Cholelithiasis; gallstones

1. What every clinician should know

Clinical features and incidence

Cholelithiasis is characterized by right upper quadrant pain and may be colicky in nature. It is often associated with fatty meals or diets, but this is not required. Occasional nausea and vomiting may occur in milder cases. More extreme cases are characterized by intractable vomiting, dehydration, severe right upper quadrant or epigastric pain, and pain that radiates to the tip of the right scapula. Occasional biliary duct or common bile duct obstruction may be present.

Obstruction of the common bile duct can cause gallstone pancreatitis. Infection also can result, particularly if obstruction occurs and causes cholecystitis (inflammation of the gallbladder), and inflammation of the ducts. These cases may be treated conservatively with intravenous antibiotics, or if severe or recurrent, may require invasive treatment to relieve the obstruction.

The incidence of cholelithiasis in pregnancy is up to 10%, but most are asymptomatic. Symptomatic cholelithiasis during pregnancy occurs at a rate of about 1-2 per 1,000. Incidence of asymptomatic cholelithiasis in non-pregnant women is about 1-2%, but is increasing due to poor diet and increasing rates of obesity in the general population. Pregnancy increases the risk of gallstone formation due to estrogen, which increases cholesterol synthesis, and progesterone, which decreases gallbladder motility. Pregnancy does not increase the risk of complications related to cholelithiasis.

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2. Diagnosis and differential diagnosis

A. Establishing the diagnosis

The symptoms are the same as in non-pregnant individuals. Initially the symptomatic patient will have biliary colic in the right upper quadrant or epigastrum that may radiate to the scapula. Nausea and vomiting are common. The symptoms are generally short lived in milder cases ( average less than 2 hours), and are typically associated with a fatty meal. Fever, tachycardia, and diaphoresis during the colicky episodes are also common.

Laboratory values include a mild leukocytosis (typically less than 15,000), and mildly abnormal transaminases. An elevated amylase suggests gallstone pancreatitis. Jaundice or elevated total bilirubin suggests obstruction of the common bile duct.

A right upper quadrant ultrasound should be obtained in all cases of suspected symptomatic cholelithiasis. It is considered diagnostic if stones are demonstrated in the gallbladder. “Sludge” is also a common ultrasound finding, and is associated with cholelithiasis. Obstruction can often be seen with a stone in the biliary or common bile duct, with proximal dilation of the affected duct. Inflammation of the gallbladder and ducts can be found by measuring wall thickness. Pancreatitis also may be seen if there is cystic formation in the pancreas due to complete obstruction, but is not necessary for the diagnosis of gallstone pancreatitis.

B. Differential diagnosis

The differential diagnosis includes hepatitis, HELLP syndrome, acute fatty liver of pregnancy and shingles. If hepatitis is suspected, antibody assessment for Hepatitis A, B and C should be obtained. HELLP syndrome is assessed through evaluation of liver function tests (e.g., ALT), platelet count, and absence of hemolysis. Acute fatty liver of pregnancy is diagnosed by a decreased glucose with increased serum ammonia, and an increased PTI. Shingles is diagnosed by the presence of a cutaneous vesicular rash that follows a dermatome in a patient who has a history of prior varicella infection.

3. Management

Management during pregnancy is the same as for a non-pregnant individual. Mild and primary episodes without evidence of obstruction may be managed conservatively, with NPO status and IV hydration until symptoms resolve. Mild cases of cholecystitis may be treated with IV antibiotics. For evidence of obstruction, endoscopy is the favored method of treatment, and may be safely performed after 48 hours of hydration and bowel rest. Endoscopic retrograde cholangiopancreatography (ERCP) can be safely performed during all trimesters and postpartum.

Cholecystectomy is reserved for cases of recurrent cholecystitis. Other indications for cholecystectomy include cholecystitis not responding to conservative measures, perforated gallbladder, or suspected gangrenous gallbladder. The latter may be suspected if gas is seen by ultrasound within the walls of or outside the gallbladder.

The surgical approach for cholecystectomy is either laparoscopic or open, and is guided by trimester of pregnancy and indication. Open cholecystectomy is performed in the third trimester in most centers, or if a gangrenous gallbladder is suspected. All other cases are preferably managed with laparoscopic cholecystectomy, as the recovery time is significantly shorter. Medications to resorb the gallstones, and also lithotripsy, are contraindicated in pregnancy.

4. Complications

The most common complication is recurrent cholecystitis, particularly if large stones are present. Progression from cholelithiasis to duct obstruction, and also development of pancreatitis are potential complications with conservative management. Spontaneous perforation is rare.

Complications of ERCP and surgical removal of the gallbladder are related to those specific treatment modalities.

5. Prognosis and outcome

A. Maternal and fetal/neonatal outcomes

Cholelithiasis is generally benign during pregnancy and does not increase the risk of obstetric complications. Cholecystitis and pancreatitis may result in generalized peritonitis. Peritoneal inflammation may cause uterine irritability, preterm contractions and preterm labor in severe cases. Definitive treatment with ERCP or cholecystectomy are not associated with long-term maternal or neonatal complications.

B. Impact on long term health

The patient should be advised to seek definitive care for her gallstones after pregnancy. This may include medications to resorb the stones, lithotripsy of the gallbladder or surgical resection.

6. What is the evidence for specific management and treatment recommendations

Cappel, MS, Friedel, D. “Abdominal pain during pregnancy”. Gastroenterol Clinics. vol. 32. 2003. pp. 1-58.

“Williams Obstetrics”.