Cholecystitis in Pregnancy

Introduction

• Description: Cholelithiasis and cholecystitis complicate more than 3% of pregnancies. Acute cholecystitis is the second most common nonobstetric indication for surgery during pregnancy (after acute appendicitis).

• Prevalence: Cholelithiasis—3%–4% of pregnancies; cholecystitis—0.25% of pregnancies.

• Predominant Age: Reproductive age.

• Genetics: Some groups are at greater risk (eg, Pima Indians).

Etiology and Pathogenesis

• Causes: The metabolic alteration leading to cholesterol stones (gallstones) is considered to be a disruption in the balance between hydroxymethylglutaryl coenzyme A (HMG-CoA) reductase and cholesterol 7α-hydroxylase. HMG-CoA controls cholesterol synthesis, whereas cholesterol 7α-hydroxylase controls the rate of bile acid formation. Patients who form cholesterol stones have elevated HMG-CoA levels and depressed cholesterol 7α-hydroxylase levels. This change in ratio increases the risk for cholesterol precipitation. During pregnancy, there is an increased rate of bile synthesis, increased cholesterol saturation of bile, and a reduced rate of gallbladder emptying, increasing the risk for stone formation and obstruction. These physiologic changes reverse by approximately 2 months after delivery. As a result, approximately 30% of stones smaller than 10 mm disappear due to unsaturation of bile in the postpartum period.

• Risk Factors: Cholecystitis is associated with an increased maternal age, multiparity, multiple gestation, and a history of previous attacks.

Signs and Symptoms

• Unchanged by pregnancy

• May be confused with symptoms of pregnancy

• Fatty food intolerance

• Variable right upper quadrant pain with radiation to the back or scapula

• Nausea or vomiting (often mistaken for “indigestion” or “morning sickness”)

• Fever is usually associated with cholangitis

Diagnostic Approach