What is the management of cholelithiasis (gallstones) without cholecystitis (inflammation of the gallbladder) during pregnancy?

From the Guidelines

Cholecystectomy is safe during pregnancy and should be considered for patients with symptomatic cholelithiasis, ideally in the second trimester, as it reduces the risk of recurrent biliary symptoms and hospitalizations 1. The management of cholelithiasis without cholecystitis in pregnancy is a complex issue that requires careful consideration of the risks and benefits of different treatment approaches. Key considerations include:

• The risk of recurrent biliary symptoms and hospitalizations with conservative management, which can be as high as 60% 1
• The safety and efficacy of laparoscopic cholecystectomy during pregnancy, which has been established in several studies 1
• The importance of minimizing fetal radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP), which can be achieved through the use of modern fluoroscopy units and careful planning 1 Some of the key benefits of surgical intervention include:
• Reduced risk of recurrent biliary symptoms and hospitalizations
• Reduced risk of complications such as acute cholecystitis, cholangitis, and pancreatitis
• Improved quality of life for the patient However, it is also important to consider the potential risks and complications of surgical intervention, including:
• The risk of spontaneous abortion and preterm labor, particularly in the first and third trimesters
• The risk of post-ERCP pancreatitis, which is higher in pregnant women than in non-pregnant women 1 Overall, the decision to perform cholecystectomy during pregnancy should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history. The use of a multidisciplinary team, including an obstetrician, perinatologist, and experienced endoscopist, can help to minimize the risks and ensure the best possible outcomes for the patient and fetus 1. In terms of specific treatment approaches, the following may be considered:
• Expectant management with dietary modifications and pain control, as needed
• Laparoscopic cholecystectomy, ideally in the second trimester
• ERCP, if necessary, with careful planning and minimization of fetal radiation exposure It is also important to note that pregnancy-related hormonal changes can contribute to gallstone formation, and many women experience resolution of symptoms after delivery when hormone levels normalize 1. Therefore, a thorough discussion of the risks and benefits of different treatment approaches, as well as careful consideration of the individual patient's medical history and risk factors, is essential for making informed decisions about the management of cholelithiasis without cholecystitis in pregnancy 1.

From the Research

Management of Cholelithiasis without Cholecystitis in Pregnancy

• The management of cholelithiasis without cholecystitis in pregnancy is crucial to prevent complications such as cholecystitis and cholangitis 2.
• Lifestyle and dietary modifications combined with medication management, such as use of gallstone dissolution agents, may be recommended for persons who have a single symptomatic episode 2.
• If symptoms become severe and/or are recurrent, laparoscopic cholecystectomy is recommended 2.
• It is recommended that individuals with an established diagnosis of cholelithiasis be referred to a surgeon and/or gastroenterologist within 2 weeks of initial presentation regardless of severity or frequency of symptoms 2.

Treatment Options

• Surgery, non-surgical therapies, and ED pain management strategies are available treatment options for symptomatic cholelithiasis 3.
• Ursodeoxycholic acid treatment has been shown to be effective in patients with postcholecystectomy pain and bile microlithiasis 4.
• Endoscopic and surgical approaches are available for the management of choledocholithiasis, with one-session treatment characterized by a shorter hospital stay and more cost benefits 5.

Diagnostic Approaches

• Ultrasonography is the gold standard for diagnosis of cholelithiasis 2.
• Laboratory tests such as white blood cell count, liver enzymes, amylase, and lipase may assist the clinician in diagnosing cholelithiasis 2.
• A systematic English literature search can be conducted to determine the appropriate management strategies for choledocholithiasis 6.