ERCP Using Gastroscope for Intra Diverticular Papilla

ERCP using gastroscope for intra diverticular papilla. While going for an easy ERCP, we found an Intradiverticular and punctiform papilla. Access was initially impossible using a duodenoscope, even in the long position. We utilized a gastroscope with a cap. Upon identifying and visualizing the punctiform access to the CBD, we inserted the sphincterotome into the orifice. While advancing the sphincterotome, we rotated it to align with the axis of the CBD. Subsequently, we introduced the guidewire to secure access. A contrast injection was performed, followed by a minor sphincterotomy. We then exchanged the gastroscope for a duodenoscope to complete the procedure.  Performing an ERCP in a patient with an intradiverticular papilla (where the major duodenal papilla is located inside a duodenal diverticulum) can be technically challenging. Using a gastroscope (instead of a standard duodenoscope) adds further complexity due to its different design and maneuverability. Here’s a structured approach to this scenario:

Key Challenges:

Visualization Difficulty – the papilla may be hidden within the diverticulum, making cannulation harder.

Unstable Scope Position – the gastroscope lacks the elevator mechanism of a duodenoscope, making fine adjustments more difficult.

Risk of Perforation – the diverticulum wall is thin, increasing the risk of injury.

Cannulation difficulty – aligning the gastroscope for proper biliary/pancreatic access can be tough.