THE RESULTS OF TREATMENT OF PREGNANT WOMEN WITH COMPLICATIONS OF CHOLELITHIASIS

Abstract

Relevance

Complications of cholelithiasis occupy the 2nd place after acute appendicitis among emergency surgical diseases of the abdominal cavity in pregnant women. Acute cholecystitis occurs in 1 case per 2000-5000 patients, up to 85% of acute pancreatitis in pregnant women (frequency 1 per 1500-4500 pregnant women) have biliary genesis. Pregnancy is a predisposing factor both to the development of gallstone disease and to the manifestation of its clinical symptoms and complications.

Purpose of the study

Analysis of the results of treatment of pregnant women with cholelithiasis complications.

Materials and methods

17 pregnant women with cholelithiasis complications were treated at the A.N. Syzganov National Research Medical Center in 2022-2023. The average age of the patients was 37.6 years (27-49 years).Patients were admitted from different regions of Kazakhstan, after a telemedicine consultation: Atyrau region – 6, Almaty – 5, Turkestan region and Shymkent – 2 each, Kyzylorda and Zhetysu regions – 1 each.

Patients were admitted at various gestation periods from 13 to 33 weeks of pregnancy: I trimester - 1, II trimester - 11 patients, the third trimester - 5 patients. Of all the treated patients, 6 (35.3%) were primiparous.

In addition to the standard complex of laboratory and instrumental studies, ultrasound of the hepatopancreatobiliary zone and magnetic resonance imaging (MRI) were performed to verify the diagnosis.

Results

All patients at the prehospital stage had a pain syndrome cholelithiasis. Mechanical jaundice occurred in 13 patients (76.5%): bilirubin levels ranged from 25.7 to 148.9 mmol/l. 3 of them (23.1%) had symptoms of remitting cholangitis with an increase in body temperature to subfebrile figures and periodic chills. An increase in C-reactive protein was observed in 8 patients: the level of CRP ranged from 5.7 to 188.6 mg/l.Aminotransferases (ALT, AST) were high in 10 patients (58.8%). A moderate increase in blood amylase upon admission was detected in 3 patients (17.6%).

Choledocholithiasis was diagnosed in 15 out of 17 patients on ultrasound, the informative value of ultrasound in the diagnosis of cholelithiasis complications was 100%. A picture of calculous cholecystitis occurred in 2 patients. It should be noted that ultrasound is not informative in regional medical organizations, before admission to them, only 5 out of 15 patients had choledocholithiasis (33.3%).

In 13 patients out of 15 (86.6%), gallbladder stones were combined with stones in choledochus, in 2 isolated choledocholithiasis was detected.

After diagnosis, all patients underwent surgical interventions. Two-stage minimally invasive surgical interventions were performed in 8 cases: 1 -endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic papillosphincterotomy (EPST) with choledocholithoextraction and stage 2 - laparoscopic cholecystectomy (LCE). Of the 8 patients who underwent the combined treatment, 5 were in the 2nd trimester of pregnancy, 3 in the third trimester. ERCP with EPST was performed in all cases under general anesthesia with a ventilator in the X-ray room, after a decrease in bilirubin and amylase indices, LCE was performed on days 3-6.

6 patients underwent only endoscopic intervention – ERCP and EPST with choledocholitextraction: 3 patients in the third trimester, 3 patients in the 2nd trimester. LCE in this group was not performed due to the absence of stones and the presence of sludge in the gallbladder in 2 cases and the threat of premature birth at 32 weeks gestation in one case. The last patient was recommended to undergo surgical treatment after delivery.

3 patients underwent only LCE due to the lack of indications for ERCP. There were no choledochal stones at admission in 2 patients, in 1 case, biliary sludge in the gallbladder, which did not require surgery, was found on a control ultrasound after ERCP with choledocholytic extraction.

Patients were discharged only after a decrease in bilirubin, liver enzymes, amylase, and inflammatory markers.

In one case, a complication was observed in the form of perforation of the duodenal diverticulum, extensive subcutaneous emphysema, acute post-catheterization pancreatitis. This complication was detected during surgery, choledochal stenting and conservative treatment were performed. The patient was discharged in a satisfactory condition.

Conclusion

The informative value of ultrasound in the diagnosis of cholelithiasis complications complications in pregnant women, conducted by experienced specialists, is comparable to MRI.  In clinical forms of choledocholithiasis, the first stage is to perform endoscopic sphincterotomy with choledocholitextraction by an experienced endoscopist and the second stage is to perform LCE.Currently, LCE can be performed in any trimester of pregnancy, if indicated. In the treatment of complications of cholelithiasis in pregnant women, close interaction of surgeons, endoscopists, doctors of functional diagnostics, obstetricians and gynecologists and intensive care specialists is necessary.