How is cholecystitis managed in pregnancy?

Management of Cholecystitis in Pregnancy

Laparoscopic cholecystectomy is the recommended treatment for cholecystitis during pregnancy, ideally performed in the second trimester, though it can be safely performed in any trimester if medically necessary. 1

Diagnosis

• Imaging: Ultrasound is the preferred initial imaging modality for diagnosing gallstones during pregnancy 1
• Clinical presentation: Typically includes right upper quadrant pain, nausea, vomiting, and possibly fever
• Laboratory findings: May include leukocytosis and elevated liver enzymes

Management Algorithm

First-line Approach:

1. Initial assessment:

   • Determine severity of symptoms
   • Evaluate gestational age
   • Assess for complications (pancreatitis, cholangitis)

2. Treatment decision based on trimester and severity:

   a) Symptomatic uncomplicated gallstones (biliary colic):

   • Conservative management with IV hydration and symptom control may be attempted initially 1
   • However, note that conservative management has a 60% recurrence rate of biliary symptoms 2
   • Patients treated conservatively are more likely to undergo cesarean delivery 2

   b) Acute cholecystitis:

   • Second trimester: Proceed directly to laparoscopic cholecystectomy (optimal timing) 1
   • First trimester: Laparoscopic cholecystectomy if symptoms are severe and recurrent 1
   • Third trimester: Laparoscopic cholecystectomy if symptoms are severe; consider coordinating with planned delivery if near term 1

Special Considerations:

1. Gallstone pancreatitis:

   • Initial conservative management with supportive care 1
   • ERCP with sphincterotomy within 24 hours for cholangitis and within 72 hours for suspected persistent common bile duct stone 1
   • Same-admission cholecystectomy reduces 30-day readmission rates (33.7% vs 5.3%) 2, 1

2. Severe cholecystitis in high-risk surgical patients:

   • Percutaneous cholecystostomy tube placement or gallbladder aspiration as "bridging" therapy 2
   • Particularly useful in first trimester (bridging to second) or third trimester (bridging to postpartum) 2

3. Late third trimester presentation:

   • Consider postponing surgery until after delivery if it doesn't pose risk to maternal or fetal health 2
   • Early delivery (37-39 weeks) may be reasonable for severe cholecystitis not responding to treatment 1

Surgical Technique

• Positioning: After first trimester, patients should be placed in left lateral or partial left lateral decubitus position to minimize compression of inferior vena cava 2
• Approach: Laparoscopic cholecystectomy has lower maternal complication rates (3.5%) compared to open cholecystectomy (8.2%) 1, 3
• Avoid: Excessive manipulation of the uterus during surgery 1

Evidence Quality and Considerations

The most recent and highest quality evidence from the American Gastroenterological Association (2024) and American College of Surgeons strongly supports laparoscopic cholecystectomy during pregnancy 2, 1. While older studies from the 1980s and 1990s favored conservative management 4, 5, more recent evidence demonstrates that surgical management results in:

• Lower readmission rates 2, 6
• Shorter hospitalization duration 6
• Reduced risk of recurrent symptoms 2

A 2023 study showed that complications were statistically higher after open cholecystectomy compared to laparoscopic approach (p=0.003), and morbidity was higher when surgery was performed in the third trimester (p=0.003) 3.

Common Pitfalls to Avoid

1. Delaying surgical intervention: Conservative management leads to recurrent symptoms in 60% of pregnant patients 2

2. Overlooking coordination of care: Management should involve gastroenterologists, surgeons, obstetricians, and anesthesiologists 1

3. Ignoring timing considerations: While laparoscopic cholecystectomy can be performed in any trimester, the second trimester remains optimal with lower risks of spontaneous abortion and preterm labor 1

4. Failing to consider percutaneous cholecystostomy: This can be an effective bridging therapy for patients who are poor surgical candidates 2, 5

5. Inadequate radiation protection during ERCP: When ERCP is necessary, it should be performed at tertiary care centers with experienced endoscopists to minimize radiation exposure and complications 1