Williams Manual of Pregnancy Complications, 23 ed.

CHAPTER 59. Diseases of the Gallbladder and Pancreas

CHOLELITHIASIS AND CHOLECYSTITIS

In the United States, 20 percent of women older than 40 years of age have gallstones. Most gallstones contain cholesterol, and its oversecretion into bile is thought to be a major factor in the pathogenesis of stones. Biliary sludge, which may increase during pregnancy, is an important precursor to gallstone formation and develops in approximately 30 percent of pregnant women. After the first trimester, both gallbladder volume during fasting and residual volume after contracting in response to a meal are twice as great as in the nonpregnant state. Incomplete emptying may result in retention of cholesterol crystals, a prerequisite for cholesterol gallstones. These findings are supportive of the view that pregnancy increases the risk of gallstones, and about 1 in 1000 pregnant women develops cholecystitis.

Clinical Presentation

Symptomatic gallbladder diseases include acute cholecystitis, biliary colic, and acute pancreatitis. Acute cholecystitis usually develops when there is obstruction of the cystic duct. Bacterial infection plays a role in most of these acute inflammatory conditions. In over half of patients with acute cholecystitis, a history of previous right-upper-quadrant pain from cholelithiasis is elicited. With acute disease, pain is accompanied by anorexia, nausea and vomiting, low-grade fever, and mild leukocytosis. Ultrasonography can be used to visualize stones as small as 2 mm. Ultrasonic examination confirms gallstones in up to 90 percent of patients (see Figure 59-1).

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FIGURE 59-1 Gallstones. A. Visualization of a lone large gallstone by sonography. Note acoustic shadowing. B. Endoscopic retrograde cholangiopancreatography (ERCP) showing multiple common duct stones. (Reproduced, with permission, from Greenberger NJ, Paumgartner G: Disease of the gallbladder and bile ducts. In: Fauci AS, Braunwald E, Kasper DL, et al (eds): Harrison’s Principles of Internal Medicine. 17th ed. New York, NY: McGraw-Hill, 2008, p. 1991.)

Management

Acute cholecystitis during pregnancy or the puerperium is initially managed in a manner similar to that for nonpregnant women. Whereas acute cholecystitis responds to medical therapy, current consensus is that early cholecystectomy is indicated. In acute cases, medical therapy is instituted prior to surgery and consists of nasogastric suction, intravenous fluids, antimicrobials, and analgesics.

In general, women who undergo a cholecystectomy during pregnancy for symptomatic gallstone disease do well. In contrast, those who are managed medically have high rates of symptom recurrence during pregnancy. Further, if cholecystitis recurs later in pregnancy, preterm labor is more likely and cholecystectomy is technically more difficult. Therefore, our management at Parkland Hospital has evolved to recommend surgical therapy, particularly in the woman with concomitant biliary pancreatitis. Laparoscopic cholecystectomy appears to be equally effective compared with open cholecystectomy in pregnant women.

Treatment during pregnancy of biliary duct obstruction by gallstones has been greatly facilitated by their removal with endoscopic retrograde cholangiopancreatography (ERCP). The procedure can be modified in many cases so that radiation exposure from fluoroscopy is avoided. Although ERCP can be safely and successfully performed in pregnancy, about 1 in 6 women so treated at Parkland developed postprocedure pancreatitis.

Asymptomatic Gallstones

Cholecystectomy is not indicated for silent stones during pregnancy.

ACUTE PANCREATITIS

Acute pancreatic inflammation is triggered by activation of pancreatic trypsinogen followed by autodigestion. During pregnancy, cholelithiasis is almost always the predisposing condition. Less commonly, nonbiliary pancreatitis occurs in the postoperative patient, or is associated with alcoholism, drugs, trauma, cystic fibrosis, or some viral infections. Certain metabolic conditions such as acute fatty liver of pregnancy and familial hypertriglyceridemia also predispose to pancreatitis.

Clinical Presentation

As in nonpregnant patients, acute pancreatitis is characterized by mild-to-incapacitating epigastric pain, nausea and vomiting, and abdominal distention. Patients are usually in distress and have low-grade fever, tachycardia, hypotension and abdominal tenderness. Up to 10 percent have associated pulmonary findings which can progress to acute respiratory distress syndrome. Serum amylase levels three times the normal upper values are confirmatory (Table 59-1), but there is no correlation with the degree of elevation and severity of disease. In fact, usually by 48 to 72 hours, serum amylase levels return to normal despite evidence for continuing pancreatitis. Measurement of serum lipase activity increases the diagnostic yield. There is usually leukocytosis and 25 percent of patients have hypocalcemia.

TABLE 59-1. Laboratory Values in 43 Pregnant Women with Pancreatitis

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Management

Therapy includes analgesics for pain, intravenous hydration, and measures to decrease pancreatic secretion by ceasing oral intake. Nasogastric suction is not necessary with mild-to-moderate disease. In most patients, acute pancreatitis is self-limited, and inflammation generally subsides within 3 to 7 days. In pregnant women with persistent or severe biliary pancreatitis, ERCP with stone removal and papillotomy have been used successfully. Antimicrobials may improve outcomes in women with bacterial superinfection of necrotizing pancreatitis, and laparotomy has been lifesaving in some cases. Cholecystectomy should be considered in all cases of biliary pancreatitis after the inflammation subsides, as recurrent pancreatitis is common in women who do not have their gallbladders removed.

Pregnancy outcomes appear to be related to the severity of disease. Fortunately, maternal mortality is uncommon with contemporary management, but fetal loss rates are increased in severe cases.


For further reading in Williams Obstetrics, 23rd ed.,

see Chapter 50, “Hepatic, Gallbladder, and Pancreatic Disorders.”