Two stage endoscopic approach for management of choledocholithiasis during pregnancy

Management of choledocholithiasis during pregnancy is difficult. The aim of this study was to evaluate the safety and efficacy of managing common bile duct (CBD) stones during pregnancy using a two-stage procedure without any fetal radiation exposure.

Eleven consecutive pregnant women treated endoscopically for choledocholithiasis between 1996-2005, at a tertiary referral center, were included in this study. All the patients were treated by biliary sphincterotomy and stenting without any fluoroscopy or ultrasound assistance during pregnancy and definitive ERCP and stone clearance after delivery. Patients were followed at one week and were asked to come for definitive treatment after delivery.

All 11 patients were experiencing pain and jaundice while two patients had cholangitis. Abdominal ultrasound revealed dilated CBD in all patients and stones in 8 patients. Every patient demonstrated marked relief after the first stage procedure without any complication. ERCP after delivery revealed no CBD stones in one patient, 5-8 mm size stones in 8 patients and large stones (>15 mm) in two patients. One patient with large CBD stones required mechanical lithotripsy while another required surgery. CBD was cleared in 8 patients with small stones. Long-term fetal and maternal outcome was good in all the patients.

A two stage approach consisting of initial sphincterotomy with stenting without fluoroscopy during pregnancy followed by definitive ERCP after delivery seems to be a justified approach. This is the best most definitive way of avoiding radiation exposure to the fetus.