Safety of ERCP during pregnancy.

OBJECTIVES: There are few data in the literature regarding the indications, therapy, and safety of endoscopic management of pancreatico-biliary disorders during pregnancy. We report the largest single center experience with ERCP in pregnancy. METHODS: We reviewed 15 patients that underwent ERCP during pregnancy. In all patients, the pelvis was lead-shielded and the fetus was monitored by an obstetrician. Fluoroscopy was minimized and hard copy radiographs taken only when essential. RESULTS: The mean patient age was 28.9 yr (15-36 yr). The mean duration of gestation was 25 wk (12-33 wk); one patient was in the first, five in the second, and nine in the third trimester. The indications were gallstone pancreatitis (n = 6), choledocholithiasis on ultrasound (n = 5), elevated liver enzymes and a dilated bile duct on ultrasound (n = 2), abdominal pain and gallstones (n = 1), and chronic pancreatitis (n = 1). ERCP findings were bile duct stones (n = 6), patulous papilla (n = 1), bile duct debris (n = 1), normal bile duct and gallstones or gallbladder sludge (n = 3), dilated bile duct and gallstones (n = 1), normal bile duct and no gallstones (n = 2), and chronic pancreatitis (n = 1). Six patients underwent sphincterotomies and one a biliary stent insertion. One sphincterotomy was complicated by mild pancreatitis. All infants delivered to date have had Apgar-scores >8, and continuing pregnancies are uneventful. Mean fluorosocopy time was 3.2 min (SD +/- 1.8). An estimated fetal radiation exposure was 310 mrad (SD +/- 164) which is substantially below the accepted teratogenic dose. CONCLUSIONS: ERCP in pregnancy seems to be safe for both mother and fetus; however, it should be restricted to therapeutic indications with additional intraprocedure safety measures.

Palliation of malignant gastric outlet obstruction using an endoscopically placed Wallstent.

BACKGROUND: Treatment options for malignant gastric outlet obstruction are limited. Surgical gastrojejunostomy, commonly performed, has significant morbidity and mortality. METHODS: Over 2 years, we prospectively studied the safety, feasibility, and outcomes for use of a newly designed expandable metal stent (Wallstent Enteral; Schneider, Minneapolis, Minn.) to treat malignant gastric outlet obstruction. Stents 16 to 22 mm in diameter and 60 to 90 mm in length were deployed directly through the endoscope. RESULTS: Twelve patients (ten women, two men; mean age 59.7 years) underwent stenting. Thereafter, six patients were able to eat a regular diet; three could eat pureed food. In three patients, the procedure was unsuccessful because of multiple obstructions not recognized before stenting (one) and stents deployed too proximally (one) or too distally (one). CONCLUSIONS: Placement of a newly designed stent through the endoscope is safe and effective palliation for various types of malignant gastric outlet obstruction and significantly improves many aspects of patient quality of life.

Evaluation of the pattern of liver tests and yield of cholangiography in symptomatic choledocholithiasis: a prospective study.

BACKGROUND: The role of ERCP in the management of choledocholithiasis in an era of minimally invasive therapy continues to be defined. METHODS: We evaluated prospectively the pattern of liver test abnormalities and yield of cholangiography after presentation with illnesses suggesting choledocholithiasis. Ninety-four consecutive patients, all with liver test abnormalities (total bilirubin, alkaline phosphatase, AST, and ALT) at presentation, had serial determinations to within 24 hours of cholangiography and were divided into four groups based on their patterns of rise or fall of liver test results as well as presenting clinical syndrome. Group I: normalized liver tests; Group II: falling liver tests, and alkaline phosphatase falling greater than 50% of the difference between presentation value and upper limit of normal; Group III: alkaline phosphatase falling less than 50%; and Group IV: any liver test with increasing levels. Clinical syndromes included cholangitis, pancreatitis, combined cholangitis and pancreatitis, and biliary pain with abnormal liver tests. RESULTS: Yields of choledocholithiasis were 13% (Group I), 50% (Group II), 67% (Group III), and 94% (Group IV). Yield by syndromes were 36% (biliary pancreatitis), 72% (biliary pain and abnormal liver tests), 87% (cholangitis), and 100% (cholangitis and pancreatitis). CONCLUSION: The degree of decline in liver test levels is inversely related to the yield of cholangiography in symptomatic choledocholithiasis; the yield of ERCP in these patients (with normalized liver tests) is low and they do not require ERCP. Pre-ERCP estimates of the likelihood of choledocholithiasis can be made on the basis of the pattern of liver tests, and biliary pancreatitis patients with normalized liver tests do not require ERCP.