ERCP Bootcamp for the Endoscopy Team (On-demand)

Joyce_Pregnancy
Pdf Summary
ERCP (endoscopic retrograde cholangiopancreatography) is a procedure used for diagnosing and treating bile duct and pancreatic duct diseases. This article discusses the considerations and techniques for performing ERCP in pregnant patients.<br /><br />Gallstones are more common during pregnancy due to hormonal changes. While only a small percentage of pregnant women experience symptoms, a smaller number may develop complications like choledocholithiasis leading to cholangitis and pancreatitis.<br /><br />ERCP may be indicated in cases of cholangitis, biliary pancreatitis, obstructive jaundice, ductal injury, and to confirm CBD stones before cholecystectomy.<br /><br />There are contraindications to performing ERCP in pregnancy, such as placental abruption, imminent delivery, ruptured membranes, and eclampsia.<br /><br />Radiation exposure from fluoroscopy during ERCP can potentially harm the fetus. The American College of Obstetrics and Gynecology states that exposure to less than 5 rad (50mGy) is not associated with harmful effects. Minimizing radiation exposure is crucial, and lead shielding and continuous fetal monitoring can be used.<br /><br />Anesthesia should be administered by an obstetrical anesthesiologist to ensure safety for the mother and fetus. Medications like propofol, meperidine, and midazolam are generally considered safe.<br /><br />Tips for performing ERCP in pregnant patients include delaying the procedure until absolutely necessary, performing it in the second trimester or after delivery if possible, and having a thorough discussion with the patient and family.<br /><br />During the procedure, the patient's position should be adjusted, radiation exposure should be minimized by using techniques like low-dose pulsed fluoroscopy and last image hold, and non-radiation techniques like EUS (endoscopic ultrasound) and cholangioscopy can be considered.<br /><br />Studies have shown varying outcomes in pregnant patients undergoing ERCP, including post-ERCP pancreatitis and higher risks of preterm delivery and low birth weight. Long-term follow-up data is limited.<br /><br />For pregnant physicians performing ERCP, it is important to follow recommendations for limiting radiation exposure and consult the hospital's Radiation Safety Officer. Wearing a fetal monitor and using additional lead shielding may be necessary.<br /><br />In summary, ERCP in pregnancy should be performed by experienced endoscopists using modern fluoroscopy equipment. Second trimester is often considered the safest time to perform the procedure. A multidisciplinary approach involving the patient, family, obstetrics, and anesthesia is crucial. Techniques to minimize radiation exposure and procedure time should be employed, while maintaining safety and effectiveness.
Keywords
ERCP
endoscopic retrograde cholangiopancreatography
bile duct
pancreatic duct
pregnant patients
choledocholithiasis
cholangitis
pancreatitis
CBD stones
radiation exposure