Cholangioscopy Technique

Updated: Dec 02, 2022
  • Author: Mohammad Wehbi, MD; Chief Editor: Kurt E Roberts, MD  more...
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SpyGlass Cholangioscopy

Cholangioscopy using the SpyGlass cholangioscopy system [32, 53, 58, 59, 18]  can be performed by a single endoscopist. The SpyScope access and delivery catheter is attached to duodenoscope by a Silastic band below the working channel of the duodenoscope. The duodenoscope along with the SpyGlass cholangioscopy system is held by one hand of the endoscopist; the other hand is used for operating the deflection wheels of the duodenoscope and the SpyGlass system. The procedure is always performed in conjunction with endoscopic retrograde cholangiopancreatography (ERCP).

The SpyGlass direct visualization probe is inserted into the optical channel of the SpyGlass catheter.

Under direct vision, the duodenoscope is passed through the oral cavity and pharynx. Then, the esophagus is intubated and the duodenoscope is passed through the esophagus and stomach to reach the second portion of the duodenum to visualize the ampulla of Vater and the papillae.

A selective and deep cannulation of the biliary tree is performed. A guide wire is then introduced and positioned in the bile duct (or pancreatic duct) under fluoroscopy.

Sphincterotomy is usually performed for better access of the biliary tree.

The SpyScope catheter and the optical probe are introduced into the duodenoscope together as a unit and advanced into the biliary ducts for direct visualization. Once inside the common bile duct (CBD), the SpyGlass catheter is slowly advanced under fluoroscopic guidance. Once the SpyScope catheter is positioned in the CBD, the guide wire is removed.

The optical probe is then advanced beyond the tip of the SpyGlass catheter. Direct visualization of biliary ducts is performed by repeated advancing and withdrawal of the SpyScope catheter in the biliary duct. The four-way tip-deflection capability of the SpyScope catheter aids in achieving better visualization of the biliary ducts.

If a suspicious lesion is found in the biliary ducts, the SpyBite forceps are introduced through the operating channel for obtaining targeted small biopsies. If biliary stones are found, SpyGlass-directed electrohydraulic or laser lithotripsy is performed.

Irrigation of the biliary ducts is performed through the two irrigation ports built within the SpyScope catheter that exit at the tip of the catheter. This clears the debris in the bile ducts and provides better visual images throughout the procedure. Lack of a suction port is a drawback of this system, but manual suction can be achieved by attaching a syringe to the operating channel.

After completion of the procedure, patients are generally kept without oral intake until the next day.


Mother-and-Baby Scopes

Cholangioscopy using a mother duodenoscope and a baby cholangioscope requires two experienced endoscopists working together to complete the procedure. [56]

The procedure starts as a regular ERCP, with the introduction of a duodenoscope under direct visualization through the mouth. The scope is advanced to the second portion of the duodenum to visualize the ampulla of Vater.

Selective cannulation of the CBD is performed. A sphincterotomy is usually performed.

Cholangiography is then performed, and a guide wire is placed in the biliary system.

The cholangioscope is introduced into the working channel of the duodenoscope to cannulate the CBD. Under fluoroscopy, the cholangioscope is slowly advanced over the guide wire to the CBD.

Once the cholangioscope is within the CBD, the guide wire may be removed. The working channel available in the cholangioscope is used for diagnostic and therapeutic interventions. Targeted small biopsies can be obtained by introducing forceps through the working channel of the cholangioscope.

Electrohydraulic or laser lithotripsy also may be performed through the working channel of the cholangioscope.


Direct Cholangioscopy

Direct cholangioscopy is a relatively new technique with limited available data. [60, 54, 55, 61]  It is a technically difficult procedure that requires a larger sphincterotomy and a dilated bile duct, but the image quality is superior.

Direct cholangioscopy can be performed as either a wire-guided or a balloon-assisted procedure.

A standard therapeutic duodenoscope is advanced to the second portion of the duodenum, in much the same fashion as with previously mentioned methods for cholangioscopy.

A guide wire is then introduced into the bile ducts under fluoroscopic guidance.

The duodenoscope is removed, leaving the guide wire in the bile ducts.

An ultraslim endoscope is then back-loaded over the guide wire with the use of a standard ERCP cannula.

Under fluoroscopic guidance, an ultraslim endoscope is advanced into the bile ducts.

If a balloon-assisted method is used, a balloon is introduced and inflated in the common hepatic duct (CHD). This is used as an anchor to advance the ultraslim endoscope into the bile ducts. [62]



The potential complications associated with cholangioscopy are numerous and range from relatively mild sequelae to life-threatening conditions, including the following:

  • Cholangitis (most common complication)
  • Abdominal pain
  • Hypotension
  • Nausea
  • Radiculopathy
  • Perforation of bile duct (from the guide wire)
  • Elevated amylase and lipase without clinical pancreatitis
  • Inflammatory syndrome