Key Clinical Updates in Cholelithiasis & Cholecystitis in Pregnancy
The most common cause of acute pancreatitis in pregnancy is gallstone disease. The diagnosis can be confirmed with an appropriate history and an elevated serum amylase or lipase. Management is conservative, including bowel rest, intravenous fluids, supplemental nutrition if necessary, and analgesics. CT imaging should be avoided unless severe complications are suspected.
Abushamma S et al. Obstet Gynecol. [PMID: 34011887]
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. ERCP should only be undertaken when there is therapeutic intent. 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 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.
The most common cause of acute pancreatitis in pregnancy is gallstone disease. The diagnosis can be confirmed with an appropriate history and an elevated serum amylase or lipase. Although pregnancy is associated with a rise in serum amylase, a value of at least two times the upper limit of normal suggests pancreatitis with the appropriate clinical scenario. Management is conservative, including bowel rest, intravenous fluids, supplemental nutrition if necessary, and analgesics. CT imaging should be avoided unless severe complications such as necrosis, abscess, or hemorrhage are suspected.
et al. A guide to upper gastrointestinal tract, biliary, and pancreatic disorders: clinical updates in women’s health care primary and preventive care review. Obstet Gynecol. 2021;137:1152.