Acute cholecystitis in pregnancy

Abstract

Incidencija akutnog kolecistitisa tijekom trudnoće je 1 na 1600 – 10000 trudnoća, a 40% trudnica sa simptomatskom kolelitijazom zahtijeva kolecistektomiju tijekom trudnoće. Kolelitijaza je češća u žena nego muškaraca, što ide u prilog trudnoći kao jednom velikom rizičnom faktoru za razvoj žučnih kamenaca. Multiparitet je rizični čimbenik za kolelitijazu jer hormonske promjene direktno utječu na formiranje žučnih kamenaca. Progesteron relaksira glatku muskulaturu žučnog mjehura što dovodi do staze žuči, a estrogen povećava hepatičku sekreciju kolesterola u žuč i time dovodi do kolesterolske hipersaturacije žuči. Simptomi bolesti žučnog mjehura tijekom trudnoće su isti kao i kod žena koje nisu trudne. U trudnoći se javlja fiziološka leukocitoza do 20000, pa to predstavlja poteškoću u dijagnostici jer leukocitoza do 20000 nema dijagnostičku vrijednost. Indikacija za konzervativno liječenje je odgađanje kolecistektomije do drugog trimestra zbog manje incidencije spontanog pobačaja nego u prvom trimestru, iako konzervativnim liječenjem je povećan rizik za maternalnu malnutriciju i zastoj u fetalnom rastu zbog smanjenog majčinog oralnog unosa hrane, što povećava rizik za spontani pobačaj i prijevremeni porod. Konzervativno liječenje simptomatske kolelitijaze u trudnoći često vodi do suboptimalnih kliničkih ishoda. Majčina bolest može predstavljat veću prijetnju za fetus nego kirurško liječenje. Fetalni mortalitet je viši poslije konzervativnog liječenja nego poslije laparoskopske kolecistektomije. Nema značajne razlike u maternalnom i fetalnom ishodu kad se uspoređuju otvorena i laparoskopska kolecistektomija. Dok laparoskopska kolecistektomija u trudnica osigurava sve prednosti laparoskopske kirurgije kao što su značajno smanjenje trajanja hospitalizacije, smanjena upotreba anestetika, brži oporavak prema regularnoj prehrani i smanjena manipulacija uterusom. Prognoza poslije kolecistektomije tijekom trudnoće je odlična.The Incidence of acute cholecystitis during pregnancy is 1 in 1,600-10,000 pregnancies, and 40% of pregnant patients with symptomatic cholelithiasis require cholecystectomy during pregnancy. Cholelithiasis is more common in women than men, which supports the pregnancy as one major risk factor for the development of gallstones. Multiparity is risk factor for cholelithiasis due to hormonal changes that directly influence on gallstone formation. Progesterone relaxes the smooth muscle of the gallbladder which leads to stasis of bile, and estrogen increases the hepatic secretion of cholesterol in the bile and thus leads to cholesterol-supersatured bile. The symptoms of gallstone disease during pregnancy are the same as in nonpregnant patients. The difficulty in establishing the diagnosis is physiologic leukocytosis up to 20,000 at labor in normal pregnancy and is not diagnostic. Indication for conservative treatment is the delay of cholecystectomy until the second trimester because of decreased spontaneous abortion rate compared to the first trimester. However, conservative treatment presents an increased risk of maternal malnutrition and intrauterine growth restriction due to reduced maternal oral intake of food, which increases the risk of miscarriage and premature birth. Conservative treatment of symptomatic cholelithiasis in pregnant women often leads to suboptimal clinical outcomes. Maternal illness may pose a greater threat to the fetus than surgery. Fetal mortality is higher after conservative treatment than after laparoscopic cholecystectomy. There are no significant differences in maternal and fetal outcomes when comparing open and laparoscopic cholecystectomy. Laparoscopic cholecystectomy in pregnant women provides all the advantages of laparoscopic surgery as well as a significant reduction in the duration of hospitalization, reduced use of anesthetics, faster recovery to a regular diet and reduced manipulation of the uterus. Prognosis after cholecystectomy during pregnancy is excellent