Cholecystitis & Pregnancy - KSherafgan

8/4/2019 Cholecystitis & Pregnancy - KSherafgan

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Cholecystitis &

PregnancyKashaf Sherafgan, MD

PGY-2, General Surgery

Englewood HospitalDecember 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 surgicalmanagement of biliary tract

disease in pregnancyLu EJ et al

American J of Surg 2004;188:755


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Methods

Retrospective multicenter studyCompared maternal and fetal

outcomes of medical vs surgicalmanagement 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 admittedwith 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 (8patients) and by premature delivery in 2 patients

Each relapse in the medically managed group accountedfor 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 managedsurgically, steroids were generally administered 24hours preoperatively to speed fetal lung maturation

Intraoperatively, attention was paid to avoidingelevations in end-tidal CO2 and maintaining volumestatus

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 5minutes


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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 nonoperativeversus operative management


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Outcome of surgical management

10 patients (13%) with symptomatic cholelithiasis managedoperatively

8 underwent surgery during the 2nd trimester & 2 during theearly 3rd trimester

4 patients underwent open cholecystectomy and 6 had lapcholecystecomy

38 patients underwent surgery in the postpartum period

Patients who underwent LC were able to tolerate clear liquids0.6 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 fetaldeaths


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Conclusions

Pregnant patients with symptomatic cholelithiasis have ahigh rate of symptomatic relapse during pregnancy

Relapse rates are similar for patients with BC and AC

Patients relapse with more severe disease, including CDSand GSP

Pregnant patients with biliary tract disease should beadvised to consider cholecystectomy for symptomaticdisease

Surgical management of symptomatic cholelithiasis is safe,reduces the need for labor induction, reduces the rate ofpreterm deliveries and reduces fetal morbidity


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Safety and risks oflaparoscopy in

pregnancyFozan HA et al: Curr Opin Obstet

Gynecol 2002, 14:375


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Advantages of Laparoscopy inPregnancy

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 depressiondue to reduced narcotic use in the postoperative period

Minimal manipulation of the uterus while obtaining adequateexposure 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 Verresneedle

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 toincreased intra-abdominal pressure and risk to mother andfetus of CO2 absorption

Clinical safety and efficacy of laparoscopy using CO2 have beenwell documented


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Timing of surgery

2nd trimester safest time to perform surgery

Miscarriage rate is 5.6% in 2nd trimester comparedwith 12% in 1st trimester

Rate of preterm labor in 2nd trimester is very low

Uterus is still small enough that it does notobliterate 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; unknownwhether 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 riskof 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 underdirect vision


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Placement of trocars for 2nd-trimesterlaparoscopic 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 outcomeevaluated by analyzing the Swedish HealthRegistry from 1973 to 1993

2233 laparoscopies vs. 2491 laparotomies inwomen with a singleton pregnancy between 4 and20 weeks gestation

No significant differences in birth weight,gestational duration, intra-uterine growthrestriction, 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 oralcontraceptive use

Stones and sludge resolve in many women during the firstyear after delivery

Hypothesized that women with multiple or closely spacedpregnancies may form gallstones as sludge recurs or persists

Ko CW et al: Biliary Sludge, Ann Intern Med. 1999;130:301


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Biliary Sludge Composition

Varies with clinicalsituation

General population

calcium bilirubinate andcholesterol monohydratecrystals

Patients receiving TPNprimarily calcium

bilirubinate

Pregnancy cholesterolmonohydrate crystals

Ko CW et al: Biliary Sludge, Ann Intern Med. 1999;130:301


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Causes of Biliary Sludge in Pregnancy

Greater bile lithogenicity

Gallbladder hypomotility

Higher estrogen levels indirectly increasecholesterol saturation of bile

Higher progesterone levels may inhibit

gallbladder contractility

Ko CW et al: Biliary sludge, Ann Intern Med. 1999;130:301


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References

Lu EJ et al: Medical vs surgical management ofbiliary tract disease in preganacy, American J ofSurg 2004; 188:755

Fozan HA et al: Safety and risks of laparoscopy inpregnancy, Curr Opin Obstet Gynecol 2002,14:375

Ko CW et al: Biliary sludge, Ann Intern Med.1999;130:301

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