Utility of Choledochoscopy/EUS to Diagnose and Treat Choledocholithiasis in Pregnancy

Abstract

Purpose: The risk of choledocholithiasis is higher during pregnancy due to alteration in bile composition and biliary stasis that occurs during gestation. Treatment of these patients during pregnancy is challenging due to the risks from sedation and fluoroscopy. This is an interesting case of application of new technique to diagnose and treat choledocholithiasis. A twenty-six year old pregnant female at 28 weeks gestation presented with right upper quadrant pain, progressive jaundice, and low-grade fever. Her past medical history was significant for sickle cell disease, preeclampsia and choledocholithiasis. She had undergone a previous ERCP for stone removal after her last pregnancy. Upon presentation to the hospital, her total bilirubin was 6.8, AST 139, ALT 113, ALP 128 and WBC count was 16,500. Transabdominal ultrasound revealed a 9-mm common bile duct with possible filling defect. In order to avoid radiation exposure to fetus by fluoroscopy, EUS and choledochoscopy were used to examined the bile duct and achieve complete clearance. The linear echoendoscope revealed multiple hyperechoic well-rounded stones throughout the common bile duct. A prior sphincterotomy had been performed, so deep cannulation of the bile duct using the SpyGlass choledochoscope (Boston Scientific) was easily achieved. The SpyScope was useful in determining the exact location of the stones. A guidewire was advanced through the SpyScope into the left intrahepatic system. A 10 mm extraction balloon was used to extract multiple yellow pigment stones from CBD. The SpyScope was then reinserted and complete clearance of the CBD was seen. A 10 Fr 5-cm plastic biliary stent was placed to ensure drainage and prevent recurrent cholangitis during the remainder of her pregnancy. The linear echoendoscope was used to confirm adequate placement of the biliary stent. Subsequently, the patient had complete resolution of her symptoms and improvement in her LFT. The incidence of gallstones during pregnancy is estimated to be between 3% and 12%. Symptomatic gallstone disease is the second most common abdominal emergency in pregnant women and may require surgical intervention. In addition to the baseline risks of ERCP, fluoroscopy poses additional risk to the fetus. Various publications have reported using ERCP during pregnancy without fluoroscopy by using bile aspiration for confirmation of CBD cannulation, sphincterotomy and balloon extraction of stones. All these approaches are not perfect with regard to ensuring complete CBD clearance. This case highlights how choledochoscopy and endoscopic ultrasound are safe alternatives to fluoroscopy for evaluation of biliary disorders during pregnancy.