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Cholelithiasis is common in pregnancy as physiologic changes such as increased cholesterol production and incomplete gallbladder emptying predispose to gallstone formation. The diagnosis is usually suspected based on classic symptoms of nausea, vomiting, and right upper quadrant pain, usually after meals, and is confirmed with right upper quadrant ultrasound. Symptomatic cholelithiasis without cholecystitis is usually managed conservatively, but recurrent symptoms are common. Cholecystitis results from obstruction of the cystic duct and often is accompanied by bacterial infection. Medical management with antibiotics is reasonable in selected cases, but definitive treatment with cholecystectomy will help prevent complications such as gallbladder perforation and pancreatitis. Cholecystectomy has successfully been performed in all trimesters of pregnancy and should not be withheld based on the stage of pregnancy if clinically indicated. Laparoscopy is preferred in the first half of pregnancy, but becomes more technically challenging in the last trimester due to the enlarged uterus and cephalad displacement of abdominal contents.

Obstruction of the common bile duct, which can lead to cholangitis, is an indication for surgical removal of gallstones and establishment of biliary drainage. Endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy is a nonsurgical alternative. Pregnant women can safely undergo ERCP provided that precautions are taken to minimize fetal exposure to radiation. There does, however, appear to be a slightly higher rate of post-procedure pancreatitis in pregnant women who undergo ERCP. Magnetic resonance cholangiopancreatography (MRCP) can also be of use in patients with suspected common bile duct obstruction. This study is particularly useful for those women in whom the etiology of common duct dilatation is unclear on ultrasound. MRCP can provide detailed evaluation of the entire biliary system and the pancreas while avoiding ionizing radiation.

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Athwal  R  et al. Surgery for gallstone disease during pregnancy does not increase fetal or maternal mortality: a meta-analysis. Hepatobiliary Surg Nutr. 2016 Feb;5(1):53–7.
[PubMed: 26904557]  
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Cappell  MS  et al. Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography. World J Gastrointest Endosc. 2018 Oct 16;10(10):308–21.
[PubMed: 30364767]  

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