Parasites and Biliary stones

Endoscopic retrograde cholangiopancreatography ١٢٥
Unsuccessful extraction: Failure to extract stones successfully after
sphincterotomy most commonly occurs because the stones are too large.
Stones greater than 15 mm in diameter are usually defined as large, and
attempts to remove them with a standard basket can result in basket
impaction (Tompkins, 1997). Alternatively, the stones may not be
excessively large, but the intrapancreatic portion of the bile duct may not
be dilated sufficiently to allow passage of the stone (Sherman and
Lehman, 1999).
Grading for the difficulty of ERCP procedures:
Schutz and Abbott (2000) presented a grading system for the
degree of difficulty of ERCP (table 4).
Grade Biliary procedures Pancreatic procedure
Grade 1 Standard cholangiogram Standard pancreatogram
Grade 2
Grade 3
Grade 4
Grade 5
Biliary sphincterotomy
Removal of 1-2 small stones
Nasobiliary drain placement
Cholangiogram in Billroth II
Biliary cytology
Pancreatic cytology
Multiple or large stones
Stricture dilation
Common duct stenting
Precut sphincterotomy
Lithotripsy
Intrahepatic therapy
in Billroth II anatomy
Cholangioscopy
Pancreatogram in Billorth
type II
Minor papilla cannulation
All pancreatic therapy
Pancreatoscopy
Table (4): Grading for the difficulty of ERCP procedures (Schutz and
Abbott, 2000)