Cholecystitis & Pregnancy

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

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

Physical examination

Afebrile Minimal scleral icterus Epigastric tenderness Positive Murphys sign Gravid uterus

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

Ultrasound

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

Ultrasound

Clinical course

NPO IV hydration Pain control

Hospital course, cont.

Day 2

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

MRCP

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

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

Hospital course, cont:

Day 7

Laparoscopic cholecystectomy Findings

Minimal adhesions Distended thin-walled GB Thick sludge

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

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

Medical versus surgical management of biliary tract disease in pregnancy

Lu EJ et al American J of Surg 2004;188:755

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

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

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

53 treated medically

Clinical presentation

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

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

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

Outcome of medical management

Relapse rate by trimester of presentation in patients managed entirely nonoperatively

Comparison of outcome after nonoperative versus operative management

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

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

Safety and risks of laparoscopy in pregnancy

Fozan HA et al: Curr Opin Obstet Gynecol 2002, 14:375

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

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

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

Laparoscopic Technique

Positioning

1st half of pregnancy Dorsal lithotomy position 2nd half of pregnancy Slight left lateral positioning to alleviate impaired venous return 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

Pneumoperitoneum

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

Placement of trocars for 2nd-trimester laparoscopic cholecystectomy

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

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

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. 1999;130:301

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. 1999;130:301

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. 1999;130:301

References

Lu EJ et al: Medical vs surgical management of biliary tract disease in preganacy, American J of Surg 2004; 188:755 Fozan HA et al: Safety and risks of laparoscopy in pregnancy, Curr Opin Obstet Gynecol 2002, 14:375 Ko CW et al: Biliary sludge, Ann Intern Med. 1999;130:301