Endoscopic retrograde cholangiography with contrast ultrasonography.

index of 50 was admitted to our intensive care unit with the clinical appearance of severe biliary pancreatitis. Bedside ultra− sonography was difficult due to the pa− tient’s obesity but revealed a dilated common bile duct (l" Fig. 1). Convention− al endoscopic retrograde cholangiogra− phy (ERC) with X−rays was considered impossible due to the obesity. Bedside endosonography (EG 383OUT; Pentax, To− kyo, Japan) was performed. Endoscopical− ly a swollen papilla excreting pus was seen. Sonographically, large areas of fluid were demonstrated around the pancreat− ic body and tail. A small remainder of undamaged pancreatic tissue was seen in the pancreatic head. The gallbladder was large and full of small stones. The main hepatic duct was dilated and filled with stone material. Bedside ERC with a duo− denoscope (TJF 160; Olympus, Tokyo, Japan) was performed using contrast ultrasonography instead of X−radiogra− phy. After cannulation of the common bile duct a second−generation ultrasound contrast agent (Sonovue) was injected through the papillotome. Bedside ultra− sonography (Sequoia, Siemens) demon− strated the contrast agent in the common bile duct and in the right and left hepatic duct (l" Fig. 2). After papillotomy, stones were extracted with a basket and a bal− loon. Therapeutic ERC using X−rays poses a problem not only in obese patients but also in pregnant women, since fluorosco− py is a risk for the fetus. Traditionally the problem was solved by wire−guided can− nulation by an experienced endoscopist using as little radiation as possible [1± 3]. In slim patients ultrasonography with− out contrast agents may be helpful [4]. Contrast ultrasonography may combine the advantages of cholangiography with X−rays and ultrasonography and should be further explored in this field.