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.