Risk factors for gallstone-related hospitalization during pregnancy and the postpartum

Evolving trends in interventions and outcomes for acute biliary pancreatitis during pregnancy: A two-decade analysis

BACKGROUND/OBJECTIVES

Cholelithiasis is the most common cause of acute pancreatitis in pregnancy. We analyzed trends in acute biliary pancreatitis (ABP) among pregnant women over the past two decades to evaluate changes in outcomes, including the incidence of severe acute pancreatitis, mortality rates, and hospital length of stay.

METHODS

Using the National Inpatient Sample, we identified adult women of childbearing age (age 18-50 years) with hospitalization for ABP from 2002 to 2020. Trends were analyzed using Cochran-Armitage and F-tests. Multivariable binary logistic regression was used to evaluate the outcome of severe acute pancreatitis (SAP).

RESULTS

45,064 pregnant and 212,009 non-pregnant women were hospitalized for ABP (2002-2020), with a significant increase in ABP during pregnancy (14.1 %→17.8 %; p < 0.001). Trend analyses in the pregnant cohort revealed increasing age (mean 27  →  28.1 years; p < 0.001), Class-III obesity (0.7 %→7.8 %; p < 0.001), comorbidities (Elixhauser index ≥3) (2.9 %→11.2 %; p < 0.001), and SAP (2.2 %→5.0 %; p < 0.001). Mortality remained very low (<0.01 %). Performance of ERCP (22.2 %→26.5 %; p < 0.001) and cholecystectomy (41.0 %→54.1 %; p < 0.001) increased while duration of hospitalization decreased (Mean 4.9  →  3.6 days; p < 0.001). Multivariable analysis revealed that the development of SAP was associated with Black race (OR 1.70, 95 % CI: 1.10-2.63) and comorbidities (OR 5.10, 95 % CI 3.64-7.14).

CONCLUSIONS

Pregnant women represent a significant portion of hospitalized ABP cases, paralleling increases in age, comorbidities, and obesity rates. Racial disparities are linked to higher odds of SAP, though comorbidities have a dominant effect. There has been an increase in guideline-recommended procedures (ERCP and cholecystectomy); however, further research is needed to address the implementation gap, considering the increased complexity of pregnant women with ABP.

Acute Gallstone Pancreatitis in Pregnancy: A Multidisciplinary Approach

A common cause of gastrointestinal-related hospitalizations in the United States of America is acute pancreatitis (AP), with an annual incidence of up to 80 cases per 100,000 people. The incidence of AP in pregnancy varies and is approximately 1 in 1000 to 1 in 10,000 births due to the prevalence of obesity and gallstone-related conditions. Deciding on the timing of surgical intervention in acute biliary pancreatitis during pregnancy remains challenging, and there are no consensus recommendations. Gallstone pancreatitis has a high recurrence rate of up to 50% during the first trimester. A 30-year-old G3P2 at 34 weeks of gestation presented to the emergency room (ER) with recurrent intermittent sudden severe epigastric and right upper quadrant abdominal pain radiating to the back. She had no history of alcohol consumption, and lipid studies were normal on presentation. A right upper quadrant ultrasound scan showed cholelithiasis without signs of acute cholecystitis and a common bile duct diameter of 0.5 cm. However, her serum lipase level was 824, compared to normal levels on her previous ER visits. Other significant labs included elevated alkaline phosphatase (ALP) of 125 and mild transaminitis, with alanine transaminase (ALT) and aspartate aminotransferase (AST) levels of 84 and 57, respectively. She was admitted on account of suspected gallstone pancreatitis and was treated supportively with IV fluids and adequate pain control with opioids. A subsequent magnetic resonance cholangiopancreatography (MRCP) revealed no obvious choledocholithiasis. After consultation with the obstetrics, gastroenterology, and general surgery teams, it was decided to defer cholecystectomy until after delivery. The patient was induced at 36 weeks of gestation, and she had an uneventful vaginal delivery. Two weeks later, she had an elective laparoscopic cholecystectomy with no complications.

A Severely Dilated Gallbladder With Multiple Gallstones After Concomitant Laparoscopic Sleeve Gastrectomy and Childbirth in a Hispanic Woman

Independent studies have associated laparoscopic sleeve gastrectomy (LSG) and pregnancy with a higher incidence of gallstones, especially in Hispanic populations. However, the synergistic impact of these risk factors is currently unknown. We present the case of a 42-year-old Hispanic woman who initially identified intermittent upper right abdominal pain, which worsened over the last four days before the presentation. Abdominal ultrasound indicated hepatic steatosis, hepatomegaly, and cholelithiasis. A hydropic gallbladder with numerous gallstones, surrounding pericholecystic inflammatory changes, and mild intra-abdominal and pelvic ascites was confirmed by computed tomography. The patient underwent an uneventful robotic-assisted cholecystectomy. A gross examination of the gall bladder measuring 15.5 x 6 x 5.5 cm revealed multiple stones measuring 1.0-1.5 cm in the lumen, the largest of which was impacted in the neck. This case underscores the importance of considering ethnicity and pregnancy history while assessing the post-LSG risk of incident cholelithiasis.

Diagnosis and Management of Acute Pancreatitis in Pregnancy

Acute pancreatitis is rare in pregnancy; however, the associated morbidity and mortality make prompt diagnosis and appropriate management essential. 1,2 Although most cases are mild and improve with limited interventions, severe cases require a multidisciplinary approach in a critical care setting. The main principles of management include identification of an etiology to guide therapy, fluid resuscitation, electrolyte repletion, early nutritional support, and pain management. Antibiotics are not indicated for prophylaxis and should be reserved for cases with a suspected infectious process. Surgical management is indicated in select cases. Management in pregnant patients has few differences which are outlined below.

Acute lithiasis cholangitis in pregnant women: About three cases

Acute lithiasis cholangitis is a rare non-obstetric emergency during pregnancy, which may threaten fetus and mother's life. It requires a codified management in order to avoid complications. In this current study, we aimed to report our center experience in the management of acute lithiasis cholangitis occurring in three pregnant women.

Association Between Trimester and Outcomes after Cholecystectomy During Pregnancy

BACKGROUND

Conventional philosophy promotes the second trimester as the ideal time during pregnancy for cholecystectomy. However, literature supporting this belief is sparse. The purpose of this study is to examine the association of trimester and clinical outcomes after cholecystectomy during pregnancy.

STUDY DESIGN

The National Inpatient Sample was queried for pregnant women who underwent cholecystectomy between October 2015 and December 2017. Patients were categorized by trimester. Multivariable logistic and continuous outcome regression models were used to evaluate the association of trimester and outcomes, including maternal and fetal complications, length of stay, and hospital charges. The primary outcome was any complication-a composite of specific clinical complications, each of which were designated as secondary outcomes.

RESULTS

A total of 819 pregnant women satisfied our inclusion criteria. Of these, 217 (26.5%) were in the first trimester, 381 (47.5%) were in the second trimester, and 221 (27.0%) were in the third trimester. Median age was 27 years (interquartile range: 23-31 years). Compared with the second trimester, cholecystectomy during the first trimester was not associated with higher rates of complications (adjusted odds ratio [AOR] 0.88, 95% confidence interval [CI]: 0.47-1.63, p = 0.68). However, cholecystectomy during the third trimester was associated with a higher rate of preterm delivery (AOR 7.20, 95% CI 3.09-16.77, p < 0.001) and overall maternal and fetal complications (AOR 2.78, 95% CI 1.71-4.53, p < 0.001). Compared with the second trimester, the third trimester was associated with 21.3% higher total hospital charges (p = 0.003).

CONCLUSIONS

Our results suggest that cholecystectomy can be performed in the first trimester without significantly increased risk of maternal and fetal complications, compared to the second trimester. In contrast, cholecystectomy during pregnancy should not be delayed until the third trimester.

Sex-Related Differences of Acute and Chronic Pancreatitis in Adults

The incidence of acute and chronic pancreatitis is increasing in the United States. Rates of acute pancreatitis (AP) are similar in both sexes, but chronic pancreatitis (CP) is more common in males. When stratified by etiology, women have higher rates of gallstone AP, while men have higher rates of alcohol- and tobacco-related AP and CP, hypercalcemic AP, hypertriglyceridemic AP, malignancy-related AP, and type 1 autoimmune pancreatitis (AIP). No significant sex-related differences have been reported in medication-induced AP or type 2 AIP. Whether post-endoscopic retrograde cholangiopancreatography pancreatitis is sex-associated remains controversial. Animal models have demonstrated sex-related differences in the rates of induction and severity of AP, CP, and AIP. Animal and human studies have suggested that a combination of risk factor profiles, as well as genes, may be responsible for the observed differences. More investigation into the sex-related differences of AP and CP is desired in order to improve clinical management by developing effective prevention strategies, diagnostics, and therapeutics.

An Update on the Lithogenic Mechanisms of Cholecystokinin a Receptor (CCKAR), an Important Gallstone Gene for Lith13

The cholecystokinin A receptor (CCKAR) is expressed predominantly in the gallbladder and small intestine in the digestive system, where it is responsible for CCK's regulation of gallbladder and small intestinal motility. The effect of CCKAR on small intestinal transit is a physiological response for regulating intestinal cholesterol absorption. The Cckar gene has been identified to be an important gallstone gene, Lith13, in inbred mice by a powerful quantitative trait locus analysis. Knockout of the Cckar gene in mice enhances cholesterol cholelithogenesis by impairing gallbladder contraction and emptying, promoting cholesterol crystallization and crystal growth, and increasing intestinal cholesterol absorption. Clinical and epidemiological studies have demonstrated that several variants in the CCKAR gene are associated with increased prevalence of cholesterol cholelithiasis in humans. Dysfunctional gallbladder emptying in response to exogenously administered CCK-8 is often found in patients with cholesterol gallstones, and patients with pigment gallstones display an intermediate degree of gallbladder motility defect. Gallbladder hypomotility is also revealed in some subjects without gallstones under several conditions: pregnancy, total parenteral nutrition, celiac disease, oral contraceptives and conjugated estrogens, obesity, diabetes, the metabolic syndrome, and administration of CCKAR antagonists. The physical-chemical, genetic, and molecular studies of Lith13 show that dysfunctional CCKAR enhances susceptibility to cholesterol gallstones through two primary mechanisms: impaired gallbladder emptying is a key risk factor for the development of gallbladder hypomotility, biliary sludge (the precursor of gallstones), and microlithiasis, as well as delayed small intestinal transit augments cholesterol absorption as a major source for the hepatic hypersecretion of biliary cholesterol and for the accumulation of excess cholesterol in the gallbladder wall that further worsens impaired gallbladder motor function. If these two defects in the gallbladder and small intestine could be prevented by the potent CCKAR agonists, the risk of developing cholesterol gallstones could be dramatically reduced.

Considering delay of cholecystectomy in the third trimester of pregnancy

INTRODUCTION

Current guidelines support laparoscopic cholecystectomy as the treatment of choice for pregnant women with symptomatic gallbladder disease, regardless of the trimester. Early intervention has remained the standard of care, but recent evidence has challenged this practice in pregnant women. We sought to compare surgical and maternal-fetal outcomes of antepartum versus postpartum cholecystectomy in New York State.

METHODS

Between 2005 and 2014, the New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for patients who underwent cholecystectomy within 3 months before (antepartum cholecystectomy, APCCY: n = 82) and after (postpartum cholecystectomy, PPCCY: n = 5040) childbirth to approximate third-trimester operations. All patients who underwent cholecystectomy during pregnancy (n = 971) were extracted to evaluate inter-trimester differences. Subgroup analysis compared APCCY patients who were not hospitalized within 1 year before APCCY (n = 80) and PPCCY patients who were hospitalized within 1 year before childbirth (n = 29) for symptomatic biliary disease. Multivariable generalized linear regression models were used to characterize the association between timing of cholecystectomy and several primary outcomes: length of stay (LOS), 30-day non-pregnancy, non-delivery readmission (NPND), bile duct injury (BDI), composite maternal outcome (antepartum hemorrhage, preterm delivery, cesarean section), any complications, and fetal demise.

RESULTS

Third-trimester APCCY women had longer LOS (Ratio: 1.44, 95% CI [1.26-1.66], p < 0.0001) and greater incidence of preterm delivery (OR 2.54, 95% CI [1.37-4.43], p = 0.0019). Cholecystectomy timing was not independently associated with differences in composite maternal outcome (p = 0.1480), BDI (p = 0.2578), 30-day NPND readmission (p = 0.7579), any complications (p = 0.2506), and fetal demise (2.44% versus 0.44%, p = 0.0545). Subgroup analysis revealed no differences in any of the seven outcomes.

CONCLUSIONS

New York Statewide data suggest that although laparoscopic cholecystectomy is safe in pregnancy, delay of cholecystectomy should be discussed in the third trimester due to an increased risk for preterm delivery.

Non-obstetric surgery in pregnancy (including bowel surgery and gallbladder surgery)

Non-obstetric surgery during pregnancy is required in 0.75-2% of pregnancies. Physiologic changes during pregnancy, both hormonal and anatomic, can have interactions with surgery and anesthesia. Indication, timing as well as risks of anesthesia and surgery should be considered in surgical decision making. The health status of the mother should always be put first. A preoperative multidisciplinary approach, also including an obstetrician and neonatologist, is mandatory. Delay in diagnosis and treatment carry risks of complications in all septic visceral indications. Considerations should be individualized.

Prevalence and risk factors of gallstone disease in patients undergoing ultrasonography at Mulago hospital, Uganda

Background

Gallstone disease (GSD) is the most prevalent medical condition in the pancreatobiliary system. The burden of GSD and its complications are major public health issues globally. It is a common cause of surgical intervention, contributing substantially to health care costs. Most patients are asymptomatic, however 20% become symptomatic after 10 years. Its prevalence differs among populations and remains unknown in Uganda.

Objective

To determine the prevalence and risk factors of GSD in patients undergoing abdominal ultrasonography at Mulago hospital, Uganda.

Methods

This was a cross-sectional study at the Department of Radiology in Mulago hospital. Convenient sampling was used to recruit individuals having an abdominal ultrasound scan. Questionnaires were used to assess risk factors, and an abdominal exam was performed for individuals with gallstones to assess symptomatology.

Results

The prevalence of GSD was 22%. Statistically significant factors associated with GSD were a history of hormonal contraceptive use OR 3.2 (1.88–5.41) and a history of previous biliary symptoms OR 2.9 (1.68–4.91). Ninety-four percent of individuals with gallstones had epigastric/right upper quadrant pain.

Conclusion

The prevalence of GSD is high in Mulago hospital; use of hormonal contraceptives and a previous history of biliary symptoms were significant risk factors for GSD in this study. Majority of patients with GSD were symptomatic with epigastric pain as the cardinal symptom. We recommend a countrywide screening program using abdominal ultrasonography to determine the prevalence of GSD in the general population. There is need to study further the risk of hormonal contraceptive use and GSD. Women on these contraceptives should be informed of the potential risk, and offered alternative options where feasible.

G Protein-Coupled Estrogen Receptor, GPER1, Offers a Novel Target for the Treatment of Digestive Diseases

There are gender differences between men and women in many physiological functions and diseases, which indicates that female sex hormones may be important. Traditionally, estrogen exerts its biological activities by activating two classical nuclear estrogen receptors, ESR1 and ESR2. However, the roles of estrogen in the regulation of physiological functions and the pathogenesis of diseases become more complicated with the identification of the G protein-coupled estrogen receptor (GPER1). Although many GPER1-specific ligands have been developed, the therapeutic mechanisms of exclusively targeting GPER1 are not yet well understood. Translational applications and clinical trial efforts for the identified GPER1 ligands have been focused primarily on the reproductive, cardiovascular, nervous, endocrine, and immune systems. More recently, research found that GPER1 may play an important role in regulating the digestive system. Cholesterol gallstone disease, a major biliary disease, has a higher prevalence in women than in men worldwide. Emerging evidence implies that GPER1 could play an important role, independent of the classical ESR1, in the pathophysiology of cholesterol gallstones in women. This review discusses the complex signaling pathways of three estrogen receptors, highlights the development of GPER1-specific ligands, and summarizes the latest advances in the role of GPER1 in the pathogenesis of gallstone formation.

Does pregnancy increase the risk of cholecystectomy following bariatric surgery? A cross-sectional cohort study

BACKGROUND

Reproductive-aged women constitute a substantial proportion of patients who undergo weight loss procedures. While the risk of gallstone disease after such procedures has been addressed extensively, the impact of pregnancy on gallstone disease after bariatric procedures has not been reported.

OBJECTIVES

To explore the effects of pregnancy on cholecystectomy rates after laparoscopic sleeve gastrectomy (LSG).

SETTING

A university hospital.

METHODS

A cross-sectional cohort study of reproductive aged women (18-45 yr) who underwent LSG. The association between pregnancy and cholecystectomy was evaluated with Cox regression analysis.

RESULTS

Of 1056 women of childbearing age who underwent LSG during 2006-2017, 128 (12.1%) subsequently experienced a pregnancy. Median follow-up durations were 3.9 and 4.9 years for women who did and did not conceive, respectively (P < .001). The median time from procedure to conception was 509 (374-1031) days. Overall, 117 (11.1%) women underwent cholecystectomy after LSG. The rate of cholecystectomy among those who conceived was higher than among those who did not (18.8% versus 10.0%, P = .005). In an unadjusted analysis, pregnancy was associated with an increased risk of cholecystectomy (hazard ratio [95% confidence interval]: 3.97 [2.58, 6.09], P < .0001). The association between pregnancy and cholecystectomy persisted after controlling for confounding factors (hazard ratio [95% confidence interval]: 3.82 [2.47, 5.92], P < .0001). Among those who experienced pregnancy, lower gestational weight gain was the only factor found to be associated with cholecystectomy after surgery (P = .05).

CONCLUSIONS

Pregnancy is associated with a 4-fold increased risk of cholecystectomy after LSG. Thus, the desire for future pregnancy should be considered before LSG.

Evaluation of management and surgical outcomes in pregnancies complicated by acute cholecystitis

OBJECTIVE

To evaluate the management of pregnancies complicated by acute cholecystitis (AC) and determine whether pregnant women are more likely to have medical and surgical complications.

METHODS

We carried out a population-based matched cohort study using the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample from 2003 to 2011. Pregnant women with AC were age matched to non-pregnant women with AC on a 1:5 ratio. Management and outcomes were compared using descriptive analysis and conditional logistic regression.

RESULTS

There were 11,835 pregnant women admitted with AC who were age matched to 59,175 non-pregnant women. As compared to non-pregnant women, women with AC were more commonly managed conservatively, odds ratio (OR) 6.1 (5.8-6.4). As compared to non-pregnant women, pregnant women with AC more commonly developed sepsis [OR 1.4 (1.0-1.9)], developed venous thromboembolism [OR 8.7 (4.3-17.8)] and had bowel obstruction [OR 1.3 (1.1-1.6)]. Among pregnant women with AC, surgical management was associated with a small but significant increased risk of septic shock and bile leak.

CONCLUSION

AC, in the context of pregnancy, is associated with an increased risk of adverse outcomes. Although the literature favors early surgical intervention, pregnancies with AC appear to be more commonly managed conservatively with overall comparable outcomes to surgically managed AC. Conservative management may have a role in select pregnant women with AC.

Outcomes of Gallstone Disease during Pregnancy: a Population-based Data Linkage Study

BACKGROUND

Gallstone disease is a leading indication for non-obstetric abdominal surgery during pregnancy. There are limited whole population data on maternal and neonatal outcomes. This population-based study aims to describe the outcomes of gallstone disease during pregnancy in an Australian setting.

METHODS

Linked hospital, birth, and mortality data for all women with singleton pregnancies in New South Wales, Australia, 2001-2012 were analysed. Exposure of interest was gallstone disease (acute biliary pancreatitis, gallstones with/without cholecystitis). Outcomes including preterm birth (spontaneous and planned), readmission, morbidity and mortality (maternal and neonatal) were compared between pregnancies with and without gallstone disease. Adjusted risk ratios (aRRs) and 99% confidence intervals were estimated using modified Poisson regression and adjusted for maternal and pregnancy factors.

RESULTS

Among 1 064 089 pregnancies, 1882 (0.18%) had gallstone disease. Of these, 239 (12.7%) had an antepartum cholecystectomy and 1643 (87.3%) were managed conservatively. Of those managed conservatively, 319 (19.0%) had a postpartum cholecystectomy. Gallstone disease was associated with increased risk of preterm birth (aRR 1.3, 99% CI 1.1, 1.6), particularly planned preterm birth (aRR 1.6, 99% CI 1.2, 2.1), maternal morbidity (aRR 1.6, 99% CI 1.1, 2.3), maternal readmission (aRR 4.7, 99% CI 4.2, 5.3), and neonatal morbidity (aRR 1.4, 99% CI 1.1, 1.7). Surgery was associated with decreased risk of maternal readmission (aRR 0.4, 99% CI 0.2, 0.7).

CONCLUSIONS

Gallstone disease during pregnancy was associated with adverse maternal and neonatal outcomes. Most women with gallstone disease during pregnancy are managed conservatively. Surgical management was associated with decreased risk of readmission.

The course and outcomes of complicated gallstone disease in pregnancy: Experience of a tertiary center

Objective:

To evaluate the course and outcomes of pregnant patients with complicated gallstone disease and to reveal the experience of a tertiary center.

Materials and Methods:

The records of 92.567 patients were evaluated using searches for diagnoses with the terms of pregnant, pregnancy, gallstone, cholecystitis, cholangitis, choledocholithiasis, pancreatitis, and endoscopic retrograde cholangiopancreatography in pregnancy in the hospital database. Patients’ age, week of gestation, parity, body mass index, definitive diagnosis, attack episodes, treatment modalities, and obstetric and neonatal complications were evaluated.

Results:

Overall, 59 women were diagnosed as having complicated gallstone disease in pregnancy. Acute cholecystitis was the most commonly diagnosed complicated gallbladder disease (62.7%). Cholecystectomy was performed in 15 women during gestation. Perinatal outcomes were as follows: one (1.7%) maternal death, 4 (6.8%) preterm deliveries, 5 (8.5%) low-birth-weight fetuses, and 1 (1.7%) missed abortion were encountered. No fetal abnormalities were encountered.

Conclusion:

A significant proportion of women experience biliary disease during pregnancy. Herein, we presented our clinical experience because the diagnosis, course, and management of complicated gallstone disease in pregnancy is complicated.

Surgery for gallstone disease during pregnancy does not increase fetal or maternal mortality: a meta-analysis

BACKGROUND

Pregnancy was traditionally considered a contraindication to cholecystectomy but is now becoming the favoured option for gallstone-related disease (GRD) during pregnancy.

METHODS

To assess if cholecystectomy during pregnancy increases the risk of preterm labour, fetal mortality and maternal mortality. PubMed and MEDLINE databases for the period from January 1966 through December 2013. Studies were both conservative and surgical intervention was utilised in the management of GRD were included. The results of the included studies were pooled using meta-analysis techniques.

RESULTS

Surgical intervention for GRD in pregnancy does not increase the risk of preterm labour, fetal mortality or maternal mortality.

CONCLUSIONS

Cholecystectomy during pregnancy for GRD is associated with low complications for the fetus and mother and should be considered in all suitable patients.

Update on the management of non-obstetric acute abdomen in pregnant patients

Acute abdomen is a rare entity in the pregnant patient, with an incidence of one in 500-635 patients. Its appearance requires a quick response and an early diagnosis to treat the underlying disease and prevent maternal and fetal morbidity. Imaging tests are essential, due to clinical and laboratory masking in this subgroup. Appendicitis and complicated biliary pathology are the most frequent causes of non-obstetric acute abdomen in the pregnant patient. The decision to operate, the timing, and the surgical approach are essential for a correct management of this pathology. The aim of this paper is to perform a review and update on the diagnosis and treatment of non-obstetric acute abdomen in pregnancy.

Non-operative management of symptomatic cholelithiasis in pregnancy is associated with frequent hospitalizations

Symptomatic cholelithiasis (SC) is common in pregnancy. Guidelines recommend laparoscopic cholecystectomy (LC) for SC in pregnancy. Our aim was to evaluate current practice patterns and outcomes for patients undergoing initial non-operative management for uncomplicated SC during pregnancy. We performed a retrospective analysis and telephone survey of all patients presenting in a 42-month period to a tertiary care center for uncomplicated SC during pregnancy. Women with complicated gallstone disease, including cholecystitis, pancreatitis, choledocholithiasis, and cholangitis were excluded. We identified 53 patients with uncomplicated SC during pregnancy. LC was performed in 4 (7.5%) antepartum and in 28 (51.7%) postpartum. The majority of LCs (21, 75%) were performed within 3 months postpartum. Of those with postpartum LC, 22 (78.6%) had recurrent postpartum symptoms prior to LC, and 14 (50%) had repeat hospitalizations prior to undergoing surgery. Given the safety of antepartum LC and the frequency of recurrent symptoms and hospitalizations, early surgical intervention during pregnancy may be the optimal strategy to reduce antepartum and early postpartum admissions for uncomplicated SC.

Cholesterol cholelithiasis in pregnant women: pathogenesis, prevention and treatment

Epidemiological and clinical studies have found that gallstone prevalence is twice as high in women as in men at all ages in every population studied. Hormonal changes occurring during pregnancy put women at higher risk. The incidence rates of biliary sludge (a precursor to gallstones) and gallstones are up to 30 and 12%, respectively, during pregnancy and postpartum, and 1-3% of pregnant women undergo cholecystectomy due to clinical symptoms or complications within the first year postpartum. Increased estrogen levels during pregnancy induce significant metabolic changes in the hepatobiliary system, including the formation of cholesterol-supersaturated bile and sluggish gallbladder motility, two factors enhancing cholelithogenesis. The therapeutic approaches are conservative during pregnancy because of the controversial frequency of biliary disorders. In the majority of pregnant women, biliary sludge and gallstones tend to dissolve spontaneously after parturition. In some situations, however, the conditions persist and require costly therapeutic interventions. When necessary, invasive procedures such as laparoscopic cholecystectomy are relatively well tolerated, preferably during the second trimester of pregnancy or postpartum. Although laparoscopic operation is recommended for its safety, the use of drugs such as ursodeoxycholic acid (UDCA) and the novel lipid-lowering compound, ezetimibe would also be considered. In this paper, we systematically review the incidence and natural history of pregnancy-related biliary sludge and gallstone formation and carefully discuss the molecular mechanisms underlying the lithogenic effect of estrogen on gallstone formation during pregnancy. We also summarize recent progress in the necessary strategies recommended for the prevention and the treatment of gallstones in pregnant women.

Delaying cholecystectomy for complicated gallstone disease in pregnancy is associated with recurrent postpartum symptoms

INTRODUCTION

Pregnancy is a risk factor for gallstone disease; in some patients, cholecystectomy may be delayed to the postpartum period. Our aim was to examine the effect of antepartum interventions on postpartum outcomes in complicated gallstone disease (CGD) during pregnancy.

MATERIAL AND METHODS

Retrospective analysis of patients seeking medical care for CGD (cholecystitis, choledocholithiasis, or gallstone pancreatitis) during pregnancy at a single tertiary care institution over a 10-year period (2002-2012). Patients were contacted via standardized telephone survey to account for outside hospitalizations.

RESULTS AND DISCUSSION

We identified 56 patients with CGD during pregnancy, 42.9 % initially presenting during the second trimester. Choledocholithiasis was the most common diagnosis (n = 30). Antepartum cholecystectomy was performed in 17.9 %. Seventeen patients did not follow up postpartum and did not complete telephone survey. Of the remaining 29 patients, 58.6 % had recurrent postpartum symptoms, 35.3 % recurred within 1 month, and 82.4 % within 3 months of delivery. Antepartum ERCP with biliary sphincterotomy decreased postpartum symptom recurrence (38.5 vs. 75.0 %, p = 0.07).

CONCLUSIONS

The majority of patients with CGD who do not undergo antepartum cholecystectomy have recurrent postpartum symptoms often within 3 months postpartum. When appropriate, physicians should advocate for antepartum or early postpartum cholecystectomy to minimize symptom recurrence and unplanned hospitalizations.

Thirty-eight cases of acute pancreatitis in pregnancy: a 6-year single center retrospective analysis

Thirty-eight pregnant inpatients with acute pancreatitis (AP) were retrospectively reviewed from 2006 to 2012 in our hospital. The incidence of pregnancy-associated AP was 2.27‰. Most (78.95%) of the attack occurred in the third trimester. The median of APACHE II score was 6 and severe AP accounted for 31.58% (12 cases). Primary diseases were absent in most cases (57.89%). The most common clinical presentations were abdominal pain (89.47%) and vomiting (68.42%). Pleural effusion and ascites were found only in the third trimester. Elevated white blood cell count, amylase and lipase were commonly found in biochemical examinations. Eleven cases required intensive care in ICU and 21 cases received caesarean section. There were 2 maternal deaths and 12 fetal losses including 4 abortions. It is concluded that AP is a rare entity in pregnancy. The incidence of pancreatitis increases with the gestational age. However, the severity is not necessarily related with the pregnancy trimesters. The diagnosis is based on clinical presentations, laboratory tests and imaging examinations. Although the treatment strategy of a pregnant woman with pancreatitis is similar to the general non-pregnant patient with AP, a multidisciplinary team consisting of gastroenterologist, gastrointestinal surgeon, radiologist, obstetrician, and ICU doctor should be set up.

A multimodal approach to acute biliary pancreatitis during pregnancy: a case series

The treatment of acute biliary pancreatitis during pregnancy remains controversial. We present our experience of treating 7 pregnant women with acute biliary pancreatitis and verified or suspected choledocholithiasis, by using magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and sphincterotomy followed by laparoscopic cholecystectomy. MRCP was performed in all patients to confirm the presence of common bile duct stones, their size and number. ERCP and sphincterotomy were performed without the use of radiation. The procedure was terminated only when all stones (the number clarified at MRCP), were retrieved into the duodenum. All patients underwent laparoscopic cholecystectomy the following day. Neither post-ERCP nor postoperative major complications were noted. All but one patient reached a healthy natural-term labor. One patient had a planned cesarean section on 35th week. The combination of MRCP, nonradiation ERCP, and immediate laparoscopic cholecystectomy provides definite treatment and seems to put both mother and fetus at lower risk than presumed.

Pregnancy associated pancreatitis revisited

OBJECTIVES

To evaluate the demographics, risk factors and outcomes of pregnancy associated pancreatitis (PAP).

STUDY DESIGN

A retrospective chart review was done using ICD-9 Code 577.0 (acute pancreatitis) from January 2005 through December 2009. Women aged 18 to 45 years, who were pregnant and 6 months after delivery were considered for the study. For each case, two women of the same age (± 4 years) with no history of pancreatitis were matched as control. Demographics, etiology, diagnostic modality and intervention were obtained.

RESULTS

During the 5 years of study, 29 cases of PAP occurred among 25,600 total hospital deliveries, yielding prevalence of 0.001%: Hispanics 48%, Caucasians 24%, African Americans 17.2%, and Asian/Pacific Islanders 13% (P<0.05). Sixty-five percent of those with pre-pregnancy body mass index (BMI) more than 30 kg/m(2) had PAP, versus 24% with BMI between 25 and 30 kg/m(2) and 10% with BMI less than 25 kg/m(2) (P<0.05). An increasing trend of PAP was seen with gestational age and number of pregnancy.

CONCLUSION

Gallstone disease is the most frequent etiology for PAP and tends to occur more often in Hispanics in New Jersey.

Risk factors associated with biliary pancreatitis in children

OBJECTIVES

Little is known about risk factors for biliary pancreatitis in children. We characterized cases of pediatric biliary pancreatitis, compared biliary with nonbiliary cases, examined differences in presentation between younger and older children, and studied features distinguishing gallstone- from sludge-induced pancreatitis.

METHODS

We evaluated 76 episodes of biliary pancreatitis from 271 cases of acute pancreatitis in children admitted to a tertiary care hospital from 1994 to 2007.

RESULTS

Of the 76 cases, 55% had gallstones, 21% had sludge, and 24% had structural defects. Hispanic children had 2.85 (P = 0.01) and 5.59 (P = 0.003) times higher probability for biliary pancreatitis than white and black children, respectively. Median serum amylase and lipase in children with biliary pancreatitis were 64% and 49% higher, respectively, compared with other causes (P < 0.05). In multiple logistic regression, aspartate aminotransferase was an independent predictor of biliary pancreatitis (odds ratio 6.69, P = 0.001). When comparing gallstone- with sludge-induced causes, obesity was an independent predictor (38% more prevalent, P < 0.01) of gallstone cases.

CONCLUSIONS

Hispanic ethnicity is a risk factor and aspartate aminotransferase is a biomarker for biliary pancreatitis over other causes. Furthermore, obesity can distinguish gallstone- from sludge-induced pancreatitis. These findings may spur prospective studies to determine the optimal evaluation and management of children with biliary pancreatitis.

Concept of the pathogenesis and treatment of cholelithiasis

Gallstone disease (GD) is a chronic recurrent hepatobiliary disease, the basis for which is the impaired metabolism of cholesterol, bilirubin and bile acids, which is characterized by the formation of gallstones in the hepatic bile duct, common bile duct, or gallbladder. GD is one of the most prevalent gastrointestinal diseases with a substantial burden to health care systems. GD can result in serious outcomes, such as acute gallstone pancreatitis and gallbladder cancer. The epidemiology, pathogenesis and treatment of GD are discussed in this review. The prevalence of GD varies widely by region. The prevalence of gallstone disease has increased in recent years. This is connected with a change in lifestyle: reduction of motor activity, reduction of the physical load and changes to diets. One of the important benefits of early screening for gallstone disease is that ultrasonography can detect asymptomatic cases, which results in early treatment and the prevention of serious outcomes. The pathogenesis of GD is suggested to be multifactorial and probably develops from complex interactions between many genetic and environmental factors. It suggests that corticosteroids and oral contraceptives, which contain hormones related to steroid hormones, may be regarded as a model system of cholelithiasis development in man. The achievement in the study of the physiology of bile formation and the pathogenesis of GD has allowed expanding indications for therapeutic treatment of GD.

Acute abdomen in pregnancy: role of sonography

OBJECTIVE

The purpose of this presentation is to review the role of sonography in evaluation of acute abdomen during pregnancy.

METHODS

Illustrative cases were collected from gravid patients who presented with signs and symptoms suspicious for acute abdomen and subsequently underwent sonography.

RESULTS

This presentation shows sonographic findings of various maternal complications that can present with acute abdominal pain in pregnant patients.

CONCLUSIONS

Sonography remains the first line of imaging in pregnant patients presenting with acute abdomen. Patient triage or additional imaging may be obtained on the basis of the sonographic findings.

BILIARY AND PANCREATIC DISEASE IN PREGNANCY

Pregnancy is a physiological condition that affects all organs. Diseases unrelated to pregnancy may present coincidentally during pregnancy or may be exacerbated by pregnancy, and may increase maternal and/or fetal morbidity or mortality. Compared with many other systems, the changes within the biliary tree and pancreas are relatively minimal. However, pregnancy is associated with an increased likelihood of cholelithiasis, which can have significant implications for the parturient.

Appendicitis and cholecystitis in pregnancy

Acute abdominal pain in pregnancy may be attributable to a broad range of nonobstetrical causes. The evaluation of an acute abdomen during pregnancy must include in the differential diagnosis appendicitis and cholecystitis, which are 2 of the most common reasons for nonobstetric surgical intervention in pregnancy. Both conditions may be associated with significant maternal and fetal morbidity and/or mortality. This study will provide a contemporary synopsis regarding the diagnosis and management of appendicitis and cholecystitis during pregnancy.

Acute pancreatitis in pregnancy

Acute pancreatitis (AP) is a rare event in pregnancy, occurring in approximately 3 in 10 000 pregnancies. The spectrum of AP in pregnancy ranges from mild pancreatitis to serious pancreatitis associated with necrosis, abscesses, pseudocysts and multiple organ dysfunction syndromes. Pregnancy related hematological and biochemical alterations influence the interpretation of diagnostic tests and assessment of severity of AP. As in any other disease associated with pregnancy, AP is associated with greater concerns as it deals with two lives rather than just one as in the non-pregnant population. The recent advances in clinical gastroenterology have improved the early diagnosis and effective management of biliary pancreatitis. Diagnostic studies such as endoscopic ultrasound, magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography and therapeutic modalities that include endoscopic sphincterotomy, biliary stenting, common bile duct stone extraction and laparoscopic cholecystectomy are major milestones in gastroenterology. When properly managed AP in pregnancy does not carry a dismal prognosis as in the past.

Acute pancreatitis and pregnancy: a 10-year single center experience

BACKGROUND

Acute pancreatitis in pregnancy is rare. We report our institutional therapeutic approaches to this disease and its effect on maternal and fetal outcomes.

METHODS

A retrospective review of medical records of pregnant women admitted to Brigham and Women's Hospital between 1996 and 2006.

RESULTS

Twenty-one patients, presenting with 34 episodes of acute pancreatitis were identified. Most attacks (56%) occurred in the second trimester. Twelve patients had biliary pancreatitis. Three had pancreatitis secondary to other causes and six had "undetermined" etiologies. Of those with biliary pancreatitis, six underwent cholecystectomy; in a third of these cases, initial conservative therapy had failed. The other six patients underwent endoscopic sphincterotomy (n=2) or conservative therapy (n=4). Fifty percent of the patients with biliary pancreatitis managed conservatively had a recurrent episode of pancreatitis vs none in the cholecystectomy group. There was no significant difference in length of hospital stay between the three treatment groups (cholecystectomy, sphincterotomy, and conservative therapy). No maternal deaths were observed; there were four preterm labors and one fetal loss.

CONCLUSION

If treated conservatively, pregnant patients with biliary pancreatitis appear to have a high recurrence rate. Early surgical intervention is appropriate, safe, and does not increase the length of hospital stay.

Imaging of gastrointestinal and hepatic diseases during pregnancy

Imaging of the abdomen for suspected gastrointestinal and hepatic disease during pregnancy is assuming greater importance. Like clinical evaluation, imaging of the abdomen and pelvis is challenging but is vitally important to prevent delayed diagnosis or unnecessary interventions. Also choice of imaging modality is influenced by factors which could impact on fetal safety such as the use of ionising radiation and magnetic resonance imaging. This article discusses important issues in imaging of gastrointestinal and hepatic disease in pregnancy and the puerperium.

New advances in acute pancreatitis

PURPOSE OF REVIEW

We endeavor to review important new advances in acute pancreatitis made in the past year. We focused on clinical aspects of acute pancreatitis, which contained new observations or insights into new or old concepts. For experimental acute pancreatitis we refer readers to a recent comprehensive review.

RECENT FINDINGS

Recently, case fatality rates of acute pancreatitis have stabilized; carbohydrate-deficient transferrin was shown to predict alcoholic acute pancreatitis; idiopathic chronic pancreatitis or occult cholelithiasis have been associated with 'recurrent acute pancreatitis' in most patients; and cystic fibrosis transmembrane conductance regulator genetic mutations were frequently found (10-50%) in patients with recurrent acute pancreatitis. In addition, alcohol was shown to increase the risk of pancreatic necrosis regardless of the cause of acute pancreatitis. Persistent organ failure and multiple organ dysfunction syndrome but not necessarily extent of necrosis were demonstrated to predict increased mortality in acute pancreatitis. Chemoprevention of post-endoscopic retrograde cholangiopancreatography acute pancreatitis remains unproven. Enteral feeding has been strongly recommended in severe acute pancreatitis. Finally, data are lacking for routine, prophylactic antibiotic administration to all patients with pancreatic necrosis.

SUMMARY

We reviewed studies this past year that further characterize the epidemiology, etiology and risk stratification of acute pancreatitis. Evolving areas include chemoprevention of post-endoscopic retrograde cholangiopancreatography acute pancreatitis and enteral feeding and antibiotics in severe acute pancreatitis. We await translation of novel therapies from the bench to bedside.