Cholangioscopy in the Management of Choledocholithiasis in Pregnancy: Two Cases and Review

Abstract

Purpose: Pregnancy increases the risk of cholelithiasis and its complications. The incidence of gallstones is 2 to 13% in pregnancy; related complications have an incidence of 0.1%. Methods that avoid fluoroscopy are preferable to avoid radiating the fetus. Seven cases of peroral cholangioscopy have been reported in pregnancy. We report two additional cases: Case 1: A 36-year oldwoman presented with painless jaundice. Her vital signs and physical exam were normal. Lab data were AST 271, ALT 508, alkaline phosphatase (AP) 257, and total bilirubin (bili) 1.4 mg/dL. Magnetic resonance cholangiography revealed choledocholithiasis. Endoscopic retrograde cholangiography (ERC) with sphincterotomy was performed with multiple stones removed from the bile duct. Stone extraction was incomplete and a biliary stent was placed. She was discharged after uncomplicated laparoscopic cholecystectomy (CCY) with the plan of future ERC. When she presented for ERC her urine pregnancy test was positive. The procedure was postponed, and obstetric evaluation confirmed a 6-week pregnancy. ERC without fluoroscopy was performed. Stent removal and single operator peroral cholangioscopy revealed a retained stone that was then removed. Cholangioscopy was used to confirm duct clearance at the end of the procedure, obviating the need for fluoroscopy. Case 2: A 25-year-old woman with 13-week pregnancy developed cholecystitis and underwent CCY with intraoperative cholangiogram revealing an obstructed bile duct suspicious for an impacted stone at the ampulla. She was referred for ERC. Lab data were bili 1.9, AST 112, ALT 164, and AP 121. At ERC a stone was noted projecting from the ampulla. An access sphincterotomy using a needle knife was performed. Upon completion of the sphincterotomy the stone spontaneously passed followed by a large quantity of bile. Wire guided cannulation of the bile duct and single operator cholangioscopy was performed with visualization of the biliary tree. Cholangioscopy confirmed that there were no retained stones. No fluoroscopy was used during the case. Choledocholithiasis in pregnancy can be managed without fluroscopy. Alternative techniques include wire-guided cannulation with aspiration of bile followed by sphincterotomy, the concomitant use of EUS, and cholangioscopy. These two cases further demonstrate cholangioscopy use in pregnancy to directly visualize the biliary system and facilitate or confirm removal of stones. No complications have been reported in any cases which used cholangioscopy. Because no confirmed level of radiation is considered safe, techniques to minimize or eliminate radiation exposure to the fetus can be utilized in facilities where the technology and trained personnel are present.