium disappeared very quickly. Pure blood was collected when the catheter was aspirated to identify the bile reflux, indicating possible cannulation of the portal vein. The procedure was terminated immediately and abdominal computed tomography showed air in the portal vein. One day after, a follow-up CT scan showed no air in the portal vein. The patient underwent repeated ERCP, and the common bile duct was cannulated. In most cases, isolated portal vein cannulation does not result in severe morbidity. However, it is important to aware of this rare complication so that no further invasive procedure is performed on the patient.

Keyword

Cholangiopancreatography; endoscopic retrograde; Portal vein; Catheterization; Choledocholithiasis

Figure

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  Fig. 1 (A) Endoscopic image showing papillary orifice covered by hooding fold. (B) Endoscopic image of major papilla before needle-knife fistulotomy. There was no damage or deformation of the papilla while trying to cannulate the bile duct. (C) Endoscopic image of major papilla after needle-knife fistulotomy. Using a needle-knife, an incision was started at the most protruding part of the infundibulum, and an incision was made about 3mm in the direction of the papillary orifice.

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  Fig. 2 After wire-guided cannulation, we injected 10 mL contrast through the papillotome but the fluoroscopy image showed that the contrast medium disappeared very quickly.

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  Fig. 3 Aspiration was performed in order to identify the bile reflux, but pure blood was collected indicating possible cannulation of the portal vein.

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  Fig. 4 (A) Abdominal computed tomography (CT) scan obtained immediately after endoscopic retrograde cholangiopancreatography showed air in the portal vein. (B) One day after, follow up CT scan presented no air in the portal vein.

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  Fig. 5 (A) Endoscopic image showing the pus was oozing from the site where the fistulotomy was performed. (B) Guide wire was inserted into the opening where the pus was drained, and then a papillotome was advanced over the guide wire.

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