Pregnancy and Cholecystitis. Acute Cholecystitis. Chronic Cholecystitis

The diseases of the biliary system are high on the list of illnesses of digestive organs. Women suffer by 2-7 times more often than men that is, probably, explained by effect of pregnancy. Chronic diseases of liver and gallbladder are encountered in 3% of pregnant. The rate of cholecystectomy at pregnancy makes up 0.1-3%.

Acute Cholecystitis. In its pathogenesis two factors are of great significance, i.e. infection and stagnation of bile, acting simultaneously, as a rule. In patients with acute cholecistitis the culture shows staphylococcus, colibacillus in bile. Hematogenous, lymphogenous and contact (from the intestine) ways of infection spread are determined. Cholestasis, caused by increase of intraabdominal pressure and hormonal imbalance in organism, changes of motor activity, position of gallbladder and ducts are of most importance in the development of acute cholecystitis during pregnancy. Hematogenous spread of infecton to biliary tract from organs of reproductive system is possible in pregnant.

Chronic Cholecystitis. Chronic cholecystitis is a chronic recurrent disease related to the presence of inflammatory changes in the gallbladder wall.

A pain syndrome prevails in the clinical picture of disease (in 88% of cases). The pregnant complains of dull, arching, boring pains, (pain may be sharp depending on type of dyskinesia), more often in the right hypochondrium irradiating to the right shoulder-blade, right shoulder, clavicle, rarer they may irradiate to the epigastrium or left hypochondrium. In addition, the pregnant may have a sense of weight in the right hypochondrium, feeling of bitter taste in the mouth, bitter eructation, nausea, vomiting, heartburn, bloating, unsteady stool.

The occurrence or strengthening of pains after inadequate diet is characteristic; 25% of women in the second half of pregnancy explain pains on account of fetal movement, its position in the uterus (the second position). On objective examination the zones of skin hyperesthesia (tender Head’s zones) are determined in the right hypochondrium, under the right shoulder-blade; on palpation tenderness in the right hypochondrium, positive Kehr’s, Ortner’s, Murphy’s symptoms are marked.

The diagnosis of exacerbation of chronic cholecystitis during pregnancy is based on complaints, anamnesis, objective data and results of additional methods of examination. Duodenal intubation and ultrasound examination of gallbladder are used for diagnostics. Biochemical examination of blood shows the decrease of bilirubin, phospholipid and cholic acid concentration, increase of cholesterol level that testify to the inflammatory process in the gallbladder.

Effect of Cholecystitis on Pregnancy. Chronic cholecystitis exacerbates the course of pregnancy. Exacerbation of chronic cholecystitis (in 91.1% of patients) develops in the III trimester of pregnancy. In 49.1% of cases chronic cholecystitis is complicated by nausea, vomiting, and in 15% — by salivation. In 23.3% of patients the vomiting proceeded for more than 12 weeks, and in 8.8% — until 29-30 weeks of gestation.

The 2nd half of pregnancy is complicated by different forms of gestosis (edema, preeclampsia) in 10% of women. Cases of premature termination of pregnancy on a background of this disease are possible.

Effect of Gestation on the Course of Cholecystitis. Pregnancy deteriorates the course of chronic cholecystitis: of 120 patients only in 7 the symptoms of exacerbation of disease were absent.

Management of Pregnancy in Patients with Cholecystitis. Chronic cholecystitis is not an indication for termination of pregnancy.

In the period of exacerbation of cholecystitis the women are recommended bed rest during 7-10 days.

At hypokinetic biliary dyskinesia (prevailing during pregnancy) a prolonged bed regimen is undesirable. Principles of treatment of chronic cholecystitis in pregnant are the same as in nonpregnant. Dietotherapy is administered without any strict limitations at observance of optimal (for every term of pregnancy) ratio of proteins, fats and carbohydrates.

At the expressed pain syndrome spasmolytic and sedative drugs are administered: papaverine hydrochloride, baralgin, etc.

Oleandomycin phosphate (0.5 g 4 times a day), ampicillin (0.25 g 4 times a day), oxacyllin (0.5 g 4 times a day), ampyoxis (0.5 g 4 times a day) by courses of 7-10 days should be administered. From the II trimester of pregnancy antibiotics of cephalosporin group (cephalecsin, cephuroxim, claphoran, etc.) can be used, as well as erythromycin (0.25 g 4 times a day), linkomycin (0.5 g 3 times a day), furazolidone, nevigramon. Bile-expelling agents should be obligatory used.

Labor should be conducted depending on individual course of the process.