Post written by Rishad Khan, MD, from the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, Thomas M. Runge, MD, MPH, from the Division of Gastroenterology, Central Ohio VA, Columbus, Ohio, and Samuel Han, MD, MS, the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.

A 45-year-old patient with cholecystitis and choledocholithiasis with a prohibitively high surgical risk had a failed ERCP at an outside hospital. He underwent EUS-guided transduodenal gallbladder drainage with a lumen-apposing metal stent and was then referred for another attempt at ERCP.

On initial views, he had no clear papillary orifice, but purulent fluid was emanating from a spot in the descending duodenum. Attempts to cannulate this area were unsuccessful. We then attempted to perform a rendezvous through the gallbladder via the recently placed transduodenal gallbladder stent but found a completely obstructed cystic duct.

We thus proceeded with EUS-guided rendezvous. A 19-gauge needle was used to perform a transduodenal puncture of the common bile duct, followed by advancement of a guidewire through the needle, into the duct, and out the major papilla into the duodenum. After wire placement, we switched back to a duodenoscope, which showed a readily visible papilla. This suggested an inverted papilla, which was subsequently everted by antegrade guidewire passage. A standard biliary cannulation was then performed alongside the rendezvous wire, followed by sphincterotomy, stone extraction, and stent placement.

This case illustrates both an interesting anatomical abnormality and a useful adjunctive technique for cases of difficult cannulation. Although a retracted papilla can be seen in stricturing biliary disease, a fully inverted papilla has not been described, to our knowledge. In this case, antegrade wire passage via EUS-guided rendezvous resulted in eversion of the papilla and enabled subsequent ERCP and management of choledocholithiasis.

Aberrant papillary morphology can lead to challenging biliary cannulation. Endoscopists who perform ERCP and EUS should be comfortable with a range of techniques for difficult cannulation, such as needle-knife fistulotomy, a double-guidewire technique, and cannulation over a pancreatic stent. When papillary morphology precludes use of these traditional techniques, EUS-guided rendezvous can be an indispensable rescue technique.

Previous inverted papilla (A), and postrendezvous everted papilla (B).

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