Cholecystitis in Pregnancy

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Chapter 203 Cholecystitis in Pregnancy

INTRODUCTION

Description: Cholelithiasis and cholecystitis complicate more than 3% of pregnancies.
Prevalence: Cholelithiasis—3% to 4% of pregnancies; cholecystitis—0.25% of pregnancies.
Predominant Age: Reproductive.
Genetics: Some races at greater risk (e.g., Pima Indians).

ETIOLOGY AND PATHOGENESIS

Causes: The metabolic alteration leading to cholesterol stones (gallstones) is thought to be a disruption in the balance between hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase and cholesterol 7α-hydroxylase. HMG-CoA controls cholesterol synthesis, whereas cholesterol 7α-hydroxylase controls the rate of bile acid formation. Patients who form cholesterol stones have elevated levels of HMG-CoA and depressed levels of cholesterol 7α-hydroxylase. This change in ratio increases the risk of precipitation of cholesterol. During pregnancy, there is an increased rate of bile synthesis and a reduced rate of gallbladder emptying, increasing the risk of stone formation and obstruction.
Risk Factors: Cholecystitis is associated with increased maternal age, multiparity, multiple gestation, and a history of previous attacks.

CLINICAL CHARACTERISTICS

Signs and Symptoms

(Unchanged by pregnancy)

• May be confused with symptoms of pregnancy
• Fatty food intolerance
• Variable right upper quadrant pain with radiation to the back or scapula
• Nausea or vomiting (often mistaken for “indigestion” or “morning sickness”)
• Fever is usually associated with cholangitis

DIAGNOSTIC APPROACH

Differential Diagnosis

• Labor
• Pre-eclampsia
• Placental accident (abruption)
• Cholestasis of pregnancy
• Gastroenteritis
• Esophageal reflux
• Malabsorption
• Irritable bowel syndrome
• Peptic ulcer disease
• Coronary artery disease
• Pneumonia
• Appendicitis

Associated Conditions: Jaundice, cirrhosis, pancreatitis, ileus, and premature labor.

Workup and Evaluation

Laboratory: Supportive, but often not diagnostic—complete blood count, serum bilirubin, amylase, alkaline phosphatase, and aminotransferase concentrations.
Imaging: Ultrasonography of the gallbladder (96% accurate in making the diagnosis of sludge or stone in the gallbladder); can visualize stones as small as 2 mm.
Special Tests: None indicated.
Diagnostic Procedures: History, physical examination, ultrasonography, and laboratory investigation.

Pathologic Findings

None.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Watchful waiting, dietary modifications aimed at reducing cholesterol and fatty food exposure.
Specific Measures: Cholelithiasis may be treated with oral therapy; surgical extirpation may be required. Cholecystectomy during pregnancy is associated with a 5% fetal loss rate, which increases to approximately 60% if pancreatitis is present at the time of surgery.
Diet: Nothing by mouth during acute attacks or until the diagnosis is established (some patients require nasogastric suction during acute attacks); reduced fatty food and cholesterol at other times.
Activity: No restriction.

Drug(s) of Choice

Ursodeoxycholic acid (Actigall) 8 to 10 mg/day divided in two to three doses. When cholecystitis is present, intravenous fluids, nasogastric suction, analgesics, and antibiotics (cephalosporin) are appropriate.
Contraindications: Known allergy, acute cholecystitis, abnormal liver function, calcified stones (not cholesterol based).
Interactions: See warning for individual agents.

FOLLOW-UP

Patient Monitoring: Normal prenatal care once acute episode is resolved.
Prevention/Avoidance: None.
Possible Complications: Acute cholecystitis, pancreatitis, ascending cholangitis, peritonitis, internal fistulization (to the gastrointestinal tract), premature labor or delivery.
Expected Outcome: Cholecystitis—generally good with either oral or surgical therapy.

MISCELLANEOUS

ICD-9-CM Code: 574.2 (others based on obstruction or inflammation).

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REFERENCES

Level II

Graham G, Baxi L, Tharakan T. Laparoscopic cholecystectomy during pregnancy: a case series and review of the literature. Obstet Gynecol Surv. 1998;53:566.

Lanzafame RJ. Laparoscopic cholecystectomy during pregnancy. Surgery. 1995;118:627. discussion 631.

Level III

Barone JE, Bears S, Chen S, et al. Outcome study of cholecystectomy during pregnancy. Am J Surg. 1999;177:232.

Block P, Kelly TR. Management of gallstone pancreatitis during pregnancy and the postpartum period. Surg Gynecol Obstet. 1989;168:426.

Coleman MT, Trianfo VA, Rund DA. Nonobstetric emergencies in pregnancy: trauma and surgical conditions. Am J Obstet Gynecol. 1997;177:497.

Ghumman E, Barry M, Grace PA. Management of gallstones in pregnancy. Br J Surg. 1997;84:1646.

Glasgow RE, Visser BC, Harris HW, et al. Changing management of gallstone disease during pregnancy. Surg Endosc. 1998;12:241.

Indar AA, Beckingham IJ. Acute cholecystitis. BMJ. 2002;325:639.

Nesbitt TH, Kay HH, McCoy MC, Herbert WN. Endoscopic management of biliary disease during pregnancy. Obstet Gynecol. 1996;87:806.

Scott LD. Gallstone disease and pancreatitis in pregnancy. Gastroenterol Clin North Am. 1992;21:803.

Sharp HT. Gastrointestinal surgical conditions during pregnancy. Clin Obstet Gynecol. 1994;37:306.

Smith RP, Nolan TE. Gallbladder disease and women: etiology, diagnosis and therapy. Female Patient. 1992;17:99.

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Chapter 203 Cholecystitis in Pregnancy

INTRODUCTION

Description: Cholelithiasis and cholecystitis complicate more than 3% of pregnancies.
Prevalence: Cholelithiasis—3% to 4% of pregnancies; cholecystitis—0.25% of pregnancies.
Predominant Age: Reproductive.
Genetics: Some races at greater risk (e.g., Pima Indians).

ETIOLOGY AND PATHOGENESIS

Causes: The metabolic alteration leading to cholesterol stones (gallstones) is thought to be a disruption in the balance between hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase and cholesterol 7α-hydroxylase. HMG-CoA controls cholesterol synthesis, whereas cholesterol 7α-hydroxylase controls the rate of bile acid formation. Patients who form cholesterol stones have elevated levels of HMG-CoA and depressed levels of cholesterol 7α-hydroxylase. This change in ratio increases the risk of precipitation of cholesterol. During pregnancy, there is an increased rate of bile synthesis and a reduced rate of gallbladder emptying, increasing the risk of stone formation and obstruction.
Risk Factors: Cholecystitis is associated with increased maternal age, multiparity, multiple gestation, and a history of previous attacks.

CLINICAL CHARACTERISTICS

Signs and Symptoms

(Unchanged by pregnancy)

• May be confused with symptoms of pregnancy
• Fatty food intolerance
• Variable right upper quadrant pain with radiation to the back or scapula
• Nausea or vomiting (often mistaken for “indigestion” or “morning sickness”)
• Fever is usually associated with cholangitis

DIAGNOSTIC APPROACH

Differential Diagnosis

• Labor
• Pre-eclampsia
• Placental accident (abruption)
• Cholestasis of pregnancy
• Gastroenteritis
• Esophageal reflux
• Malabsorption
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