Abstract
Introduction :
The occurrence of acute lithiasis cholangitis is rare during pregnancy. Its incidence doesn’t exceed 1/1200 parturient. It represents a medical-surgical emergency that can threaten the vital prognosis of both mother and fetus. Clinical presentation is variable, ranging from simple pain in right hypochondrium to septic shock. Medical imaging may be helpful to make diagnosis, in combination with other clinical and biological findings. The aim of our study was to describe clinical and morphological features of acute cholangitis in pregnant women, as well as management modalities.
Methods:
We report three cases of acute cholangitis complicating cholelithiasis in pregnant women, collected in the department of surgery A in “Charles Nicolle” hospital of Tunis, Tunisia.
Results:
The mean age of the patients was 31.3 ± 7 years. The mean term of pregnancy was 19 weeks. Two patients were in first trimester of pregnancy and one patient in third trimester. Abdominal pain was the main complaint in all patients and was located in right hypochondrium. Fever was noted in only one patient and jaundice in 3 patients. No patient had hyperleukocytosis, CRP was elevated in 2 patients, and liver function tests were disturbed in 3 patients. Abdominal ultrasound was performed in all patients showing a lithiasis, non-distended, and thin-walled gallbladder in all cases. Two patients had a dilated main bile duct. No patient had an abdominal CT scan or biliary MRI. All patients received both vitamin K supplementation and antibiotic therapy intravenously, then operated on. Average time from admission to surgery was one day. A right subcostal approach was performed in all cases. Cholecystectomy and cholangiography were performed in two patients showing dilated bile ducts with presence of at least two stones. A false biliary fistula was found in the third patient allowing direct access after cholecystectomy, extraction of stones, and verification of main biliary duct with choledochoscope, avoiding cholangiography. Postoperative course was simple in all patients. Hospitalization’s duration was 14 days for two patients and 12 days for one patient and intensive care unit stay was one day for two patients and two days for one patient. Pregnancy was carried to term for two patients. One patient was lost to follow-up.
Conclusion:
Acute lithiasis cholangitis is a rare situation in pregnant women. Diagnosis is often easy considering typical clinical presentation, but can lead to serious complications for both mother and fetus if diagnosis is delayed. Management is based on antibiotic therapy and bile duct clearance. Endoscopic sphincterotomy may be a good alternative to surgical treatment, allowing bile ducts’ clearance, postponing cholecystectomy to postpartum period.