Saudi Journal of Gastroenterology
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CASE REPORT Table of Contents   
Year : 1999  |  Volume : 5  |  Issue : 1  |  Page : 32-35
Gallstone pancreatitis in pregnancy


1 Department of Surgery, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
2 Department of Surgery, Surgical Critical Care, General & Trauma Surgery, Duke University Medical Center, Durham, North Carolina, USA

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Date of Submission05-Mar-1997
Date of Acceptance21-May-1998
 

How to cite this article:
Abdul Jabbar AS, Al Shanafey SN, Vaslef SN. Gallstone pancreatitis in pregnancy. Saudi J Gastroenterol 1999;5:32-5

How to cite this URL:
Abdul Jabbar AS, Al Shanafey SN, Vaslef SN. Gallstone pancreatitis in pregnancy. Saudi J Gastroenterol [serial online] 1999 [cited 2019 Dec 15];5:32-5. Available from: http://www.saudijgastro.com/text.asp?1999/5/1/32/33524


Gallstones and alcohol are both common causes of acute pancreatitis but gallstone pancreatitis is a rare occurrence during pregnancy. It occurs more during the third trimester, followed by the first then the second trimester. It has been considered dangerous to both mother and fetus but an early diagnosis can improve the prognosis. There is no clear consensus about the proper treatment. This presentation illustrates a case of gallstone pancreatitis during the third trimester and its management. A surgical strategy was recommended in the literature which will minimize fetal and maternal morbidity and mortality while also reducing relapses and hospital utilization from gallstone pancreatitis complicating pregnancy. The role of laparoscopic cholecystectomy and other endoscopic modalities in pregnancy were also discussed.

Gallstones are usually reported as the most common cause of acute pancreatitis during pregnancy [1],[2],[3],[4],[5] . Gallstone panereatitis is a rare occurrence during pregnancy with few reports in the literature addressing the problem [6] . The occurrence of acute pancreatitis is more likely during the third trimester followed by the first then the second trimester. There is no well-defined relation to parity [7] .

During pregnancy, plasma triglyceride levels normally increase threefold, with peaks achieved during the third trimester, a,25% to 50% increase in plasma cholesterol levels also occurs [8],[9] . The explanation for hypeitiiglyceridemia is an effect of high concentrations of circulating estrogen during pregnancy. High serum progesterone levels result in hypotonia of the bile duct and decreased emptying of the gallbladder [10] . The stasis and increased concentration of cholesterol in the bile are the factors believed important in the formation and deposition of calculi of the biliary tract. The intermittent passage of small gallstones from the gallbladder into the common bile duct with temporary obstruction of the  Sphincter of Oddi More Details gives rise to pancreatitis [11] .

Symptoms that suggest the diagnosis of acute pancreatitis are similar to those in non-pregnant women, mid-epigastric or right upper quadrant pain with radiation to the back is the cardinal complaint. Other expected features, such as nause, vomiting, ileus, and low-grade fever, likewise occur during pregnancy.

Measurement of amylase and lipase concentration in peripheral blood remains the key diagnostic step in a pregnant patient with suspected acute pancreatitis. The diagnosis of acute pancreatitis has also been aided by the availability of ultrasound where the pancreas can be visualized if there is some changes such as edema that support the diagnosis and it has the virtue of identifying gallstones as a possible cause [1] .

Acute pancreatitis has been considered dangerous to both mother and fetus but an early diagnosis and management can improve the prognosis [10] .

Gallstone pancreatitis during pregnancy represents a clinical challenge with regard to management options and there is no clear consensus about the proper treatment. Some authors recommend medical therapy for all patients [3],[12],[13] and others support surgical intervention [2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14] .


   Case report Top


A 33-year-old Saudi woman (gravida 3, para 2) at 40 weeks of pregnancy presented with a complaint of epigastric pain radiating to the back, with associated nausea and vomiting for few hours duration. She had the same problem during her last pregnancy and relieved by analgesia and improved after delivery. There was no history of ulcer disease. The patient did not have pain between pregnancies.

She was admitted to the King Faisal Specialist Hospital labor ward where the patient was afebrile with normal vital signs but she was in pain. Abdominal examination revealed a 40 weeks pregnant lady with epigastric tenderness and uterine tenderness. Vaginal examination revealed 2 cm dilated cervix and 1 cm long.

Because it was not typical for delivery pain, other causes of abdominal pain were suspected. Serum amylase was performed at that time and it was elevated (1200 a/1). Abdominal ultrasonography revealed multiple small gallbladder stones with edematous pancreas, the intrahepatic and extrahepatic and extrahepatic duct were not dilated. The common bile duct was 0.71 cm in diameter but there was no CBD stones [Figure - 1]. The patient was diagnosed as a case of gallstone pancreatitis and she was treated conservatively.

Labor was induced the next day with normal vaginal delivery and excellent apgar score. Because of the persisting pain and elevated serum amylase, endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy was done the next day [Figure - 2]. The papilla was inflamed. The common bile duct was mildly dilated but there were no stones.

After five days. laparoscopic cholecystectomy was performed. The postoperative course was uneventful and serum amylase decreased gradually to the normal range. The patient was discharged on the second postoperative day in good condition


   Discussion Top


Acute pancreatitis is a rare occurrence during pregnancy. In more than 45,000 deliveries, Swisher et al noted only 30 cases of pancreatitis (or 1 in 1500 deliveries) for an incidence of 0.07 percent [6] . Since the advent of ultrasonography, gallstones have been found to be the cause in 70 percent to 100 percent of the reported cases [2],[15] .

The management of gallstone pancreatitis during pregrancy is supportive, just as it is in non-pregnant patients [1] . The essential managment elements are adequate fluid replacement intravenously and analgesia with detailed monitoring and support of renal and respiratory function [15] .

Controversy exists in the literature as to the appropriate managment of gallstone pancreatitis occuring during pregnancy. Some authors advocate avoiding surgery [12],[13],[18] whereas others have determined that cholecystectomy can be performed safely during pregnancy [17],[19],[20],[21] . The controversy is because of a lack of prospective comparison of operative versus nonoperative management, as well as the relatively few instances reported in individual retrospective series [14] .

Nonoperative management of symptomatic gallstones has generally been advocted before for pregnant patients. The rate of relapse in gallstone pancreatitis during pregnancy is high. More than 70 percent of these patients who presented in the first trimester developed another episode of biliary induced pain before delivery [6] . Fetal and maternal mortality were as high as 21 percent and 60 percent respectively [3] . With modem medical, obstetric and surgical management, fetal and maternal morbidity and mortality secondary to gallstone pancreatitis are minimal [16] . Dixon et al experience indicates that conservative management is associated with recurrent episodes as well as a significant rate of fetal loss [17] . Block and Kelly's experience with this disease indicates that delaying surgical treatment indefinitely is associated with recurrent episodes of gallstone pancreatitis requiring multiple hospitalization as well as higher fetal mortality and maternal morbidity [2] . The avoidance or even delaying appropriate surgical therapy for gallstone pancreatitis during pregnancy no longer seems warranted [14] .

Evidently the second trimester is the optimal time for elective operation during pregnancy because the peak period of spontaneous abortion is passed, organogenesis Js complete, the uterus is not large enough to impinge on the operative field, and the induction of premature labor may be less likely than in the third trimester [18],[22] . The surgery performed during the second trimester is safe and associated with little maternal morbidity, no fetal loss, and a substantial reduction in total hospital days [17] .

A recommended aggressive surgical strategy is suggested in the literature involving elective second trimester cholecystectomies for all pregnant gallstone pancreatitis patients [6] . All patients should be treated according to the trimester of presentation. In the first trimester, patients should be treated medically, and then operated on electively in the second trimester. Second trimester patients should be stabilized and then taken to the operating room. Third trimester patients should be treated medically until delivery and then should undergo cholecystectomy immediately post-partum (as in our case). Any patient who deteriorates clinically should be evaluated for surgery or ERCP sphincterotomy regardless of the trimester [23] . This strategy will minimize fetal and maternal morbidity while reducing relapses and hospital utilization from pancreatitis complication pregnancy [6] .

Laparoscopic cholecystectomy is now the preferred method for managing gallstone pancreatitis in the general population [24] . It has been stated earlier that pregnancy is an absolute contraindication to laparoscopic cholecystectomy [25] . However, recent reports described the safety of laparoscopic cholecystectomy performed in appropriate circumstances during pregnancy [25],[26] . Morrell et al recommend initiation of pneumatic compression device at the induction of anesthesia to prevent or decrease the risk of thromboembolic disease during pregnancy [26] . Furthermore, the operating table should be rotated to displace the uterus from the inferior vena cava so that venous return is unimpaired. A lead shield should be placed over the uterus to maximize fetal protection from radiation, and an open technique (Hasson trocar) should be used for initial trocar placement to help avoid injury to the gravid uterus. Preoperative fetal and uterine monitoring are needed to follow both fetal status and uterine contractility [26] . Endoscopic management should be considered in women presenting with gallstone pancreatitis during pregnancy. Endoscopic retrograde cholangiopancreatography and sphincterotomy can be performed safely and successfully in pregnancy with minimal exposure to radiation [23] . Uomo et al performed endoscopic sphincterotomy in two pregnant women with gallstone pancreatitis due to CBD stones without the use of X-ray [27] . A careful sonographic evaluation may allow localization and removal of the stone without fluoroscopy. Binmoeller and Katon reported on the use of the needle knife papillotome for endoscopic extraction of an impacted common bile duct stone in a pregnant patient [28] . This technique can only be used by the expert biliary endoscopist who understands the indication and risks of this procedure.

 
   References Top

1.Scott LD. Gallstone disease and pancreatitis in pregnancy. Gastroenterol Clinic North Am 1992;21:803-15.  Back to cited text no. 1    
2.Block P, Kelly TR. Management of gallstone pancreatitis during pregnancy and the postpartum period. Surg Gynecol Obstet 1989;168:426-8.  Back to cited text no. 2  [PUBMED]  
3.Montgomery WH, Miller FC. Pancreatitis and pregnancy. Obstet Gyencol 1970;35:658.  Back to cited text no. 3    
4.Tegenfeldt EG, Kirkland HB, Brown FG. Gallstones, pancreatitis and pregnancy. Am Surg 1967;33:88.  Back to cited text no. 4    
5.Yamauchi H. Sanamura M, Takeda K, et al. Hyperlipidemia and pregnancy associated with pancreatitis with reference to plasma exchange as a therapeutic intervention. Tohoku J Exp Med 1986;148:197.  Back to cited text no. 5    
6.Swisher SG, Hunt KK, Schmit PJ, Hiyama DT, Bennion RS, Thompson JE. Management of pancratitis complicating pregnancy. The American Surgeon 1994;60:759-62.  Back to cited text no. 6  [PUBMED]  
7.Klein KB. Pancreatitis in pregnancy. In Rustgi VK, Cooper JN (Eds.) Gastrointestinal and hepatic complications in pregnancy. New York, John Wiley & Sons 1986;138-44.  Back to cited text no. 7    
8.Knepp RH, Warath MR, Carrol CJ. Lipid metabolism in pregnancy, changes in lipoprotein, triglyceride and cholesterol in normal pregnancy and the effects of diabetes mellitus. J Reprod Med 1973;10:95-100.  Back to cited text no. 8    
9.Potter MG. Observations of the gallbladder and bile during pregnancy at term. JAMA 1936;106:1070-77.  Back to cited text no. 9    
10.Joupilla, Mokka, Larmi TK. Acute pancreatitis in pregnancy. Surg Gynecol Obstet 1974;139:879-82.  Back to cited text no. 10    
11.Kelly TR. Gallstone pancreatitis, pathophysiology. Arch Surg 1976;80:488-92.  Back to cited text no. 11    
12.Greene J, Rogers A, Rubin L. Fetal loss after cholecystectomy during pregnancy. Canad Med Assoc J 1963;88:576-7.  Back to cited text no. 12  [PUBMED]  [FULLTEXT]
13.Hiatt JR, Hiatt JCG, Williams RA, Klein SR. Biliary disease in pregnancy. Am J Surg 1986;151:263-5.  Back to cited text no. 13    
14.McKellar DP, Anderson CT, Boynton CJ. Cholecystectomy during pregnancy without fetal loss. Surg Gynecol Obstet 1992;174:465-8.  Back to cited text no. 14    
15.McKay AJ, O'Neill J, lmrie CW. Pancreatitis, pregnancy and gallstones. Brit J Obstet Gynaecol 1980;87:47-50.  Back to cited text no. 15    
16.Swisher SG, Schmit PJ, Hunt KK, Hiyama DT, Bennion RS, Swisher EM, Thompson JE. Biliary disease during pregnancy. Am J Surg 1994;168:576-81.  Back to cited text no. 16  [PUBMED]  
17.Dixon NP, Faddis DM, Siberman H. Aggressive management of cholecystitis during pregnancy. Am J Surg 1987; 154:292-4.  Back to cited text no. 17    
18.Hill LM, Johnson CE, Lee RA. Cholecystectomy in pregnancy. Obstet Gynecol 1975;63:1157-64.  Back to cited text no. 18    
19.Kammerer WS. Non-obstetric surgery during pregnancy. Med Clin North Am 1979;63:1157-64.  Back to cited text no. 19  [PUBMED]  
20.O'Neill J. Surgical conditions complicating pregnancy. Aust NZ J Obstet Gynaecol 1969;9:249-52.  Back to cited text no. 20    
21.Printen KJ. Cholecystectomy during pregnancy. Am J Surg 1987;154:292-4.  Back to cited text no. 21    
22.Simon JA. Biliary tract disease and related surgical disorders during pregnancy. Clin Obstet Gynecol 1983;26:810-21.  Back to cited text no. 22  [PUBMED]  
23.Baillie J, Carins SR, Colton PB. Endoscopic management of choledocholithiasis during pregnancy. Surg Gynecol Obstet 1990;171:1-4.  Back to cited text no. 23    
24.Tang E, Stain SC, Tang G, Froes E, Berne TV. Timing of laparoscopic surgery in gallstone pancreatitis. Arch Surg 1995;130:496-500.  Back to cited text no. 24  [PUBMED]  
25.Elerding SC. Laparoscopic cholecystectomy in pregnancy. Am J Surg 1993;165:652-7.  Back to cited text no. 25    
26.Morrel DG, Mullins JR, Harrison PB. Laparoscopic cholecystectomy during pregnancy in symptomatic patients. Surgery 1992;112:856-9.  Back to cited text no. 26    
27.Uomo G, Manes G, Picciotto FP, Rabitti PG. Endoscopic treatment of acute biliary pancreatitis in pregnancy. J Clin Gastroenterol 1994;18:250-2.  Back to cited text no. 27  [PUBMED]  
28.Binmoeller KF, Katon RM. Needle knife papillotomy for an impacted common bile duct stone during pregnancy. Gastrointestinal Endoscopy 1990;36:607-9.  Back to cited text no. 28  [PUBMED]  

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Correspondence Address:
Alaa S.O Abdul Jabbar
Department of Surgery (MBC-40), King Faisal Specialist Hospital & Research Center, P.O. Box 3354, Riyadh 11211
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864758

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