Gadolinium as an alternative contrast agent for therapeutic ERCP in the iodine-allergic patient

Introduction

Radiographic visualization of the pancreaticobiliary tree at endoscopic retrograde cholangiopancreatography (ERCP) requires an intraductal contrast agent. The standard contrast medium for ERCP is a water-soluble iodine-based agent. However, there are occasions in which use of iodine-based agents is ill advised. Patients who have previously had a severe adverse reaction to contrast are at greatest risk of having another upon re-exposure. Prophylaxis with steroids is felt to offer some measure of protection and is generally advised [1] [2].

Nonallergic contraindications (e. g., thyrotoxicosis) may allow few alternatives. Urgency of the intervention may not allow an appropriate time interval for contrast allergy prophylaxis. Air cholangiography [3] or direct cholangioscopy are options in such situations. We report the use of gadolinium as the sole contrast agent for ERCP in the following examples where a history of allergy precluded the use of iodinated contrast.

Patient 1

A 65-year-old gentleman underwent outpatient evaluation for jaundice developing in the context of weight loss and epigastric pain. Endoscopic ultrasonography (EUS) and ERCP were arranged as open endoscopy procedures without a preprocedure clinic visit as the travel distance was prohibitive. The preprocedure assessment immediately before the endoscopies uncovered a history of iodine-based contrast allergy described as itching and hives after contrast-enhanced CT scan. After additional informed consent from the patient to address the risk of contrast reaction more specifically, ERCP was performed using gadodiamide (Omniscan; Nycomed, Princeton, NJ, USA).

Biliary cannulation was achieved using a guidewire cannulation technique with the angled 0.035-inch guide wire and was confirmed by aspiration. Full-strength gadodiamide in the amount of 15 ml was injected, producing the cholangiogram in [Fig. 1]. A stricture of the distal common bile duct could be visualized radiographically. Palliation was provided with a 10-Fr biliary stent.

Fig. 1 Patient 1. Cholangiogram demonstrates a duct cut-off (arrow) with a mildly dilated biliary tree upstream.

No post-ERCP complications were observed. Pre-ERCP liver profile showed alkaline phosphatase 961 IU/L (reference range 25 – 100 IU/L) and total bilirubin 5.9 mg/dl (0.2 – 1.3 mg/dl). Lab results 6 weeks following stent placement showed normal total bilirubin (0.3 mg/dl).

Patient 2

A 45-year-old woman was evaluated in pancreaticobiliary clinic for sphincter of Oddi dysfunction type II on the basis of typical pain and dynamic liver function test (LFT) abnormalities. She reported a prior history of anaphylaxis (throat swelling, syncope) in response to iodine-based contrast following CT scan at another center. The following day she underwent ERC with biliary manometry and biliary sphincterotomy. The cholangiogram performed with gadodiamide was normal ([Fig. 2]). A pancreatogram was not attempted for fear of a suboptimal image. There were no post-ERC complications.

The patient returned 5 months later with recurrent pain after a prolonged symptom-free interval. ERCP was planned for evaluation of pancreatic sphincter hypertension. There was concern regarding the likely quality of pancreatography with a non-iodine-based agent, so the patient was given corticosteroids and H₁-blocker prophylactically with the thought that an iodine-based agent would probably be needed.

Pancreatic manometry, performed after aspiration confirmed location, was normal. Biliary manometry likewise was normal. A pancreatogram using full-strength gadopentetate dimeglumine (Magnevist; Bayer Schering Pharma, Montville, NJ, USA) was normal ([Fig. 3]). A prophylactic small-caliber pancreatic duct stent was placed over a 0.018-inch guide wire. There were no post-ERCP complications.

Fig. 2 Patient 2. Normal cholangiogram. Fig. 3 Patient 2. 5 months after the image in Fig. 2 was made. The 0.018-inch guide wire rests within the main pancreatic duct, faintly outlined (arrows) with contrast.

Patient 3

A 29-year-old man was referred for sphincter of Oddi dysfunction type II on the basis of typical pain and dynamic LFT abnormalities. He had experienced rash, itching, and wheezing after previous intravenous iodine-based contrast exposure. Prophylaxis for iodine-based contrast was prescribed in the event that noniodinated contrast provided inadequate visualization. Biliary manometry was normal; cholangiogram using gadodiamide was also normal ([Fig. 4]), but pancreatic manometry was abnormal. The normal pancreatogram is shown ([Fig. 5]). A dual sphincterotomy was effected. Subsequently, a small-caliber pancreatic duct stent was placed over the 0.018-inch guide wire. The patient experienced post-ERCP pain, without pancreatic enzyme elevation, requiring hospitalization that resolved with conservative measures 72 hours after the procedure.

Fig. 4 Patient 3. Normal cholangiogram; catheter can be seen in the cystic duct stump. Fig. 5 Patient 3. The pancreatogram before sphincterotomy. A patent dorsal duct is apparent (arrow).

Patient 4

A 34-year-old woman was transferred for urgent ERCP after developing a postcholecystectomy bile leak; a same-day return to her referring facility had been arranged. She reported having experienced severe pruritus associated with intravenous pyelogram a decade earlier. Circumstances did not permit an appropriate prophylaxis interval. ERCP was therefore completed using gadodiamide.

A leak from the cystic duct stump was identified ([Fig. 6]). This was treated with a 10-Fr biliary stent. No postprocedure complications were identified. The leak resolved.

Fig. 6 Patient 4. Cystic duct stump leak (stars) following cholecystectomy.

Patient 5

A 60-year-old man was seen in pancreaticobiliary clinic for an urgent visit. He demonstrated clinical features of cholangitis and was admitted to hospital (initially the intensive care unit because of hypotension). The patient and family recalled an iodine-based contrast allergy event corroborated in data provided by the referring physician. There was concern about the use of prophylactic corticosteroids because of the active infectious issues, and the decision was made to forgo the use of an iodine-based agent.

The cholangiogram using full-strength gadodiamide was remarkable for several filling defects of the common bile duct ([Fig. 7 a]). A biliary sphincterotomy was effected, followed by biliary stent placement. The decision was made not to attempt duct clearance given the presence of purulent bile and suboptimal fluoroscopic views with the gadolinium-based agent. The cholangitis resolved following endoscopic decompression, and the patient was discharged. He returned 4 weeks later, iodine-based contrast was used after appropriate prophylaxis, and stone extraction was completed ([Fig. 7 b]).

Fig. 7 Patient 5. a Filling defects within the distal bile duct visualized using gadolinium-based contrast agent. b Iodine-based agent in the same patient gives clearly superior visualization.

References

• 1 American College of Radiology .Manual on Contrast Media, v.6, 2008. Accessible at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/contrast_manual.aspx
• 2 Lasser E C, Berry C C, Mishkin M M. et al . Pretreatment with corticosteroids to prevent adverse reactions to nonionic contrast media.  AJR Am J Roentgenol. 1994;  162 523-526
• 3 Mosca S, Secondulfo M, Defez M. et al . Air contrastography technique for successful urgent ERCP in a high risk allergic patient.  Am J Gastroenterol. 2001;  96 3458-3460
• 4 Dorta G, Uske A, Blum A L. Meglumine gadoterate: a new safe radiocontrast medium for endoscopic retrograde cholangiopancreatography?.  Digestion. 1997;  58 289-292
• 5 Vehmas T, Markkola A T. Gd-DTPA as an alternative contrast agent in conventional and interventional radiology.  Acta Radiologica. 1998;  39 223-226
• 6 Maluf-Filho F, Rocha M S, Sakai P. Use of a neutral gadolinium chelate as a contrast medium for ERCP: case report.  Gastrointest Endosc. 2005;  61 917-918
• 7 Mishkin D, Carpenter S, Croffie J, Chuttani R. et al . ASGE technology status evaluation report: radiographic contrast media used in ERCP.  Gastrointest Endosc. 2005;  62 480-484
• 8 Draganov P, Cottton P B. Iodinated contrast sensitivity in ERCP.  Am J Gastroenterol. 2000;  95 1398-1401
• 9 Draganov P, Pan J-J, Forsmark C. Prospective evaluation of adverse reactions to iodine-containing contrast media after ERCP [abstract].  Gastrointest Endosc. 2008;  67 AB107
• 10 Cochran S T, Bomyea K, Sayre J W. Trends in adverse events after IV administration of contrast media.  AJR. 2001;  176 1385-1388
• 11 Morcos S K, Thomsen H S. Adverse reactions to iodinated contrast media.  Eur Radiol. 2001;  11 1267-1275
• 12 Slack J D, Slack L A, Orr C. Recurrent severe reaction to iodinated contrast media during cardiac catheterization.  Heart Lung. 1982;  11 348-352
• 13 Mosca S, Secondulfo M, Defez M. et al . Air contrastography technique for successful urgent ERCP in a high risk allergic patient.  Am J Gastroenterol. 2001;  96 3458-3460
• 14 Ersoy H, Rybicki F J. Biochemical safety profiles of gadolinium-based extracellular contrast agents and nephrogenic systemic fibrosis. J Magn Reson.  Imaging. 2007;  26 1190-1197
• 15 Williams M D, Moody A B, Newlands C A, Howlett D C. Gadolinium an alternative contrast agent for sialography in patients with iodine sensitivity.  Int J Maxillofac Surg. 2003;  32 651-652
• 16 Spinosa D J, Kaufmann J A, Hartwell G D. Gadolinium chelates in angiography and interventional radiology: a useful alternative to iodinated contrast media for angiography.  Radiology. 2002;  223 319-325
• 17 Spinosa D J, Angle J F, Hagspiel K D. et al . Interventional uroradiologic procedures performed using gadodiamide as an alternative to iodinated contrast material.  Cardiovasc Intervent Radiol. 2000;  23 72-75
• 18 Amar A P, Larsen D W, Teitelbaum G P. Percutaneous carotid angioplasty and stenting with the use of gadolinium in lieu of iodinated contrast medium: technical case report and review of the literature.  Neurosurgery. 2001;  49 1262-1265; discussion 1265–1266
• 19 Strunk H M, Schild H. Actual clinical use of gadolinium-chelates for non-MRI applications.  Eur Radiol. 2004;  14 1055-1062
• 20 Nelson K L, Gifford L M, Lauder-Huber C. et al . Clinical safety of gadopentate dimeglumine.  Radiology. 1995;  196 439-443
• 21 Shellock F G, Kanal E. Safety of magnetic resonance imaging contrast agents.  J Magn Reson Imaging. 1999;  10 477-484