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Cholecystitis

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... with symptomatic cholelithiasis managed operatively 8 underwent surgery during the 2nd trimester & 2 during the early 3rd trimester 4 patients underwent open ... – PowerPoint PPT presentation

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Title: Cholecystitis


1
Cholecystitis Pregnancy
  • Kashaf Sherafgan, MD
  • PGY-2, General Surgery
  • Englewood Hospital
  • December 21st 2005

2
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

3
Physical examination
  • Afebrile
  • Minimal scleral icterus
  • Epigastric tenderness
  • Positive Murphys sign
  • Gravid uterus

4
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

5
Ultrasound
  • Small shadowing gallstone within GB
  • No wall thickening
  • No pericholecystic fluid
  • No biliary dilatation
  • CBD 5 mm

6
Ultrasound
7
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8
Clinical course
  • NPO
  • IV hydration
  • Pain control

9
Hospital course, cont.
  • Day 2
  • AST / ALT 68 / 154
  • Alk Phos 98
  • T/D Bili 2.1 / 1.8
  • Amylase 117
  • Lipase 135

10
MRCP
  • Multiple gallstones
  • No evidence of biliary duct dilatation
  • CBD 5 mm
  • No evidence of CBD stones or intraluminal filling
    defects

11
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12
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13
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

14
Hospital course, cont
  • Day 7
  • Laparoscopic cholecystectomy
  • Findings
  • Minimal adhesions
  • Distended thin-walled GB
  • Thick sludge

15
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

16
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

17
Medical versus surgical management of biliary
tract disease in pregnancy
  • Lu EJ et al
  • American J of Surg 2004188755

18
Methods
  • Retrospective multicenter study
  • Compared maternal and fetal outcomes of medical
    vs surgical management
  • Impact of complications of gallstone disease,
    including gallstone pancreatitis and
    choledocholithiasis, on fetal outcome

19
Results
  • 76 women with 78 pregnancies were admitted with
    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 (8 patients) and by premature
    delivery in 2 patients
  • Each relapse in the medically managed group
    accounted for an additional five days in hospital

20
Clinical presentation
21
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

22
Management, cont.
  • For patients with potentially viable fetuses
    managed surgically, steroids were generally
    administered 24 hours preoperatively to speed
    fetal lung maturation
  • Intraoperatively, attention was paid to avoiding
    elevations in end-tidal CO2 and maintaining
    volume status
  • 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 5 minutes

23
  • Hospital stay
  • GSP or CDS 15.6 days
  • Biliary colic 4.6 days
  • Acute Cholecystitis 7.0 days
  • One patient had a 54-day hospitalization for
    complications of GSP and chronic abd pain

24
Outcome of medical management
25
Relapse rate by trimester of presentation in
patients managed entirely nonoperatively
26
Comparison of outcome after nonoperative versus
operative management
27
Outcome of surgical management
  • 10 patients (13) with symptomatic cholelithiasis
    managed operatively
  • 8 underwent surgery during the 2nd trimester 2
    during the early 3rd trimester
  • 4 patients underwent open cholecystectomy and 6
    had lap cholecystecomy
  • 38 patients underwent surgery in the postpartum
    period
  • Patients who underwent LC were able to tolerate
    clear liquids 0.6 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 fetal deaths

28
Conclusions
  • Pregnant patients with symptomatic cholelithiasis
    have a high rate of symptomatic relapse during
    pregnancy
  • Relapse rates are similar for patients with BC
    and AC
  • Patients relapse with more severe disease,
    including CDS and GSP
  • Pregnant patients with biliary tract disease
    should be advised to consider cholecystectomy for
    symptomatic disease
  • Surgical management of symptomatic cholelithiasis
    is safe, reduces the need for labor induction,
    reduces the rate of preterm deliveries and
    reduces fetal morbidity

29
Safety and risks of laparoscopy in pregnancy
  • Fozan HA et al Curr Opin Obstet Gynecol 2002,
    14375

30
Advantages of Laparoscopy in Pregnancy
  • 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 depression due to reduced narcotic use in
    the postoperative period
  • Minimal manipulation of the uterus while
    obtaining adequate exposure
  • Less uterine irritability
  • Lower rates of spontaneous abortion, preterm
    labor, premature delivery

31
Disadvantages
  • More challenging in the presence of an enlarged
    uterus
  • Possibility of puncturing the gravid uterus with
    a Verres needle
  • 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 to increased intra-abdominal pressure
    and risk to mother and fetus of CO2 absorption
  • Clinical safety and efficacy of laparoscopy using
    CO2 have been well documented

32
Timing of surgery
  • 2nd trimester safest time to perform surgery
  • Miscarriage rate is 5.6 in 2nd trimester
    compared with 12 in 1st trimester
  • Rate of preterm labor in 2nd trimester is very
    low
  • Uterus is still small enough that it does not
    obliterate the operative field compared with the
    uterus in 3rd trimester
  • Theoretical risk of teratogenesis is very low

33
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 unknown
    whether 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 risk of maternal hypercarbia and fetal
    acidosis

34
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 under direct vision

35
Placement of trocars for 2nd-trimester
laparoscopic cholecystectomy
36
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

37
Fetal Outcome
  • Impact of laparoscopic surgery on fetal outcome
    evaluated by analyzing the Swedish Health
    Registry from 1973 to 1993
  • 2233 laparoscopies vs. 2491 laparotomies in women
    with a singleton pregnancy between 4 and 20
    weeks gestation
  • No significant differences in birth weight,
    gestational duration, intra-uterine growth
    restriction, infant death, or fetal malformation

38
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 oral contraceptive use
  • Stones and sludge resolve in many women during
    the first year after delivery
  • Hypothesized that women with multiple or closely
    spaced pregnancies may form gallstones as sludge
    recurs or persists

Ko CW et al Biliary Sludge, Ann Intern Med.
1999130301
39
Biliary Sludge Composition
  • Varies with clinical situation
  • General population calcium bilirubinate and
    cholesterol monohydrate crystals
  • Patients receiving TPN primarily calcium
    bilirubinate
  • Pregnancy cholesterol monohydrate crystals

Ko CW et al Biliary Sludge, Ann Intern Med.
1999130301
40
Causes of Biliary Sludge in Pregnancy
  • Greater bile lithogenicity
  • Gallbladder hypomotility
  • Higher estrogen levels indirectly increase
    cholesterol saturation of bile
  • Higher progesterone levels may inhibit
    gallbladder contractility

Ko CW et al Biliary sludge, Ann Intern Med.
1999130301
41
References
  • Lu EJ et al Medical vs surgical management of
    biliary tract disease in preganacy, American J of
    Surg 2004 188755
  • Fozan HA et al Safety and risks of laparoscopy
    in pregnancy, Curr Opin Obstet Gynecol 2002,
    14375
  • Ko CW et al Biliary sludge, Ann Intern Med.
    1999130301
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