What should be included in an ERCP (Endoscopic Retrograde Cholangiopancreatography) report for a patient with a history of choledochocele and a dilated Common Bile Duct (CBD) who underwent sphincterotomy and sphincteroplasty for stone extraction?

ERCP Report Template for Choledochocele with CBD Stones

Your ERCP report should document the choledochocele diagnosis with specific measurements, detail the sequential therapeutic interventions (sphincterotomy followed by sphincteroplasty), and explicitly note that stone extraction was only successful after sphincteroplasty—this sequence is clinically significant and should be clearly stated. 1, 2

Essential Report Components

Patient History Section

• Document the known choledochocele diagnosis with any prior imaging or ERCP findings 1
• Note presenting symptoms (abdominal pain, biliary obstruction, pancreatitis, or elevated liver enzymes) 1, 2
• Include relevant laboratory values, particularly liver function tests and bilirubin levels 3

Procedural Findings Section

• Specify the CBD diameter measurement (30 mm in your case), noting this represents massive dilation consistent with choledochocele 2, 4
• Describe the choledochocele morphology: document whether you observed a radiolucent halo around the distal CBD, bulbous dilation pattern, or any morphologic changes during the procedure 4
• Explicitly state the location and size of stones (you noted "small stones") 5
• Document any associated findings such as waisting, pseudowebs, or wrinkling of the distal CBD that may have been visible 4

Therapeutic Interventions Section

This is the critical portion where you must detail the sequence of events:

• First intervention: Sphincterotomy performed 5, 6

  • Document the extent/length of the sphincterotomy 2
  • Explicitly state: "No stones passed spontaneously after sphincterotomy" 2

• Second intervention: Sphincteroplasty performed 2

  • Describe the technique used (balloon dilation is commonly employed for choledochoceles) 5
  • Document: "Stone extraction was successful following sphincteroplasty" 2
  • Specify extraction method (basket, balloon sweep, or other) 5, 6

• Confirm complete duct clearance with final cholangiogram or fluoroscopic imaging showing free flow of contrast into the duodenum 5

Post-Procedure Assessment

• Document successful biliary decompression 5
• Note whether any stent was placed (generally not needed if complete clearance achieved) 5
• State immediate complications or their absence 7, 6

Critical Documentation Points

The fact that sphincterotomy alone was insufficient but sphincteroplasty achieved stone clearance is clinically important because:

• Choledochoceles with large CBD dilation (>15-30 mm) often require more extensive papillary opening than standard sphincterotomy provides 5, 2
• This documents that your therapeutic escalation was appropriate and necessary 2
• It provides justification for the additional procedure and informs future management decisions 1, 2

Follow-Up Recommendations to Include

• Surveillance endoscopy should be considered for choledochoceles that are drained but not resected, given the potential (though low) risk of dysplasia 1
• Document plan for cholecystectomy if gallbladder is still in situ 5, 3
• Recommend follow-up imaging or laboratory studies to confirm resolution of biliary obstruction 5

Common Pitfalls to Avoid

• Do not simply state "sphincterotomy and stone extraction performed" without specifying the sequence and that sphincteroplasty was required 2
• Avoid vague descriptions of CBD size; the 30 mm measurement is diagnostically significant and should be prominently stated 2, 4
• Do not omit documentation of complete duct clearance, as retained stones carry significant morbidity risk (cholangitis, recurrent pancreatitis) 5
• Ensure you document the choledochocele type if identifiable (Type A vs Type B), though this may require correlation with the anatomic relationship to the ampullary orifice 1