Biliary disease in pregnancy with an emphasis on the role of ERCP

The incidence of gallstones during pregnancy is estimated to be between 3% and 12%. About one-third of pregnant patients with cholelithiasis become symptomatic and may require surgical intervention. Choledocholithiasis during pregnancy although infrequent usually requires therapeutic intervention. Abdominal ultrasonography is insensitive for the detection of common bile duct stones. Magnetic resonance imaging is not being associated with known adverse effects and seems to be an excellent diagnostic modality in this context. Paramagnetic contrast agents have been associated with increased spontaneous abortion rates and other abnormalities in animals and should only be used when absolutely necessary. Endoscopic ultrasonography is highly accurate for the detection of common bile duct stones and may be useful before consideration of endoscopic retrograde cholangiopancreatography (ERCP) in select patients. The second trimester seems to be the safest time to perform surgery, as organogenesis is complete and the incidence of spontaneous abortion lower. ERCP followed by sphincterotomy and stone extraction is very effective and can be performed safely during all trimesters of pregnancy with a premature delivery rate less than 5%. All efforts to minimize radiation exposure should be undertaken. These include lead shielding and avoiding hard copy radiographs. When possible, category B (such as meperidine) or C drugs only should be used for sedation during pregnancy. Therapeutic ERCP is now the standard of care for treating choledocholithiasis during pregnancy. Endoscopic sphincterotomy for symptomatic patients with normal cholangiograms is controversial. Consideration of ERCP demands a judicious approach, paying careful attention to risks and benefits of intervention.