[Endoscopic management of choledocholithiasis during pregnancy]. / Manejo endoscópico de la coledocolitiasis durante el embarazo.

BACKGROUND: Gallstones and extrahepatic biliary obstruction is a difficult management problem during pregnancy. Choledocholithiasis may cause cholangitis or pancreatitis, potentially life-threatening conditions. As surgery may result in significant fetal mortality when performed on these patients. Endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) are preferred and could be performed safely in pregnant women provided suitable precautions are taken to minimize exposure to radiation. OBJECTIVE: To show our experience in ERCP and ES for symptomatic choledocholithiasis during pregnancy. MATERIAL AND PATIENTS: We described our experience in seven young women (mean age, 27.4 years) who presented with symptoms caused by choledocholithiasis, one in first trimester of pregnancy, four in second trimester, and two in third month. All had obstructive jaundice corroborated by abnormal liver function test and dilation of biliary tree on abdominal ultrasound. RESULTS: All had ERCP, ES, and stone extraction without complication and went on to deliver healthy babies at term. A lead apron was positioned over the abdomen of the mother to shield the fetus during roentgenographic fluoroscopy. Mean fluoroscopy time was 26 (range, 5-60 sec). CONCLUSIONS: Endoscopic management should be considered in women presenting with choledocholithiasis during pregnancy.

[Endoscopic diagnosis and treatment of non-traumatic bilhemia. A case report]. / Diagnóstico endoscópico y tratamiento de bilhemia de origen no traumática. Reporte de un caso.

Biliovascular fistulas are abnormal communications with two types of clinical manifestations depending on type of flow in fistulous tract: 1) hemorrhage into biliary tract known as hemobilia, or 2) bile into bloodstream, known as bilhemia. Historically, this complication has been treated with surgery; however, technological progress at present allows treatment with intervention techniques without surgery being mandatory. In 1975, Clemens and Wittrin introduced the term bilhemia, a rare complication of hepatic damage producing excessively high levels of serum bilirubin and moderate rise of hepatic enzymes secondary to post-traumatic intrahepatic biliovenous fistula. Although this pathology is rare, it is considered dangerous; of 50 patients reported in the literature, 25 died due to this problem. The main purpose of treatment is to release tract obstruction by endoscopic sphincterotomy of Vater's papilla or, if the process is localized in proximal areas of biliary tract, through percutaneous biliary drainage or preferably nasobiliary drainage with continuous suction. This procedure can at least produce temporary relief and occasionally fistula closure. A longer effect can be achieved with biliary stent placement. We describe what is, to our knowledge, the first case of diagnosis and successful treatment of non-traumatic bilhemia with endoscopic sphincterotomy and nasobiliary catheter placement.

Endoprótesis biliares: utilidad terapéutica en ictericia obstructiva / Biliary endoprothesis: its therapeutic usefulness in obstructive jaundice

Entre octubre de 1990 y diciembre de 1994, se valoraron 200 pacientes en quienes se colocó endoprótesis en la vía biliar. La distribución por sexo fue de 102 mujeres y 98 hombres, con rangos de edad entre los 18 y los 94 años. Las indicaciones para el procedimiento fueron: obstrucción biliar maligna en 96 casos, coledocolitiasis de difícil manejo en 47, estenosis iatrogénica de la vía biliar en 27, fístula biliar en 12, compresión de colédoco por pancreatitis crónica en nueve, por pancreatitis aguda en seis, colangitis supurativa en dos y un paciente con estenosis de la papila de Vater. Inmediatamente después de la colocación de las prótesis se observó drenaje adecuado de bilis al duoneno. Como complicaciones, se presentaron cinco migraciones, 14 cuadros de obstrucción de las prótesis con colangitis subsecuente, una hemorragia secundaria a esfinterotomía y una prancreatitis grave con defunción. Se concluye que la colocación de endoprótesis es de gran utilidad para mantener permeable la vía biliar. Las pocas complicaciones en manos esperimentadas, su bajo costo y mínima morbimortalidad, la hacen el método de primera elección en los procesos obstructivos de la vía biliar.