Spyglass Cholangioscopy for Management of Choledocholithiasis During Pregnancy: Decreasing Fetal Risks with Advancement in Technology: 2010 ACG/AstraZeneca Clinical Vignette Award, 2010 Presidential Poster: 581

Purpose: Gallstone formation is a frequent occurrence during pregnancy. Management of gallstone complications must address concerns for both mother and fetus. Gallstone pancreatitis is a potentially life threatening complication. An ERCP may be a necessary intervention for treatment during pregnancy. However, the potential risks of ionizing radiation for the fetus are high. Avoidance of radiation exposure during pregnancy is optimal, but may not always be possible. We present a case of ERCP gallstone identification and extraction without radiation during pregnancy with the use of the Spyglass Direct Visualization System. Results: A 26-year-old G3P2 woman, in her first trimester of pregnancy, presented with post-prandial abdominal pain and vomiting. Her exam was significant for jaundice. Laboratory studies revealed an elevated lipase of 3175 U/L and bilirubin 3.9 mg/dL (direct 1.5 mg/dL). Transabdominal ultrasound showed choledocholithiasis and bile duct dilation to 12 mm diameter. An ERCP with sphincterotomy and stone extraction facilitated by Spyglass Direct Visualization System was performed. The major papilla was cannulated with a 4.4 Fr sphincterotome and hydrophilic 0.035” guidewire. Bile was seen flowing around the guidewire. The sphincterotome was then advanced over the wire, and 10 cc of clear yellow bile was aspirated. A biliary sphincterotomy was performed, and the bile duct was swept with a 9 mm extraction balloon. A single 8 mm stone was easily extracted. The Spyglass SpyScope was exchanged over the guidewire and cholangioscopy was performed. The common bile duct, common hepatic duct, and left and right intrahepatic ducts were directly visualized. Debris and two additional 2 mm stones were seen in the bile duct. Saline lavage through the cholangioscope flushed the residual stones into the duodenum. The entire procedure was performed without the use of fluoroscopy. The patient tolerated the procedure well with complete resolution of her symptoms and normalization of the laboratory values. Conclusion: Management of a pregnant woman with choledocholithiasis presents specific challenges. Gallstone complications may require the performance of an ERCP. Minimization of fluoroscopy use during pregnancy is optimal. We describe the ability to completely eliminate ionizing radiation exposure during biliary stone identification and extraction using the Spyglass Direct Visualization System. This technological advancement enhances diagnostic and therapeutic biliary intervention and minimizes fetal risks.