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Clinical Case 056: Momma got a rolling stone

This young lady – 32 years old, currently 14 weeks by dating scan, G1P0 presented with epigastric pain and vomiting a hour after dining out at _____ (insert multinational drive-thru takeaway of your choice).

She is rolling on the bed in pain, unable to lay still for more than a few seconds.  No PV blood etc, the pain is colicky – upper abdomen.

She is large – BMI around 40 but otherwise has no previous medical history.  No surgical history.

After loading with opiates IV she settles enough to allow a bedside scan; 

Her uterus looked as it should – singleton, active fetus apropriate for dates. Kidneys NAD, no hydronephrosis. But…  her gallbag is chock full of small stones. Not much evidence of cholecystitis

OK, here are my clinical questions:

Q1: – she is early in her pregnancy – and has multiple stones which may well cause ongoing symptoms in he coming months.  Should she see a surgeon and be considered for laparoscopic cholecystectomy OR just suck it up, hope she has mild or no further attacks for the next 6 – 9 months and get her gallbladder sorted out after pregnancy.

Q2:-  Would it make a difference if this were her third attack this pregnancy, or there was some evidence of cholecystitis on imaging?

Q3: – Does it matter how far along she is?  Would you change your management if she were 10 weeks  vs.  34 weeks?

The rate of recurrence of biliary symptoms is high in pregnancy – the hormones are against us! Various studies state 50 – 70% will have further episodes of pain etc. And there is a rate of maternal and fetal morbidity in this scenario – not as benign as we think.  This study by Jelin (Surgical Endoscopy, 2008) modeled an improved quality of pregnancy with no change in fetal loss if surgery was done.  Earlier intervention in the pregnancy gave more “quality weeks of pregnancy” saved.  Dhupar (Surgical Endoscopy, 2010) and Lu et al (Americ Journ of Surgery, 2004) showed cholecystectomy was safe and delivered better outcomes in their small case series.  There is not a lot of quality data out there, but it seems safe and might have benefits in terms of symptomatology and reduced obstetric complications.

So in summary, I think there is a firm place for lap cholecystectomy in the pregnant woman.  Surgical intervention earlier in the pregnancy seems to offer more bang for the buck and is certainly technically more attractive if you are the guy inserting the ports or giving the anesthetic!

Now here is my question to the readers.

What is the value of seeing gallstones in the above scenario – pregnant or not – if you have a patient in the ED with belly pain suggestive of gallstone disease, and you see them on the bedside US – how should we roll with this information?  We know asymptomatic stones are common – so how does this information change our decision-making?  Could we overcall the cause-effect in this scenario, or even worse – miss another / possibly serious diagnosis?

Let me know your thoughts.    Casey

 

Comments

  1. Hey Casey,
    Great case. The literature you presented on benefits of lap choley in pregnancy is great info! Your question about the utility of ultrasound here is an interesting one as you ask could we “miss other diagnosis by attributing the pain to gallstones”. I think that’s certainly possible, but the case you describe seems pretty classic GB, and I would probably stop testing with those images and that story. If her pain was RLQ, then obviously it’s a different story with a US showing only stones and no signs of cholecystitis.
    As we’ve discussed regarding US before, this image by itself is not definitive for much at all, but taken in the context of the entire story that you gave I think it’s an incredible piece of information that GREATLY increases your post-test probability of this pain being from the GB, so much so that my testing is done in this case. If my pre-test prob was low enough before the scan (i.e. RLQ pain instead RUQ pain) then this would still be helpful, but not clinching.
    I had a case similar to this in Africa one time with diffuse instead of localized pain in a 1st trimester patient and they were going to perform culdocentesis for possible ectopic until they brought her to us and when we looked we found classic cholecystitis with wall thickened, stones, and fluid around GB. This case wasn’t as classic of a story, but it was a much more specific scan with all those findings. She then had GB removed and kept normal pregnancy.
    More information is always better as long as the physician is sophisticated enough to interpret it, especially if it’s a “free” (read no radiation) study. So yes, I think the ultrasound is useful here……big surprise, huh!
    Thanks for the great case!
    Matt

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