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Answer 2
  1. ERCP now followed by cholecystectomy in the second trimester. Gallstones and gallstone-related diseases are common in pregnancy. The case patient’s acute cholecystitis has been brought under control by fluids and antibiotics. Her dilated ducts and lack of resolution of her jaundice and the elevations of her transaminases strongly point to a stone or stones in the common bile duct (choledocholithiasis). In addition, the patient is at high risk for recurrent cholecystitis. The best course of action would be to perform ERCP now (with appropriate pregnancy precautions) to remove the stone(s) and allow normal internal biliary drainage, followed by cholecystectomy in the second trimester, when the surgery is generally felt to be safe. Failure to drain the biliary tree would put the patient at risk for pancreatitis and/or cholangitis. ERCP alone would not remove the risk of cholecystitis. Percutaneous transhepatic cholangiography usually would only be attempted if ERCP was unsuccessful.

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