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Demystifying endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy

Published:October 08, 2017DOI:https://doi.org/10.1016/j.ejogrb.2017.10.008

      Abstract

      Background

      For many years, ERCP was avoided in pregnancy given the concerns regarding the adverse effects that, with special focus on radiation, could occur in the developing fetus. However, the postponement or rejection of ERCP in pregnant women, may lead to a higher risk for mother and fetus, especially when the indication is unequivocal, namely cholangitis, biliary pancreatitis and symptomatic choledocholithiasis.

      Summary and key messages

      This review aims to summarize the scarce literature on the subject in order to plan ERCP in pregnancy with the highest safety. The use of techniques that reduce radiation and increase the protection of pregnant women allow radiation levels far below the safety limits.
      We also discuss the various alternatives of ERCP without radiation. EUS can eliminate the need for ERCP with doubtful choledocholithiasis and plan the best approach in those with previous evidence. The possibility of performing “ERCP” with a linear echoendoscope uniquely under ultrasound control has been described. Conversely, the two-step strategy (initial sphincterotomy with stent placement without fluoroscopy and after delivery, ERCP with lithiasis extraction) proved to be safe obviating fluoroscopy. In conclusion, ERCP can be performed in pregnancy safely and effectively with minimal radiation or even no-radiation at all.

      Keywords

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      References

        • Everson G.T.
        Pregnancy and gallstones.
        Hepatology. 1993; 17: 159-161
      1. The epidemiology of gallstone disease in rome, Italy. Part I. prevalence data in men. The Rome group for epidemiology and prevention of cholelithiasis (GREPCO).
        Hepatology. 1988; 8: 904-906
        • Henriksson P.
        • Einarsson K.
        • Eriksson A.
        • Kelter U.
        • Angelin B.
        Estrogen-induced gallstone formation in males: relation to changes in serum and biliary lipids during hormonal treatment of prostatic carcinoma.
        J Clin Invest. 1989; 84: 811-816
      2. Gallbladder disease as a side effect of drugs influencing lipid metabolism. Experience in the Coronary Drug Project.
        N Engl J Med. 1977; 296: 1185-1190
        • Liu B.
        • Beral V.
        • Balkwill A.
        Childbearing, breastfeeding, other reproductive factors and the subsequent risk of hospitalization for gallbladder disease.
        Int J Epidemiol. 2009; 38: 312-318
        • Adilson CunhaFerreira F.M.F.
        • Marum Mauad Fernando
        • Gadelha Antônio
        • Spara Patrícia
        • Filho Isac Jorge
        Clinical and ultrasonographic risk factors associated with asymptomatic gallstones in women.
        Radiol Bras. 2004; 37: 77-82
        • Kern Jr., F.
        • Everson G.T.
        • DeMark B.
        • et al.
        Biliary lipids, bile acids, and gallbladder function in the human female: effects of pregnancy and the ovulatory cycle.
        J Clin Investig. 1981; 68: 1229-1242
        • Ko C.W.
        • Beresford S.A.
        • Schulte S.J.
        • Matsumoto A.M.
        • Lee S.P.
        Incidence, natural history, and risk factors for biliary sludge and stones during pregnancy.
        Hepatology. 2005; 41: 359-365
        • Valdivieso V.
        • Covarrubias C.
        • Siegel F.
        • Cruz F.
        Pregnancy and cholelithiasis: pathogenesis and natural course of gallstones diagnosed in early puerperium.
        Hepatology. 1993; 17: 1-4
        • Committee A.SoP. Shergill A.K.
        • Ben-Menachem T.
        • et al.
        Guidelines for endoscopy in pregnant and lactating women.
        Gastrointest Endosc. 2012; 76: 18-24
        • Othman M.O.
        • Stone E.
        • Hashimi M.
        • Parasher G.
        Conservative management of cholelithiasis and its complications in pregnancy is associated with recurrent symptoms and more emergency department visits.
        Gastrointest Endosc. 2012; 76: 564-569
        • Raijman I.
        Performing endoscopic retrograde cholangiography without radiation exposure: are we ready for it?.
        Gastrointest Endosc. 2016; 84: 770-772
        • Amis E.S.
        Risks of radiation exposure in the endoscopy suite: principles, cautions, and risks to patients and endoscopy staff.
        Techn Gastrointest Endoscopy. 2007; 9: 213-217
        • Dumonceau J.M.
        • Garcia-Fernandez F.
        • Verdun F.
        • et al.
        Radiation protection in digestive endoscopy: European society of digestive endoscopy (ESGE) guideline.
        Endoscopy. 2012; 44: 408-424
      3. Committee Opinion No. 656: guidelines for diagnostic imaging during pregnancy and lactation.
        Obstet Gynecol. 2016; 127: e75-e80
        • Kahaleh M.
        • Hartwell G.D.
        • Arseneau K.O.
        • et al.
        Safety and efficacy of ERCP in pregnancy.
        Gastrointest Endoscopy. 2004; 60: 287-292
        • Tham T.
        Safety of ERCP during pregnancy.
        Am J Gastroenterol. 2003; 98: 308-311
        • Protection ICoR
        Pregnancy and medical radiation.
        Ann ICRP. 2000; 84
        • Huda A.
        • Garzon W.J.
        • Filho G.C.
        • et al.
        Evaluation of staff, patient and fetal radiation doses due to endoscopic retrograde cholangiopancreatography (ERCP) procedures in a pregnant patient.
        Radiat Prot Dosimetry. 2016; 168: 401-407
        • Jamidar P.A.
        • Beck G.J.
        • Hoffman B.J.
        • et al.
        Endoscopic retrograde cholangiopancreatography in pregnancy.
        Am J Gastroenterol. 1995; 90: 1263-1267
        • Board NRP
        Protection of pregnant patients during diagnostic medical exposures to ionising radiation.
        Doc NRPB. 2009; : 3-16
        • Inamdar S.
        • Berzin T.M.
        • Sejpal D.V.
        • et al.
        Pregnancy is a risk factor for pancreatitis after endoscopic retrograde cholangiopancreatography in a national cohort study.
        Clin Gastroenterol Hepatol. 2016; 14: 107-114
        • Tang S.J.
        • Mayo M.J.
        • Rodriguez-Frias E.
        • et al.
        Safety and utility of ERCP during pregnancy.
        Gastrointest Endosc. 2009; 69: 453-461
        • Shelton J.
        • Linder J.D.
        • Rivera-Alsina M.E.
        • Tarnasky P.R.
        Commitment, confirmation, and clearance: new techniques for nonradiation ERCP during pregnancy (with videos).
        Gastrointest Endosc. 2008; 67: 364-368
        • Sharma S.S.
        • Maharshi S.
        Two stage endoscopic approach for management of choledocholithiasis during pregnancy.
        J Gastrointest Liver Dis. 2008; 17: 183-185
        • Zhou Y.
        • Zhang X.
        • Zhang X.
        • et al.
        ERCP in acute cholangitis during third trimester of pregnancy.
        Hepatogastroenterology. 2013; 60: 981-984
        • Vohra S.
        • Holt E.W.
        • Bhat Y.M.
        • Kane S.
        • Shah J.N.
        • Binmoeller K.F.
        Successful single-session endosonography-based endoscopic retrograde cholangiopancreatography without fluoroscopy in pregnant patients with suspected choledocholithiasis: a case series.
        J Hepatobil Pancreat Sci. 2014; 21: 93-97
        • Lee Y.T.
        • Chan F.K.
        • Leung W.K.
        • et al.
        Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: a randomized study.
        Gastrointest Endosc. 2008; 67: 660-668
        • Sharma R.
        • Menachery J.
        • Choudhary N.S.
        • Kumar M.
        • Puri R.
        • Sud R.
        Routine endoscopic ultrasound in moderate and indeterminate risk patients of suspected choledocholithiasis to avoid unwarranted ERCP: a prospective randomized blinded study.
        Indian J Gastroenterol. 2015; 34: 300-304
        • Ersoz G.
        • Turan I.
        • Tekin F.
        • Ozutemiz O.
        • Tekesin O.
        Nonradiation ERCP with endoscopic biliary sphincterotomy plus papillary balloon dilation for the treatment of choledocholithiasis during pregnancy.
        Surg Endosc. 2016; 30: 222-228
        • Singla V.
        • Arora A.
        • Tyagi P.
        • Sharma P.
        • Bansal N.
        • Kumar A.
        Failed common bile duct cannulation during pregnancy: rescue with endoscopic ultrasound guided rendezvous procedure.
        Endosc Ultrasound. 2016; 5: 201-205
        • Swisher S.G.
        • Hunt K.K.
        • Schmit P.J.
        • Hiyama D.T.
        • Bennion R.S.
        • Thompson J.E.
        Management of pancreatitis complicating pregnancy.
        Am Surg. 1994; 60: 759-762
        • Neudecker J.
        • Sauerland S.
        • Neugebauer E.
        • et al.
        The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery.
        Surg Endosc. 2002; 16: 1121-1143
        • Cosenza C.A.
        • Saffari B.
        • Jabbour N.
        • et al.
        Surgical management of biliary gallstone disease during pregnancy.
        Am J Surg. 1999; 178: 545-548
        • Jackson H.
        • Granger S.
        • Price R.
        • et al.
        Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review.
        Surg Endosc. 2008; 22: 1917-1927
        • Veerappan A.
        • Gawron A.J.
        • Soper N.J.
        • Keswani R.N.
        Delaying cholecystectomy for complicated gallstone disease in pregnancy is associated with recurrent postpartum symptoms.
        J Gastrointest Surg. 2013; 17: 1953-1959