Acute cholecystitis usually develops when the cystic duct is obstructed. Bacterial infection plays a role in 50 to 85 percent of cases. In more than half of patients with acute cholecystitis, a history of prior right upper quadrant pain from cholelithiasis is elicited. With acute disease, pain is accompanied by anorexia, nausea and vomiting, low-grade fever, and mild leukocytosis. As shown in Figure 55-3, sonography can help visualize stones, and both false-positive and false-negative rates range from 2 to 4 percent (Greenberger, 2015). In acute cases, medical therapy consists of IV luids, antimicrobials, analgesics, and in some instances, nasogastric suction, before surgical therapy. Laparoscopic cholecystectomy is the preferred treatment for most patients.
After the irst trimester, the gallbladder fasting volume and the residual volume after postprandial emptying are doubled. Incomplete emptying may result in retention of cholesterol crystals, a prerequisite for cholesterol gallstones. Maringhini and colleagues (1993) showed that the incidence of biliary sludge-which can be a forerunner to gallstones-and gallstones in pregnancy are 31 and 2 percent, respectively. Ko and colleagues (2014), however, cited a combined incidence of <5 percent. Others have identiied asymptomatic gallstones in
FIGURE 55-3 This sonogram shows mUltiple hyperechoic gallstones filling an anechoic gallbladder.
2.5 to 10 percent of more than 1500 pregnant or postpartum women (Maringhini, 1993; Valdivieso, 1993).
Postpartum, sludge frequently regresses, and occasionally gallstones will resorb. Still, within a year ter delivery, hospitalization for gallbladder disease remains relatively common, particularly for women managed conservatively in pregnancy. Jorge and coworkers (2015) reported that half of 53 women with symptomatic gallstones in pregnancy underwent postpartum cholecystectomy. In 80 percent of these women, recurrent symptoms developed prior to surgery, requiring readmission in half.
Acute cholecystitis during pregnancy or the puerperium is common and usually associated with gallstones or biliary sludge. Symptomatic cholecystitis is initially managed in a manner similar to that for nonpregnant women. In the past, most favored medical therapy. However, the recurrence rate during the same pregnancy is high, and 25 to 50 percent of women ultimately required cholecystectomy for persistent symptoms. Moreover, if cholecystitis recurs later in gestation, preterm labor is more likely and cholecystectomy is technically more diicult.