Endoscopic ultrasound-assisted, fluoroscopy-free, trans-papillary biliary drainage in pregnancy. We have no financial disclosures. Pregnancy is associated with an increased tendency to form biliary sludge and gallstones. This is due to increased effect of estrogen, increasing bilithogenicity, and the relaxing effect of progesterone, which increases biostasis and reduces GB mortality. As a consequence, about a third of pregnant women have some biliary sludge, and a smaller percentage actually develop gallstones. However, as the pregnancy resolves, the sludge and stones resolve too in most cases. A minority of patients, they may develop symptomatic cholecystitis. While ERCP is considered safe and effective in pregnancy considering the risk-benefit ratio, there is always the concern of radiation exposure of the fetus. While up to 50 mSv is generally considered safe for the fetus, there is no absolute threshold to define safety. We can try reducing the exposure by lead shielding. However, we now know most of the radiation exposure to the fetus comes from scatter within the pregnant woman's body. We can try reducing the dose of radiation given to the patient by collimating the beams as much as possible and using only brief taps of fluoroscopy. There is a concept of fluoroscopy-free ERCP, where wire-guided cannulation is done and confirmation of biliary cannulation is by bile aspiration, followed by stent placement. However, there is no real way of knowing whether we are placing the stent crossing the obstructing stone or we might actually enter the cystic duct here, so adequacy of drainage is always a question. We here describe another approach to biliary drainage in pregnancy in carefully selected patients. Our patient, a 31-year-old pramigravida, in her last trimester of pregnancy presented a week-long history of jaundice, which was painful and associated with pruritus. There was also some low-grade fever. Her evaluation showed leukocytosis and bilirubin of 11.3 mg per deciliter. Ultrasound showed bilobar, central and peripheral biliary ductal dilatation. However, due to her body habitus, mid and distal CBD were obscured. However, there was presence of GB sludge. So this patient had a high likelihood of choledochorlithiasis being the ideology of her biliary obstruction. As per the Tokyo criteria, she fit into moderate cholangitis. So we counseled this patient regarding the benefits and risks of ERCP during pregnancy. She was quite apprehensive about the radiation exposure to the fetus. We decided to take her up for an endoscopic ultrasound for confirmation of the etiology of biliary obstruction and same-session ERCP. From the cardiac, we can see that there's cross dilatation of the intrahepatic biliary radicals and we can trace the bile duct further down. Here the GB and the cystic duct is joining into the CBD and here we can see a stone in the mid-CBD. A view from the descending duodenum shows presence of at least two stones over here, each measuring almost 12-13 mm and this we saw the view of the papilla. Here we can see the papilla. The papilla looked to be in a good position even from the endoscopic view of the EUS scope. We decided to go ahead with biliary drainage using the same echo endoscope in the same setting, hoping that we would not have to use fluoroscopy at all. Here we went in with a soft hydrophilic guide wire, insinuating it gently at the orifice without inserting the sphincter dome in and gradually we are trying to nudge the guide wire into the orifice. The papilla was actually quite bulky but the orifice was quite easily evident and here we can see that the sphincter dome is now sliding inside the papilla, it was actually going quite softly. Here we can see that the sphincter dome has slid inside the papilla and here on the EUS view, after pulling the scope back a couple of centimeters, we can see the sphincter dome and this is the stone. The sphincter dome is actually crossing the stone and going in the CBD. So we pulled the scope back a little bit and here we can see that bile is entering the sphincter dome and it was confirmed by bile aspiration outside as well. So we placed a guide wire and here we are inserting a stent into the CBD. We thereafter confirmed the placement of stent using EUS. We can see that the stone is over here and we can see that the stent is definitely crossing the stone. Here is the cystic duct and then we decided to do a sphincterotomy. Once the stent was secured and the bilirubin was obtained, we decided to go ahead with opening, doing a liberal sphincterotomy alongside the previously placed stent and here we have been able to do a good sphincterotomy and we can see one of the stones actually dropping out. Just to be a little more safe because the sphincterotomy was wide and the bile duct was dilated, we placed one more stent just in case there was a slippage of the previous stent. After the bilirubin drainage, the patient's pain resolved. She was not having any fever and the WBC counts normalized and six weeks later she delivered a healthy baby. These are the images that are taken when the patient came for follow-up after her delivery. We can see that the two stents are here in situ, they have not migrated. This is almost three months after the procedure and cholangiogram showing at least three stones here. One is behind the scope and two over here. This was a large stone which we could not deliver by ERCP. The patient is now posted for a laser lithotripsy. So can an echo endoscope be used instead of a duodenoscope for trans-papillary bilirubin drainage? While they have similar fields of view, there are certain major differences. The duodenoscope looks backward while the echo endoscope looks slightly forward. This is a comparison of a backwards 5 degree and a forwards 55 degree angle. Also the accessory exit and the elevator spans are quite different for both scopes. This is the usual angle at which we see the papilla with the duodenoscope. The EOS scope looks at it very differently. So it has to be actually manipulated to get into the right view. And then the elevator used with a curved sphincter dome. We actually pre-curved the sphincter dome a little bit to achieve the right angles. So bilirubin drainage in pregnancy is always a challenge, but can the echo endoscope do it all? Can it serve as a diagnostic and therapeutic modality at the same time for trans-papillary bilirubin drainage? While there is certainly an appeal that there is no radiation to the foetus, it will be a single procedure, an on-table confirmation of adequate drainage or CBD clearance. However, there are certain challenges to be overcome. The scope handles very differently. The viewing angles are very shallow. The elevator is much more limited and the forward bending section is much longer for the echo endoscope. However, in carefully selected patients with the right papilla morphology, the right risk profile and depending upon the comfort and the experience of the endoscopist, this may be a modality worth exploring.

echo endoscope

trans-papillary biliary drainage

pregnant patients

biliary sludge

gallstones

biliary drainage in pregnancy