Endoscopic Retrograde Cholangiopancreatography during Pregnancy: Really Guarantee to Safety?

Acute cholangitis and biliary pancreatitis caused by bile duct stones are not infrequently develop during pregnancy, they can cause serious complications and wastage for both mother and fetus.1 For pancreaticobiliary diseases in pregnancy, endoscopic retrograde cholangiopancreatography (ERCP) has been suggested as an effective alternative to surgery.2

During the procedure, radiation exposure is essentially develop on patient and subsequently exposed to the fetus can result in unpredictable future. These can bring a vague anxiety for patients and operators with regard to the procedure.3

In this issue of Gut and Liver, Lee et al.4 present that ERCP during pregnancy is relatively safe based on check the abnormality of the fetus in the relatively long-term follow-up period after the procedure and major complications associated with the procedure has not occurred. In addition, authors study shows that the ancillary diagnosis using endoscopic ultrasound (EUS) make a more safe and secure to help ERCP procedure when the patient complaint the symptoms obviously with difficult to diagnose the definitive cause. Also the study shows that just applying the shortening the procedure time, pregnant women to wear protectors and small amount of radiation exposure using the method of reducing the radiation exposure of the fetus, whereby they are possible to reach below the level of the international standards for exposure cause a serious problem. According to recently published papers related to the ERCP in the event that the radiation exposure of the fetus, the radiation dose to the fetus exposed is decreased through detailed and attentive care.5,6 That is, limit X-ray beam on-time, limit the number of recorded images acquired and adjust the patient position (supine, prone, or lateral) to minimize fetal exposure.

According to published articles,7–9 some authors reported removed common bile duct stones with two-step ERCP for pregnant women according to the stage of pregnancy. If the patients were in late pregnancy, the stones were removed through a second ERCP after the pregnancy was terminated. If the patients were in early or mid-pregnancy, they underwent endoscopic retrograde biliary drainage and continued gestation. Their stents and stones were removed through a third ERCP 1 week after parturition, whereas others reported sphincterotomy with removing bile duct stone during the first ERCP procedure. The two groups were all safe procedures on maternal and fetal status and they did not show statistically significant complication rate related to procedure compare to nonpregnant group. In particular, sphincterotomy itself is secure whether or not the drain tube can be inserted and that significant results are reported to help preventing recurrent cholangitis and biliary pancreatitis.

In case of the patients are constantly complaining of biliary pain after performing ERCP, if the cause is confident to face the gallbladder or acute cholecystitis, undergo preventive cholecystectomy is reasonable. In contrast, the gallbladder stones without symptoms, first trimester and bile duct obstruction with stricture itself are recommended to delay surgery. In other words, we should apply in more stringent indications, rather than just indications of cholecystectomy applied in the non-pregnant group.10

If you plan to diagnostic ERCP with treatment due to doubt situation, it will be needed to longstanding procedure time, post-ERCP severe acute pancreatitis and eventually develop maternal and fetal risk. We should use nonradiation exposure techniques for the diagnosis of biliary stones such as EUS, magnetic resonance cholangiopancreatography, and EUS appropriately, thereby it is very important to know whether the ERCP indications are secure.11

In conclusion, ERCP for pancreatobiliary disease during pregnancy can be safe and effective procedure regardless of the period of pregnancy. The using guidelines related to radiation exposure protection in this study are to meet current several international standard recommendations.