Cholecystitis

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Cholecystitis Pregnancy

• Kashaf Sherafgan, MD
• PGY-2, General Surgery
• Englewood Hospital
• December 21st 2005

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Case Presentation

• 23-year-old woman, 16 weeks pregnant
• c/o abd pain x 2 days
• RUQ pain, radiating to back
• Nausea vomiting
• Similar complaint X 3 over 2 months
• Last ER presentation 2 days ago

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Physical examination

• Afebrile
• Minimal scleral icterus
• Epigastric tenderness
• Positive Murphys sign
• Gravid uterus

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Laboratory workup

• WBC 7400 (78.2 neutrophils)
• AST / ALT 103 / 200
• Alk Phos 128
• T / D Bili 3.5 / 1.9
• Amylase 108
• Lipase 106
• UA Moderate bilirubin

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Ultrasound

• Small shadowing gallstone within GB
• No wall thickening
• No pericholecystic fluid
• No biliary dilatation
• CBD 5 mm

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Ultrasound
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Clinical course

• NPO
• IV hydration
• Pain control

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Hospital course, cont.

• Day 2
• AST / ALT 68 / 154
• Alk Phos 98
• T/D Bili 2.1 / 1.8
• Amylase 117
• Lipase 135

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MRCP

• Multiple gallstones
• No evidence of biliary duct dilatation
• CBD 5 mm
• No evidence of CBD stones or intraluminal filling
  defects

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Hospital course, cont.

• Day 5
• Pain on PO intake
• Increasing scleral icterus
• AST / ALT 60 / 146
• Alk Phos 102
• T/D Bili 4.2 / 2.1
• Amylase 149
• Lipase 368

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Hospital course, cont

• Day 7
• Laparoscopic cholecystectomy
• Findings
• Minimal adhesions
• Distended thin-walled GB
• Thick sludge

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Post-operative course

• Immediately post op
• AST / ALT 56 / 137
• Alk Phos 134
• T/D Bili 3.0 / 2.0
• Amylase / Lipase 1.3 / 127

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Post-op course, cont.

• POD 2
• AST / ALT 36 / 97
• Alk Phos 117
• T/D Bili 1.8 / 1.4
• Discharged home in stable condition

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Medical versus surgical management of biliary
tract disease in pregnancy

• Lu EJ et al
• American J of Surg 2004188755

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Methods

• Retrospective multicenter study
• Compared maternal and fetal outcomes of medical
  vs surgical management
• Impact of complications of gallstone disease,
  including gallstone pancreatitis and
  choledocholithiasis, on fetal outcome

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Results

• 76 women with 78 pregnancies were admitted with
  biliary tract disease
• 63 presented with symptomatic cholelithiasis, 10
  underwent surgery while pregnant
• No deaths, preterm deliveries, or ICU admissions
• 53 treated medically
• Courses complicated by symptomatic relapse in 20
  patients (38), labor induction to control
  biliary colic (8 patients) and by premature
  delivery in 2 patients
• Each relapse in the medically managed group
  accounted for an additional five days in hospital

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Clinical presentation
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Management

• Initially conservative management
• IVF
• NPO
• Narcotics
• Antibiotics
• Surgery performed for patients with
• Refractory pain
• Deteriorating clinical status
• Those who presented in the second trimester

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Management, cont.

• For patients with potentially viable fetuses
  managed surgically, steroids were generally
  administered 24 hours preoperatively to speed
  fetal lung maturation
• Intraoperatively, attention was paid to avoiding
  elevations in end-tidal CO2 and maintaining
  volume status
• Mothers in their second or third trimester were
  tilted 15 to 20 to their left to minimize
  compression of the IVC, and FHR was monitored by
  surface ultrasound every 5 minutes

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• Hospital stay
• GSP or CDS 15.6 days
• Biliary colic 4.6 days
• Acute Cholecystitis 7.0 days
• One patient had a 54-day hospitalization for
  complications of GSP and chronic abd pain

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Outcome of medical management
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Relapse rate by trimester of presentation in
patients managed entirely nonoperatively
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Comparison of outcome after nonoperative versus
operative management
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Outcome of surgical management

• 10 patients (13) with symptomatic cholelithiasis
  managed operatively
• 8 underwent surgery during the 2nd trimester 2
  during the early 3rd trimester
• 4 patients underwent open cholecystectomy and 6
  had lap cholecystecomy
• 38 patients underwent surgery in the postpartum
  period
• Patients who underwent LC were able to tolerate
  clear liquids 0.6 days sooner and regular diet
  0.3 days sooner than patients who underwent OC
• No preterm deliveries, relapse of disease after
  surgery, maternal or neonatal ICU admissions or
  maternal or fetal deaths

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Conclusions

• Pregnant patients with symptomatic cholelithiasis
  have a high rate of symptomatic relapse during
  pregnancy
• Relapse rates are similar for patients with BC
  and AC
• Patients relapse with more severe disease,
  including CDS and GSP
• Pregnant patients with biliary tract disease
  should be advised to consider cholecystectomy for
  symptomatic disease
• Surgical management of symptomatic cholelithiasis
  is safe, reduces the need for labor induction,
  reduces the rate of preterm deliveries and
  reduces fetal morbidity

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Safety and risks of laparoscopy in pregnancy

• Fozan HA et al Curr Opin Obstet Gynecol 2002,
  14375

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Advantages of Laparoscopy in Pregnancy

• General
• Early return of bowel function
• Early ambulation
• Short hospital stay
• Rapid return to normal activity
• Low rate of wound infection and hernia
• Less pain after the operation
• Compared with laparotomy, associated with less
  fetal depression due to reduced narcotic use in
  the postoperative period
• Minimal manipulation of the uterus while
  obtaining adequate exposure
• Less uterine irritability
• Lower rates of spontaneous abortion, preterm
  labor, premature delivery

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Disadvantages

• More challenging in the presence of an enlarged
  uterus
• Possibility of puncturing the gravid uterus with
  a Verres needle
• Enlarging uterus displaces intestines out of the
  pelvis ? increased risk of bowel or uterine
  injury by Verres needle, trocar
• Theoretical concern of decreased uterine blood
  flow due to increased intra-abdominal pressure
  and risk to mother and fetus of CO2 absorption
• Clinical safety and efficacy of laparoscopy using
  CO2 have been well documented

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Timing of surgery

• 2nd trimester safest time to perform surgery
• Miscarriage rate is 5.6 in 2nd trimester
  compared with 12 in 1st trimester
• Rate of preterm labor in 2nd trimester is very
  low
• Uterus is still small enough that it does not
  obliterate the operative field compared with the
  uterus in 3rd trimester
• Theoretical risk of teratogenesis is very low

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Laparoscopic Technique

• Positioning
• 1st half of pregnancy Dorsal lithotomy position
• 2nd half of pregnancy Slight left lateral
  positioning to alleviate impaired venous return
• Pneumoperitoneum
• Use of nitrous oxide has been advocated unknown
  whether it is safer than CO2
• Helium use in pregnant ewes is associated with
  less incidence of maternal and fetal acidosis
• Maintaining intra-abdominal pressure less than 12
  mm Hg and minimizing the length of operative time
  decreases risk of maternal hypercarbia and fetal
  acidosis

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Laparoscopic Technique, cont.

• Trocar insertion and placement
• Due to the enlarged gravid uterus, care should be
  taken with trocar insertion
• 1? trocar - Inserted using open technique after
  determining height of the fundus
• Can also be inserted at supraumbilical,
  subxiphoid midline or left upper quadrant
• Use of an optical trocar allows the surgeon to
  see tissue planes and intra-abdominal organs as
  the trocar is inserted
• Depending on the height of the uterus, 2? trocars
  inserted higher than those in the nonpregnant
  condition and under direct vision

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Placement of trocars for 2nd-trimester
laparoscopic cholecystectomy
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Tocolytics and Glucocorticoids

• Prophylactic tocolysis not usually needed
• Can be administered if patient experiences
  uterine irritability or contraction
• Some surgeons administer glucocorticoids to women
  in the late 2nd or 3rd trimester to enhance lung
  maturity

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Fetal Outcome

• Impact of laparoscopic surgery on fetal outcome
  evaluated by analyzing the Swedish Health
  Registry from 1973 to 1993
• 2233 laparoscopies vs. 2491 laparotomies in women
  with a singleton pregnancy between 4 and 20
  weeks gestation
• No significant differences in birth weight,
  gestational duration, intra-uterine growth
  restriction, infant death, or fetal malformation

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Biliary Sludge Pregnancy

• High prevalence of sludge in the peripartum
  period
• Incidence
• Sludge 26 to 31
• Gallstones 2 to 5
• Risk factors
• Sludge No clear risk factors have been
  identified
• Gallstones Age, obesity and cumulative months
  of oral contraceptive use
• Stones and sludge resolve in many women during
  the first year after delivery
• Hypothesized that women with multiple or closely
  spaced pregnancies may form gallstones as sludge
  recurs or persists

Ko CW et al Biliary Sludge, Ann Intern Med.
1999130301
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Biliary Sludge Composition

• Varies with clinical situation
• General population calcium bilirubinate and
  cholesterol monohydrate crystals
• Patients receiving TPN primarily calcium
  bilirubinate
• Pregnancy cholesterol monohydrate crystals

Ko CW et al Biliary Sludge, Ann Intern Med.
1999130301
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Causes of Biliary Sludge in Pregnancy

• Greater bile lithogenicity
• Gallbladder hypomotility
• Higher estrogen levels indirectly increase
  cholesterol saturation of bile
• Higher progesterone levels may inhibit
  gallbladder contractility

Ko CW et al Biliary sludge, Ann Intern Med.
1999130301
41
References

• Lu EJ et al Medical vs surgical management of
  biliary tract disease in preganacy, American J of
  Surg 2004 188755
• Fozan HA et al Safety and risks of laparoscopy
  in pregnancy, Curr Opin Obstet Gynecol 2002,
  14375
• Ko CW et al Biliary sludge, Ann Intern Med.
  1999130301