Parasites and Biliary stones

Endoscopic retrograde cholangiopancreatography ١١١
clockwise rotation of the shaft of the endoscope while its tip is deflected
upwards, so that the descending duodenum is entered, and advancing the
tip of the endoscope downward which is better achieved paraodoxically
by withdrawing the endoscope (Mani et al., 1996).
Sometime, it is difficult to achieve the “straight scope position” and
in this condition the papilla is reached by advancing the shaft of the
endoscope while the patient is in supine position using the “long loop
technique”. However, it is unpleasant to the patient, and the fine
movements of the tip are transmitted less effective as the control wire for
tip deflection and catheter elevation are stretched. However, long loop
route may sometimes be the only method of getting (face on) to the
papilla, which is high up under the superior duodenal angle (Whitehouse,
1996).
Location and cannulation of the papilla:
Biliary cannulation:
The use of pancreatic techniques is a newer approach to improve
safety and success at biliary access.Techniques include placement of a
pancreatic guidewire, or a cannula, to aid cannulation, and/or placement
of a pancreatic stent to reduce the risk of pancreatitis. Placement of a
guidewire deep into the main pancreatic duct may facilitate cannulation
of the bile duct (figure 19) with a second device beside the pancreatic
wire. The pancreatic wire serves a number of functions, including to open
a stenotic papillary orifice, to stabilize the papilla, to lift it toward the
working channel, to straighten the pancreatic duct and the common
channel, to drain the pancreatic duct, potentially to minimize repeated
injections into the pancreatic duct, and to allow access for placement of a
pancreatic stent if felt necessary (Dumoncea et al., 1998).