Endoscopic Retrograde Cholangiopancreatography (ERCP) During Pregnancy: A Case of Gallstone Pancreatitis (GSP) During Pregnancy Managed by ERCP and Temporary Biliary Stent

Peter R. McNally, DO, MACG,
Jose A. Perez, RN,
Kasia Lucia, RN and
Pamela J. Ives, RN

Case Study:

A 34 year old, gravida 3, para 2, female at 32 weeks gestation presented to our obstetrical triage with a complaint of daily intermittent band like epigastric pain that radiated to the right shoulder for the previous 5 days. The patient related initial onset this pain 3 months previously. Initially, the pain was less severe, intermittent and most often occurring after meals. The morning of admission the patient experienced severe, right upper quadrant pain radiating to the scapula, and thoracolumbar region, the pain was associated with nausea and heartburn, but no vomiting. There were no symptoms of dark urine, fever or chills. Past medical history was remarkable for psoriasis. The patient had no previous surgeries. She was a non-smoker, non-drinker and had no allergies to medicines. Her only medications were prenatal vitamins, Tums, and acetaminophen for abdominal pain. Review of systems revealed frequent symptoms of gastroesophageal reflux and plaque psoriasis on the lower extremities. Physical examination revealed the patient to be 5’4” tall with a weight of 208 lbs. She was afebrile with normal vital signs. Pertinent physical findings showed the patient was comfortable without pain, white sclera, gravid uterus 4 finger breaths below the xiphoid. Laboratory tests remarkable for elevated amylase, lipase and liver associated enzymes, Table 1.

Test (normal values) Day of Admission (DOA) DOA + 1 day
AST (14 - 36) 164 61
ALT (9 - 52) 170 124
Alkaline Phosphatase (38 - 126) 126 96
Total Bilirubin (0.2 - 1.3) 0.7 0.4
Amylase (30 - 110) 426  
Lipase (23 - 300) 4303 160

Ultrasound of the right upper quadrant revealed numerous small mobile gallbladder stones, Figure 1A and 1B. The gallbladder wall thickness was normal without peri-cholecystic fluid and the common bile duct was 5.4 mm in diameter. The sonographic murphy’s sign was negative. Sonographic fetal examination showed normal fetal heart rate, gestational age, and activity.

Figure 1A

Figure 1B


The following day laboratory tests showed normalization of lipase and mild persistent elevation in liver associated enzyme tests, Table 1. Other causes of pancreatitis such as include trauma, medications, hypertriglyceridemia and hypercalcemia were excluded. Magnetic resonance cholangiography was performed and showed multiple small to medium sized gallstones and prominent common bile duct without stones.

The treatment options for this patient included observation, laparoscopic cholecystectomy or therapeutic ERCP. The presence of numerous gallstones suggested the likelihood for recurrent GSP was high and ruled out the option for observation. Gestational cholelithiasis in the absence of cholecystitis permitted the option of postponing laparoscopic cholecystectomy to the postpartum period and avoiding intrapartum surgical risks pertaining to the fetus and gravid uterus. Ultimately, a multidiscipline decision favored the therapeutic ERCP option. The patient and spouse gave informed consent for ERCP understanding the risks to the mother, fetus and pregnancy. Many ERCP options from sphincterotomy, balloon stone extraction and placement of a temporary biliary stent were discussed. The family emphasized their preference to employ techniques that would minimize radiation to the fetus.

The second hospital day she was taken to the operating room and placed under general anesthesia. After supine endotracheal intubation the patient was reposition in a semi-prone position. Lead shielding was draped below and above the gravid uterus. A therapeutic lateral viewing video duodenoscope (TJF-Q180V, Olympus America, Inc.) was passed per os and positioned in a favorable biliary position, looking upward toward the ampullary orifice, Figure 2A. A fluoro Tip ERCP Cannula (Boston Scientific Corp) with 50% dilute ISOVUE-300 (Bracco Diagnostics, Inc.) contrast was gently manipulated within the papillary orifice, until free biliary cannulation was achieved and confirmed by aspiration of bile, Figure 2B and 2C.

Figure 2A

Figure 2B

Figure 2C

 

Contrast was injected and a single spot fluoroscopic image taken confirming biliary ductal anatomy, Figure 3.

Figure 3

 

The cannula was then gently advanced and biliary cannulation confirmed by additional aspiration of bile. A hydrophilic, stripe colored guidewire (Hydra Jagwire Guidewire, Boston Scientific) was back loaded and advanced 5-7 cm into the biliary tree using just endoluminal observation of the multicolored spiral guide wire, Figure 4. A spot fluoroscopic image confirmed the distal tip of the wire to be in the intrahepatic biliary radicals. Using just endoluminal observation of the Jagwire, the diagnostic cannula was then removed and a 7 French 7 cm Amsterdam biliary stent back loaded and advanced into the common duct, Figure 5. Total fluoroscopic exposure was 8 seconds (mGym2, 0.161) and total procedure time was 15 minutes. Post ERCP, fetal monitoring demonstrated normal fetal movement and heart tones.

Figure 4

Figure 5


The day after ERCP the mother and fetus were doing well. The mother had no abdominal pain or fever and her diet was advanced without incident and then discharge from the hospital that day. The remainder of her last trimester of pregnancy was uneventful. She delivered a healthy 40 week male infant.

Four weeks postpartum the patient underwent tandem ERCP and laparoscopic cholecystectomy. ERCP identified the stent to be in a good biliary position, it was lassoed and removed. Cholangiogram revealed multiple filling defects in the common bile duct, Figure 6. After Jagwire exchange, a combination sphincterotome and stone removal device (STONETOME™, Boston Scientific, Inc.) was inserted into the common duct. A 5 mm sphincterotomy performed, followed by balloon extraction of over a dozen, soft, yellow-white, mulberry stones, Figure 7. Laparoscopic cholecystectomy was uneventful and the patient was discharge to home that evening.

Figure 6

Figure 7

 

Discussion:

Acute pancreatitis during pregnancy is uncommon, estimated to occur in 1 - 3 out of 10,000 pregnancies.1,2,3,4 The spectrum of pancreatitis ranges from mild pancreatitis to serious pancreatitis associated with necrosis, abscess, pseudocysts and multi-organ failure. The most common cause of gestational pancreatitis is biliary stone disease (~70%). Other important causes of pancreatitis that must be considered include alcohol abuse (12%), idiopathic (17%), hyperlipidemia (4%), hyperparathyroidism, trauma, medications and fatty liver of pregnancy.2

Most cases of GSP are caused by small stones, that usually pass spontaneously.5 The management of GSP may be directed toward the origin of stones (gallbladder) or persistence of biliary stones.5,6 Advances in a variety of imaging techniques have streamlined GSP decision algorithms. High resolution transabdominal ultrasound, magnetic resonance imaging and endoscopic ultrasound are very accurate in determining retention of common bile duct stones. When the common bile duct is clear of stones (by US or MRCP) and the pregnancy is within the first or second trimester, laparoscopic cholecystectomy is the usual recommended course of action.2,4,6 Simple observation in this setting is fraught with high likelihood of recurrent pancreatitis and maternal/fetal complications.2,4,7,8 In the third trimester the gravid uterus can make laparoscopic cholecystectomy more difficult, in this circumstance the option for therapeutic ERCP is dependent upon the availability of endoscopic expertise.9,10,11 The goal or ERCP is to relieve distal obstruction by sphincterotomy, stone extraction and/or biliary stent placement. During ERCP the gravid uterus should be shielded with lead and fluoroscopy minimized. In the case presented in this report, the third trimester made therapeutic ERCP a preferred option over laparoscopic cholecystectomy. Simple “wait and watch” observation seemed to be a poor option due to the number of gallstones and history of recurrent symptoms. The technique of identifying bile in the cannula minimized fluoroscopic exposure and the placement of a biliary stent offered protection from recurrent stone passage from the gallbladder for the remainder of the pregnancy. The findings at the second ERCP performed in the postpartum period, supported this course of action as numerous common bile duct stones were identified and removed.

Our patient delivered a healthy term male infant at 40 weeks of gestation. The last eight weeks of pregnancy after therapeutic ERCP were uneventful for episodes of biliary colic or pancreatitis. The “minimalist” technique of using aspiration of bile in the ERCP cannula to confirm biliary position and the placement of a biliary stent, instead of several additional steps to include sphinterotomy, biliary balloon sweeps and/or placement of a biliary stent avoided excessive maternal/fetal fluoroscopy exposure and minimized total procedure time. The removal of the biliary stent and common bile duct stones was performed in tandem prior to laparoscopic cholecystectomy in the postpartum period.

Accurate complication rates for ERCP performed for gestational GSP are difficult to determine due to variance in technique, experience, stone burden and the severity of pancreatitis. Tiwari, et al, conducted a retrospective review of 19 studies including 214 ERCPs in pregnant women and the procedure related complications included spontaneous abortion (0.9%), fetal distress (0.6%), post procedure pancreatitis (4.6%) and preterm labor occurred in 4.6% of cases.12Tang et al, in 2009, reported retrospective results of 68 ERCP performed in 65 pregnant women.13 Their study showed that term delivery of the baby was achieved in 53 patients (89.8%), but 11 patients (16%) suffered post-ERCP pancreatitis.13 Single center reports on the results of ERCP for GSP during pregnancy by Barthel,14 Sharma,15 Farca,16 and Daas17 all demonstrate favorable results. However, their patient numbers are small, and technical variations were significant. Farca and Das employed a “minimalist” approach of just biliary stenting (n=27), Barthel performed biliary sphincterotomy in all patients (n=3) even in the absence of CBD stones, and Sharma employed biliary sphincterotomy with stenting followed by postpartum stent and stone removal (n=11). The combined analysis of results from these four individual centers identified good results in all, with post ERCP pancreatitis occurring in only 1 patient,14 but none had recurrent pancreatitis.

Conclusions:

Gestational GSP is an uncommon illness in pregnancy that can have great consequences for the mother and the fetus. The management of gestational GSP requires a multidisciplinary approach for successful outcome. When GSP is mild and gallstones remain, but common duct is clear by imaging studies, then laparoscopic surgery is the preferred course of action, especially in the first and second trimester of pregnancy. However, when the same circumstances are evident in the third trimester therapeutic ERCP in expert hands appears to be the preferred option.

 

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