Elsevier

Gastrointestinal Endoscopy

Volume 76, Issue 3, September 2012, Pages 564-569
Gastrointestinal Endoscopy

Original article
Clinical endoscopy
Conservative management of cholelithiasis and its complications in pregnancy is associated with recurrent symptoms and more emergency department visits

https://doi.org/10.1016/j.gie.2012.04.475Get rights and content

Background

Pancreaticobiliary complications of gallstones are common in pregnancy and can result in serious sequelae. Previous studies have shown conflicting results regarding different approaches of treatment.

Objective

To compare the outcomes of conservative treatment versus operative and endoscopic interventions in the management of complications related to gallstones during pregnancy.

Design

Retrospective chart review.

Setting

Tertiary-care referral facility.

Patients

A total of 112 patients who had complications related to gallstones during pregnancy.

Intervention

Patients were classified into 3 groups: conservative treatment, laparoscopic cholecystectomy (LC), and ERCP.

Main Outcome Measurements

We collected demographic data and information regarding treatment complications and pregnancy outcomes.

Results

A total of 112 pregnant patients met the inclusion criteria, with a mean age of 25 years. Main clinical presentations were biliary colic (n = 56), biliary pancreatitis (n = 27), acute cholecystitis (n = 17), and choledocholithiasis (n = 12). A total of 68 patients underwent conservative treatment, 13 patients underwent ERCP, 27 patients had LC, and 4 patients received both ERCP and LC. Recurrent biliary symptoms were significantly more common in patients who received conservative treatment (P = .0005). The number of emergency department visits was significantly higher in the conservative treatment group compared with the active intervention group (P = .0006). The number of hospitalizations also was higher in the conservative treatment group (P = .03). Fetal birth weight was similar in both groups (P = .1). Patients treated conservatively were more likely to undergo cesarean section operations for childbirth (P = .04).

Limitations

Single-center, retrospective study.

Conclusion

Conservative treatment of cholelithiasis and its complications during pregnancy is associated with recurrent biliary symptoms and frequent emergency department visits. ERCP and LC are safe alternative approaches during pregnancy.

Section snippets

Patients

After obtaining Institutional Review Board permission, we underwent a retrospective chart review of the records of patients with biliary disease in pregnancy in the period January 1998 to January 2009. We performed a search on all pregnant patients in this time period with the International Classification of Disease codes for acute cholecystitis, chronic cholecystitis, choledocholithiasis, acute pancreatitis, and recurrent biliary colic. We also searched for the Current Procedural Terminology

Data

The following data were collected in an Access database 2007 (Microsoft Corp., Redmond, WA): age of patient, trimester of pregnancy, diagnostic imaging results (US, MRCP), nature of the gallbladder disease (cholelithiasis, sludge, choledocholithiasis, cholecystitis), symptoms, associated complications including ascending cholangitis or acute biliary pancreatitis, laboratory test data, the use of fluoroscopy during the procedure, the use of sedation during the procedure, duration of the

Statistical analysis

Continuous data were reported as mean and standard deviation (SD). Categorical data were reported as proportions. The Fisher exact test was used to measure the association between categorical data. An unpaired t test was used to measure the association between continuous data. A P value of < .05 was considered statistically significant. All analyses were performed by using SAS, Version 9 (Statistical Analysis System, Cary, NC). Subgroup analysis was done for patients with recurrent biliary

Patient characteristics

A total of 112 pregnant patients were included in this study. Mean age at presentation was 25 years. A total of 66 patients (59%) were Hispanic, 29 patients (25.8%) presented in the first trimester, 43 patients (38.3%) presented in the second trimester, and 40 patients (35.7%) presented in the third trimester. Recurrent gallbladder colic was noted in 56 patients, biliary pancreatitis in 27 patients, acute cholecystitis in 17 patients, and CBD obstruction in 12 patients. The conservative

ERCP

Among the 17 patients who underwent ERCP, 4 were in the first trimester, 7 in the second trimester, and 6 in the third trimester. Eleven patients presented with CBD obstruction, 4 with biliary pancreatitis, and 2 with recurrent biliary colic. ERCP was performed at a mean of 3.7 days after the onset of the symptoms by experienced endoscopists. The mean duration of the procedure was 43 minutes. The CBD cannulation rate was 100%. Biliary sphincterotomy was done in 15 patients (88%). Precut biliary

Biliary-related outcomes

In our cohort, 81 patients continued to receive gastroenterology follow-up in our hospital (50 in the conservative treatment group and 31 in the active intervention group). Only 4 patients (12.9%) in the active intervention group (either LC or ERCP) had recurrent biliary symptoms, whereas 30 patients (60%) in the conservative treatment group had recurrent biliary symptoms in the follow-up period. The number of recurrent biliary symptoms was significantly higher in the conservative treatment

Discussion

In this study, pregnant patients with symptomatic cholelithiasis treated with conservative treatment had more episodes of recurrent biliary symptoms and a higher number of emergency department visits and hospitalizations related to biliary complications. Conservative management also resulted in early induction of labor related to biliary symptoms in 14% of patients. The mode of delivery was cesarean section in 35% of patients treated conservatively, which is significantly higher than that in

References (16)

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DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

If you would like to chat with an author of this article, you may contact Dr Othman at [email protected].

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