GALLSTONES

                                           GALLSTONES

                 

      Biliary tract  disease is the second  most common  non- obstetric  surgical problem, though it affects only 1 in 1600  to 10000 pregnancies. Cholelithiasis has been documented in 10  percent  of pregnancies and  cholecystitis reportedly affects  0.1 percent  of pregnant patients.

        Pregnancy related  physiological  changes : a. Progesterone causes smooth  muscle relaxation  and  a decrease  in gallbladder tone.  Weakened  contractions and  decreased  emptying  lead to increased  gallbladder  volume  during  fasting  and after eating. In  turn, biliary  stasis  contributes  to cholesterol  crystal sequestration ,  theoretically leading to the  formation  of sludge and stones. b. Elevated  estrogen levels during  pregnancy may further  increase the lithogenicity  of bile. c. Lower  gallbladder  ejection  fractions  and increasing  parity seem  to increase the risk of  sludge formation. A high pre-pregnancy body mass  index  also  may increase the  risk  of sludge  formation. Despite these  physiologic changes, it is unclear if  pregnancy increases  the incidence of gallstones  and  cholecystitis . In  a German  population  study looking  at 1111 females, current pregnancy and the number of prior pregnancies were not associated with an increased  risk.

       The clinical presentation of acute  cholecystitis is similar  to the non- pregnant patient. The pregnant - patient who has right upper  quadrant  tenderness  should undergo ultrasound  evaluation  first because it is  noninvasive and quickly obtained.  MR cholangiography can be suspected  but not demonstrated on  ultrasound.  Symptomatic  cholelithiasis often is managed initially with  a conservative approach,  delaying elective cholecystectomy until after delivery. If conservative  management fails, or if repeated hospitalizations are required, especially  in the same  trimester, cholecystectomy is indicated. Recent studies have  shown, earlier surgical intervention  for biliary tract disease in pregnancy is safe with reduced hospital stay, reduced use of  medications, lower rates  life- threatening complications and lower preterm deliveries. The  laparoscopic cholecystectomy  has been performed safely in all trimesters. The use of an  open  technique for entry, insufflations to 12 mm Hg, and  maintaining a left lateral decubitus  position minimize risk to the fetus and  help maintain adequate placental blood flow during  surgery.

        Patients presenting with acute cholecystitis and symptomatic choledocholithiasis  during pregnancy  should be considered  in a higher  risk  category. If  complications such  as cholangitis or gallstone  pancreatitis develop, maternal mortality  approaches 15 percent, and fetal loss occurs in 60 percent of cases . 

        Surgical approaches  include open cholecystectomy with choledochotomy  or laparoscopic  cholecystectomy with ERCP (endoscopic retrograde cholangiopancreatography ) with sphincterotomy  for  stone extraction or stent placement has been shown  to be  safe during pregnancy.  Although  not routinely recommended, intraoperative  cholangiography   is safe  after fetal organogenesis is complete  and does not increase the risk   of preterm  labor or adverse fetal outcomes.