Symptomatische Choledocholithiasis in der Schwangerschaft – Einsatz der Sonografie, ERCP und EUS

Zusammenfassung

Anhand einer akuten biliären Pankreatitis bei einer hochschwangeren Patientin wird ein Überblick über die notwendige Diagnostik und die endoskopische Therapie gegeben. Insbesondere der Sonografie kommt eine zentrale Stellung für das weitere Prozedere zu. Gelingt es nicht, aus Klinik, Laborchemie und perkutaner Sonografie eine ausreichend fundierte Entscheidung zu treffen, so stellt die Endosonografie (oder die extraduktal applizierte Minisondentechnik) die Methode der Wahl für das weitere diagnostische Vorgehen dar. Diese invasive diagnostische Methode sollte jedoch in ERCP-Bereitschaft erfolgen, um hier zum Schutze des Fetus schnell und mittels nur einer Sedierung der Mutter zum definitiven Ergebnis zu kommen. Da eine ERCP in der Schwangerschaft immer eine Belastung für Mutter und Fetus darstellt und die Strahlenbelastung so gering wie möglich gehalten werden sollte, ist dieser Eingriff, da er unter Zeitdruck erfolgt, grundsätzlich nur von erfahrenen Untersuchern durchzuführen. Unter optimalen Bedingungen stellen Endosonografie und ERCP auch in der Schwangerschaft risikoarme Eingriffe dar.

Abstract

We present an overview of the management of acute bilary pancreatitis in pregnancy with particular reference to endoscopy. Ultrasound is the gold standard for diagnosis. If clinical symptoms, laboratory parameters and transabdominal ultrasound do not allow appropriate decision making, endoscopic ultrasound (EUS) is the method of choice. EUS is preferably performed prior to ERCP during the same clinical session, this is of particular relevance for pregnant women with regards to the safety of mother and fetus. However, because the procedure is performed under fluoroscopic guidance, there are potential risks related to the radiation exposure. ERCP, especially in pregnant patients demands high expertise from the endoscopist, and with due diligence and attention to detail, the procedure can be safely performed.

Schlüsselwörter

Schwangerschaft - Cholelithiasis - Choledocholithiasis - Pankreatitis

Key words

pregnancy - cholelithiasis - choledocholithiasis - pancreatitis

Literatur

• 1 Glasgow R E, Visser B C, Harris H W et al. Changing management of gallstone disease during pregnancy.  Surg Endosc. 1998;  12 (3) 241-246
• 2 Everson G T. Gallbladder function in gallstone disease.  Gastroenterol Clin North Am. 1991;  20 (1) 85-110
• 3 Al Hashem H, Muralidharan V, Cohen H et al. Biliary disease in pregnancy with an emphasis on the role of ERCP.  J Clin Gastroenterol. 2009;  43 (1) 58-62
• 4 Tsimoyiannis E C, Antoniou N C, Tsaboulas C et al. Cholelithiasis during pregnancy and lactation. Prospective study.  Eur J Surg. 1994;  160 (11) 627-631
• 5 Pannwitz H, Nurnberg D, Berndt H. Epidemiology of gallbladder calculi in young females.  Leber Magen Darm. 1990;  20 (4) 189-192, 194
• 6 Porras L TC, Napoli E D, Canullan C M et al. Minimally invasive management of acute bilary tract disease during pregnancy.  HPB Surg. 2009;  published online, ID 829020 DOI: 10.1155/2009/829020
• 7 Lu E J, Curet M J, El Sayed Y Y et al. Medical versus surgical management of biliary tract disease in pregnancy.  Am J Surg. 2004;  188 (6) 755-759
• 8 Printen K J, Ott R A. Cholecystectomy during pregnancy.  Am Surg. 1978;  44 (7) 432-434
• 9 Nesbitt T H, Kay H H, McCoy M C et al. Endoscopic management of biliary disease during pregnancy.  Obstet Gynecol. 1996;  87 (5 Pt 2) 806-809
• 10 Akcakaya A, Ozkan O V, Okan I et al. Endoscopic retrograde cholangiopancreatography during pregnancy without radiation.  World J Gastroenterol. 2009;  15 36-52
• 11 Swisher S G, Hunt K K, Schmit P J et al. Management of pancreatitis complicating pregnancy.  Am Surg. 1994;  60 (10) 759-762
• 12 Chen C P, Wang K G, Su T H et al. Acute pancreatitis in pregnancy.  Acta Obstet Gynecol Scand. 1995;  74 (8) 607-610
• 13 Freistuhler M, Braess A, Petrides A S. Ultrasound-controlled endoscopic papillotomy in pregnancy in severe biliary pancreatitis.  Z Gastroenterol. 1999;  37 (1) 27-30
• 14 Dabbas N, Abdelaziz M, Hamdan K et al. Gallstone-induced perforation of the common bile duct in pregnancy.  HPB Surg. 2008;  published online, ID 174202 DOI: 10.1155/2008/174202
• 15 Piotrowski J J, Van Stiegmann G, Liechty R D. Spontaneous bile duct rupture in pregnancy.  HPB Surg. 1990;  2 (3) 205-209
• 16 Hendrickx L, Van Hee R H, Hubens A. Spontaneous rupture of the cystic duct during pregnancy.  Neth J Surg. 1981;  33 (5) 247-249
• 17 Kapoor V K. Management of bile duct injuries: a practical approach.  Am Surg. 2009;  75 (12) 1157-1160
• 18 Scott L D. Gallstone disease and pancreatitis in pregnancy.  Gastroenterol Clin North Am. 1992;  21 (4) 803-815
• 19 Dietrich C F, Gouder S, Hocke M et al. Endosonographie der Choledocholithiasis und ihrer Differentialdiagnosen.  Endoskopie Heute. 2004;  17 160-166
• 20 Portincasa P, Altomare D F, Moschetta A et al. The effect of acute oral erythromycin on gallbladder motility and on upper gastrointestinal symptoms in gastrectomized patients with and without gallstones: a randomized, placebo-controlled ultrasonographic study.  Am J Gastroenterol. 2000;  95 (12) 3444-3451
• 21 Tseng M, Everhart J E, Sandler R S. Dietary intake and gallbladder disease: a review.  Public Health Nutr. 1999;  2 (2) 161-172
• 22 Hauters P, Neve d R, Pourbaix de A et al. Cholelithiasis: a serious complication after total gastrectomy.  Br J Surg. 1988;  75 (9) 899-900
• 23 Misciagna G, Centonze S, Leoci C et al. Diet, physical activity, and gallstones – a population-based, case-control study in southern Italy.  Am J Clin Nutr. 1999;  69 (1) 120-126
• 24 Caroli-Bosc F X, Deveau C, Peten E P et al. Cholelithiasis and dietary risk factors: an epidemiologic investigation in Vidauban, Southeast France. General Practitioner’s Group of Vidauban.  Dig Dis Sci. 1998;  43 (9) 2131-2137
• 25 Kratzer W, Kron M, Hay B et al. Prevalence of cholecystolithiasis in South Germany – an ultrasound study of 2,498 persons of a rural population.  Z Gastroenterol. 1999;  37 (12) 1157-1162
• 26 Grimes D A. Spontaneous perforation of the gallbladder from cholecystitis with acute appendicitis in pregnancy. A case report.  J Reprod Med. 1996;  41 (6) 450-452
• 27 Petrozza J C, Mastrobattista J M, Monga M. Gallbladder perforation in pregnancy.  Am J Perinatol. 1995;  12 (5) 339-341
• 28 Dhupar R, Smaldone G M, Hamad G G. Is there a benefit to delaying cholecystectomy for symptomatic gallbladder disease during pregnancy?.  Surg Endosc. 2010;  24 (1) 108-112
• 29 Glenn F S, McSherry C K, Charles K. Gallstones and pregnancy among 200 young women treated with Cholecystectomy.  Surg Gynecol Obset. 1992;  175 41-46
• 30 Ramin K D, Ramin S M, Richey S D et al. Acute pancreatitis in pregnancy.  Am J Obstet Gynecol. 1995;  173 (1) 187-191
• 31 Uomo G, Manes G, Picciotto F P et al. Endoscopic treatment of acute biliary pancreatitis in pregnancy.  J Clin Gastroenterol. 1994;  18 (3) 250-252
• 32 Karakan T, Cindoruk M, Alagozlu H et al. EUS versus endoscopic retrograde cholangiography for patients with intermediate probability of bile duct stones: a prospective randomized trial.  Gastrointest Endosc. 2009;  69 (2) 244-252
• 33 Johnson A G, Hosking S W. Appraisal of the management of bile duct stones.  Br J Surg. 1987;  74 (7) 555-560
• 34 Murison M S, Gartell P C, McGinn F P. Does selective peroperative cholangiography result in missed common bile duct stones?.  J R Coll Surg Edinb. 1993;  38 (4) 220-224
• 35 Sherman S, Ruffolo T A, Hawes R H et al. Complications of endoscopic sphincterotomy. A prospective series with emphasis on the increased risk associated with sphincter of Oddi dysfunction and nondilated bile ducts.  Gastroenterology. 1991;  101 (4) 1068-1075
• 36 Lambert M E, Betts C D, Hill J et al. Endoscopic sphincterotomy: the whole truth.  Br J Surg. 1991;  78 (4) 473-476
• 37 Masci E, Toti G, Mariani A et al. Complications of diagnostic and therapeutic ERCP: a prospective multicenter study.  Am J Gastroenterol. 2001;  96 (2) 417-423
• 38 Halme L, Doepel M, Numers von H et al. Complications of diagnostic and therapeutic ERCP.  Ann Chir Gynaecol. 1999;  88 (2) 127-131
• 39 Brandes J W, Scheffer B, Lorenz-Meyer H et al. ERCP: Complications and prophylaxis a controlled study.  Endoscopy. 1981;  13 (1) 27-30
• 40 Loperfido S, Angelini G, Benedetti G et al. Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study.  Gastrointest Endosc. 1998;  48 (1) 1-10
• 41 Thatcher B S, Sivak Jr M V, Tedesco F J et al. Endoscopic sphincterotomy for suspected dysfunction of the sphincter of Oddi.  Gastrointest Endosc. 1987;  33 (2) 91-95
• 42 Neoptolemos J P, Bailey I S, Carr-Locke D L. Sphincter of Oddi dysfunction: results of treatment by endoscopic sphincterotomy.  Br J Surg. 1988;  75 (5) 454-459
• 43 Roberts-Thomson I C, Toouli J. Is endoscopic sphincterotomy for disabling biliary-type pain after cholecystectomy effective?.  Gastrointest Endosc. 1985;  31 (6) 370-373
• 44 Geenen J E, Hogan W J, Dodds W J et al. The efficacy of endoscopic sphincterotomy after cholecystectomy in patients with sphincter-of-Oddi dysfunction.  N Engl J Med. 1989;  320 (2) 82-87
• 45 Wojtun S, Gil M, Gil J. Recognition of ERC-induced pancreatitis in patients with choledocholithiasis by an analysis of laboratory findings.  Hepatogastroenterology. 2000;  47 (32) 550-553
• 46 Freeman M L, Nelson D B, Sherman S et al. Complications of endoscopic biliary sphincterotomy.  N Engl J Med. 1996;  335 (13) 909-918
• 47 Sharma S K, Larson K A, Adler Z et al. Role of endoscopic retrograde cholangiopancreatography in the management of suspected choledocholithiasis.  Surg Endosc. 2003;  17 (6) 868-871
• 48 Sivak Jr M V. EUS for bile duct stones: how does it compare with ERCP?.  Gastrointest Endosc. 2002;  56 (6 Suppl) S175-S177
• 49 Thorboll J, Vilmann P, Jacobsen B et al. Endoscopic ultrasonography in detection of cholelithiasis in patients with biliary pain and negative transabdominal ultrasonography.  Scand J Gastroenterol. 2004;  39 (3) 267-269
• 50 Amouyal P, Amouyal G, Levy P et al. Diagnosis of choledocholithiasis by endoscopic ultrasonography.  Gastroenterology. 1994;  106 (4) 1062-1067
• 51 Amouyal P, Palazzo L, Amouyal G et al. Endosonography: promising method for diagnosis of extrahepatic cholestasis.  Lancet. 1989;  2 (8673) 1195-1198
• 52 Paul A, Millat B, Holthausen U et al. Diagnosis and treatment of common bile duct stones (CBDS). Results of a consensus development conference. Scientific Committee of the European Association for Endoscopic Surgery (E.A.E.S.).  Surg Endosc. 1998;  12 (6) 856-864
• 53 Sugiyama M, Atomi Y. Acute biliary pancreatitis: the roles of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography.  Surgery. 1998;  124 (1) 14-21
• 54 Sugiyama M, Atomi Y. Endoscopic ultrasonography for diagnosing choledocholithiasis: a prospective comparative study with ultrasonography and computed tomography.  Gastrointest Endosc. 1997;  45 (2) 143-146
• 55 Chak A, Hawes R H, Cooper G S et al. Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis.  Gastrointest Endosc. 1999;  49 (5) 599-604
• 56 Kumar M, Prashad R, Kumar A et al. Relative merits of ultrasonography, computed tomography and cholangiography in patients of surgical obstructive jaundice.  Hepatogastroenterology. 1998;  45 (24) 2027-2032
• 57 Shim C S, Joo J H, Park C W et al. Effectiveness of endoscopic ultrasonography in the diagnosis of choledocholithiasis prior to laparoscopic cholecystectomy.  Endoscopy. 1995;  27 (6) 428-432
• 58 Varghese J C, Liddell R P, Farrell M A et al. The diagnostic accuracy of magnetic resonance cholangiopancreatography and ultrasound compared with direct cholangiography in the detection of choledocholithiasis.  Clin Radiol. 1999;  54 (9) 604-614
• 59 Horrow M M. Ultrasound of the extrahepatic bile duct: issues of size.  Ultrasound Q. 2010;  26 (2) 67-74
• 60 Meyenberger C, Bertschinger P, Wirth H P et al. Dilatation of the common bile duct: what does endoscopic sonography contribute?.  Schweiz Med Wochenschr. 1994;  124 (15) 642-648
• 61 Ascunce G, Ribeiro A, Rocha-Lima C et al. Single-session endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography for evaluation of pancreaticobiliary disorders.  Surg Endosc. 2010;  24 (6) 1447-1450
• 62 Petrone M C, Arcidiacono P G, Testoni P A. Endoscopic ultrasonography for evaluating patients with recurrent pancreatitis.  World J Gastroenterol. 2008;  14 (7) 1016-1022
• 63 Norton S A, Alderson D. Prospective comparison of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the detection of bile duct stones.  Br J Surg. 1997;  84 (10) 1366-1369
• 64 Williams E J, Green J, Beckingham I et al. Guidelines on the management of common bile duct stones (CBDS).  Gut. 2008;  57 (7) 1004-1021
• 65 Maluf-Filho F, Dotti C M, Halwan B et al. An evidence-based consensus statement on the role and application of endosonography in clinical practice.  Endoscopy. 2009;  41 (11) 979-987
• 66 Lachter J, Rubin A, Shiller M et al. Linear EUS for bile duct stones.  Gastrointest Endosc. 2000;  51 (1) 51-54
• 67 Kohut M, Nowakowska-Dulawa E, Marek T et al. Accuracy of linear endoscopic ultrasonography in the evaluation of patients with suspected common bile duct stones.  Endoscopy. 2002;  34 (4) 299-303
• 68 Buscarini E, Tansini P, Vallisa D et al. EUS for suspected choledocholithiasis: do benefits outweigh costs? A prospective, controlled study.  Gastrointest Endosc. 2003;  57 (4) 510-518
• 69 Amouyal P, Amouyal G, Levy P et al. Diagnosis of choledocholithiasis by endoscopic ultrasonography.  Gastroenterology. 1994;  106 (4) 1062-1067
• 70 Amouyal P, Palazzo L, Amouyal G et al. Endosonography: promising method for diagnosis of extrahepatic cholestasis.  Lancet. 1989;  2 (8673) 1195-1198
• 71 Aubertin J M, Levoir D, Bouillot J L et al. Endoscopic ultrasonography immediately prior to laparoscopic cholecystectomy: a prospective evaluation.  Endoscopy. 1996;  28 (8) 667-673
• 72 Lédinghen de V, Lecesne R, Raymond J M et al. Diagnosis of choledocholithiasis: EUS or magnetic resonance cholangiography? A prospective controlled study.  Gastrointest Endosc. 1999;  49 (1) 26-31
• 73 Edmundowicz S A, Aliperti G, Middleton W D. Preliminary experience using endoscopic ultrasonography in the diagnosis of choledocholithiasis.  Endoscopy. 1992;  24 (9) 774-778
• 74 Lachter J, Rubin A, Shiller M et al. Linear EUS for bile duct stones.  Gastrointest Endosc. 2000;  51 (1) 51-54
• 75 Montariol T, Msika S, Charlier A et al. Diagnosis of asymptomatic common bile duct stones: preoperative endoscopic ultrasonography versus intraoperative cholangiography – a multicenter, prospective controlled study. French Associations for Surgical Research.  Surgery. 1998;  124 (1) 6-13
• 76 Palazzo L, Girollet P P, Salmeron M et al. Value of endoscopic ultrasonography in the diagnosis of common bile duct stones: comparison with surgical exploration and ERCP.  Gastrointest Endosc. 1995;  42 (3) 225-231
• 77 Polkowski M, Palucki J, Regula J et al. Helical computed tomographic cholangiography versus endosonography for suspected bile duct stones: a prospective blinded study in non-jaundiced patients.  Gut. 1999;  45 (5) 744-749
• 78 Prat F, Amouyal G, Amouyal P et al. Prospective controlled study of endoscopic ultrasonography and endoscopic retrograde cholangiography in patients with suspected common-bileduct lithiasis.  Lancet. 1996;  347 (8994) 75-79
• 79 Sugiyama M, Atomi Y. Acute biliary pancreatitis: the roles of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography.  Surgery. 1998;  124 (1) 14-21
• 80 Sugiyama M, Atomi Y. Endoscopic ultrasonography for diagnosing choledocholithiasis: a prospective comparative study with ultrasonography and computed tomography.  Gastrointest Endosc. 1997;  45 (2) 143-146
• 81 Liu C L, Lo C M, Chan J K et al. Detection of choledocholithiasis by EUS in acute pancreatitis: a prospective evaluation in 100 consecutive patients.  Gastrointest Endosc. 2001;  54 (3) 325-330
• 82 Chak A, Hawes R H, Cooper G S et al. Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis.  Gastrointest Endosc. 1999;  49 (5) 599-604
• 83 Norton S A, Alderson D. Prospective comparison of endoscopic ultrasonography and endoscopic retrograde cholangiopancreatography in the detection of bile duct stones.  Br J Surg. 1997;  84 (10) 1366-1369
• 84 O’Toole D, Palazzo L. Choledocholithiasis – a practical approach from endosonographer.  Endoscopy. 2006;  38 523-529
• 85 Liu C L, Lo C M, Chan J K et al. EUS for detection of occult cholelithiasis in patients with idiopathic pancreatitis.  Gastrointest Endosc. 2000;  51 (1) 28-32
• 86 Kohut M, Nowak A, Nowakowska-Dulawa E et al. Endosonography with linear array instead of endoscopic retrograde cholangiography as the diagnostic tool in patients with moderate suspicion of common bile duct stones.  World J Gastroenterol. 2003;  9 (3) 612-614
• 87 Prat F, Edery J, Meduri B et al. Early EUS of the bile duct before endoscopic sphincterotomy for acute biliary pancreatitis.  Gastrointest Endosc. 2001;  54 (6) 724-729
• 88 Shaffer E A. Gallbladder sludge: what is its clinical significance?.  Curr Gastroenterol Rep. 2001;  3 (2) 166-173
• 89 Chak A, Hawes R H, Cooper G S et al. Prospective assessment of the utility of EUS in the evaluation of gallstone pancreatitis.  Gastrointest Endosc. 1999;  49 (5) 599-604
• 90 Menzel J, Domschke W. Gastrointestinal miniprobe sonography: the current status.  Am J Gastroenterol. 2000;  95 (3) 605-616
• 91 Wehrmann T, Martchenko K, Riphaus A. Catheter probe extraductal ultrasonography vs. conventional endoscopic ultrasonography for detection of bile duct stones.  Endoscopy. 2009;  41 (2) 133-137
• 92 Seifert H, Wehrmann T, Hilgers R et al. Catheter probe extraductal EUS reliably detects distal common bile duct abnormalities.  Gastrointest Endosc. 2004;  60 (1) 61-67
• 93 Lédinghen de V, Lecesne R, Raymond J M et al. Diagnosis of choledocholithiasis: EUS or magnetic resonance cholangiography? A prospective controlled study.  Gastrointest Endosc. 1999;  49 (1) 26-31
• 94 Taylor A C, Little A F, Hennessy O F et al. Prospective assessment of magnetic resonance cholangiopancreatography for noninvasive imaging of the biliary tree.  Gastrointest Endosc. 2002;  55 (1) 17-22
• 95 Scheiman J M, Carlos R C, Barnett J L et al. Can endoscopic ultrasound or magnetic resonance cholangiopancreatography replace ERCP in patients with suspected biliary disease? A prospective trial and cost analysis.  Am J Gastroenterol. 2001;  96 (10) 2900-2904
• 96 Lomas D J, Bearcroft P W, Gimson A E. MR cholangiopancreatography: prospective comparison of a breath-hold 2D projection technique with diagnostic ERCP.  Eur Radiol. 1999;  9 (7) 1411-1417
• 97 Linares T P, Vivas A S, Espinel D J et al. Current status of endoscopic retrograde cholangiopancreatography. What is the effect of the introduction of magnetic resonance cholangiography?.  Gastroenterol Hepatol. 2001;  24 (10) 483-488
• 98 Hussein F M, Alsumait B, Aman S et al. Diagnosis of choledocholithiasis and bile duct stenosis by magnetic resonance cholangiogram.  Australas Radiol. 2002;  46 (1) 41-46
• 99 Griffin N, Wastle M L, Dunn W K et al. Magnetic resonance cholangiopancreatography versus endoscopic retrograde cholangiopancreatography in the diagnosis of choledocholithiasis.  Eur J Gastroenterol Hepatol. 2003;  15 (7) 809-813
• 100 Varghese J C, Liddell R P, Farrell M A et al. The diagnostic accuracy of magnetic resonance cholangiopancreatography and ultrasound compared with direct cholangiography in the detection of choledocholithiasis.  Clin Radiol. 1999;  54 (9) 604-614
• 101 Soehendra N. Surgery in pregnancy from an endoscopy viewpoint.  Langenbecks Arch Chir. 1981;  355 229-231
• 102 Morrell D G, Mullins J R, Harrison P B. Laparoscopic cholecystectomy during pregnancy in symptomatic patients.  Surgery. 1992;  112 (5) 856-859
• 103 McKellar D P, Anderson C T, Boynton C J et al. Cholecystectomy during pregnancy without fetal loss.  Surg Gynecol Obstet. 1992;  174 (6) 465-468
• 104 Wilkinson E J. Acute pancreatitis in pregnancy: a review of 98 cases and a report of 8 new cases.  Obstet Gynecol Surv. 1973;  28 (5) 281-303
• 105 Curet M J. Laparoscopic surgery in pregnant patients. San Diego, California USA; 1997
• 106 Sungler P, Heinerman P M, Steiner H et al. Laparoscopic cholecystectomy and interventional endoscopy for gallstone complications during pregnancy.  Surg Endosc. 2000;  14 (3) 267-271
• 107 Baillie J, Cairns S R, Putman W S et al. Endoscopic management of choledocholithiasis during pregnancy.  Surg Gynecol Obstet. 1990;  171 (1) 1-4
• 108 Baron T H, Schueler B A. Pregnancy and radiation exposure during therapeutic ERCP: time to put the baby to bed?.  Gastrointest Endosc. 2009;  69 (4) 832-834
• 109 Drury K A, Spalding E, Donaldson D et al. Floppy-infant syndrome: Is oxazepam the answer?.  Lancet. 1977;  2 (8048) 1126-1127
• 110 Speight A N. Floppy-infant syndrome and maternal diazepam and/or nitrazepam.  Lancet. 1977;  2 (8043) 878
• 111 Haram K. „Floppy infant syndrome” and maternal diazepam.  Lancet. 1977;  2 (8038) 612-613
• 112 Chong V H, Jalihal A. Endoscopic management of biliary disorders during pregnancy.  Hepatobiliary Pancreat Dis Int. 2010;  9 (2) 180-185
• 113 Brownsey A. Study examines radiation dose estimates for pregnant women undergoing therapeutic ERCP.  American Society for Gastrointestinal Endoscopy. 2009;  70 734-736
• 114 Samara E T, Stratakis J, Enele Melono J M et al. Therapeutic ERCP and pregnancy: is the radiation risk for the conceptus trivial?.  Gastrointest Endosc. 2009;  69 (4) 824-831
• 115 Chong V H. EUS complements ERCP during pregnancy.  Gastrointest Endosc. 2009;  70 (6) 1285-1286