Pregnant gall bladder attack

[nitroglycerine]

I got a call from a surgeon requesting an epidural for the acute pain control. Eleven weeks pregnant with severe pain due to an acute gall bladder attack. He does not want to operate. Any thoughts as to pros and cons of doing vs. not doing it? Anybody did it before, or heard, or read about it?
Thanks.

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[Idiopathic]

bad idea. would need close to a T4 level, maybe not even then. Also, if the diaphragm is irritated then the shoulder pain will be unmanageable with epidural.

i dont blame him, i wouldnt want to do it either, and its elective as long as no cholecystitis. sounds like dietary modification, opiates and tylenol are in her immediate future!

edit: i know you can do GB surgery with epidural, but I think to do this, you would need to guarantee that you can get rid of the visceral pain of an acute attack, which I dont think could be accomplished safely with an epidural.

 

[SLUser11]

I got a call from a surgeon requesting an epidural for the acute pain control. Eleven weeks pregnant with severe pain due to an acute gall bladder attack. He does not want to operate. Any thoughts as to pros and cons of doing vs. not doing it? Anybody did it before, or heard, or read about it?
Thanks.

I can only address the surgeon's decision since I'm not an anesthesia pro, but I want to point out that laparoscopic cholecystectomy during pregnancy is very safe, and our old practices of waiting until the 2nd trimester, or even post-partum, to operate are probably outdated.

I've done reviews of the literature, and the general rule of thumb is that it's safe if necessary, so any patient with gallstone pancreatitis or cholecystitis should have cholecystectomy regardless of trimester, as the risk to the fetus is probably greater from the disease process than from the surgery.

If the patient has mild symptomatic cholelithiasis, it's wise to wait until the second trimester to operate, as organogenesis is over, miscarriage rates are lower, etc. You can put the preggo on a low-fat diet with prn narcotics.

However, if the patient's symptoms are so severe that she needs inpatient admission, and an anesthesia consult for a possible epidural, then she probably needs an operation. I think the stress of the pain plus anorexia/poor PO intake is more risky to the fetus than a laparoscope.

On a side note, if the patient has severe, constant pain (i.e. not colicky and not resolving) that's lasted long enough to contact anesthesia for an epidural, then it's probably not simple biliary colic. It's either cholecystitis or some completely other diagnosis.

I hope that helps.

 

[jwk]

We do lap chole's on pregnant women all the time. Just not a big deal anymore. And there's no way we'd even think about the epidural.

 

[nitroglycerine]

Thanks, fellas. All very helpful tips. I said to him that I doubted it was a good idea and he didn't insist. Quite an unusual but not an unreasonable request. May be a good oral exam question.

 

[Ketafol20]

Thanks, fellas. All very helpful tips. I said to him that I doubted it was a good idea and he didn't insist. Quite an unusual but not an unreasonable request. May be a good oral exam question.

At first I wanted to say, " what the phuck?".

Then I started to think about it and since I wasn't privy to the conversation I decided that you are just working with a surgeon looking for some way to help his pt. Anyhow, no way would I place an epidural for this.

 

[Robert Loblaw]

other than the fact that this is sort of way off the beaten path, i have yet to see a good argument for not placing an epidural here. we do thoracic epidurals all the time, don't we? i cant think of a great physiologic reason why a thoracic epidural is absolutely contraindicated in a first trimester parturient. fetal exposure to narcotics/LAs is probably less. risk of wet tap? not increased and, okay, if it happens not a big deal. decreased catechols, decreased maternal stress--better for the baby. risk of fetal demise? can't see why it would be increased from 72 hours of a thoracic epidural.

obviously if something goes wrong, you are probably on an island by yourself...what if she had multiple rib fractures from an mva and had an sao2 in the low 90s from splinting, and you were being asked to place one for pain control to improve respiratory function?

 

[joshmir]

If you were asked on the boards why you you would not place it, what would you say?

If she has not had opiates titrated to effect, I may say that she has lower-risk interventions that may prove effective

What would you guys say?

 

[Robert Loblaw]

yeah...board question would be a parturient in her 11th week on high-dose methadone for h/o heroin abuse in intractable pain from cholelithiasis, surgeon asking for epidural for pain control.

 

[DrBeaker]

My thoughts. I'm only 6 weeks into CA-1 so please feel free to destroy my post.

Besides narcotics, you could try to block some other recepors. ketamine-NMDA, alpha-2 agonists- before entertaining an epidural.

She is 11 weeks. 1-2 weeks until the 2nd trimester. I realize it's not an urgent/emergent case like an appy, but why not just go to the OR if the above doesn't work? Avoid nitrous, midaz. Inform patient the risks of birth defects, loss of pregnancy.

Seems like taking care of the problem would benefit not only mom, but baby. Uterus is not able to auto-regulate blood flow. If catechols are circulating from pain, potential for reduced placental blood flow.

Just my thoughts...

 

[Ketafol20]

I don't believe there is any contraindication to placing the epidural in a pregnant pt. I just don't see an indication for an epidural for gall bladder pain. I'd treat her like any other bad gall bladder, surgery or diet control and narcotics as needed for pain.

Why are we so afraid to give narcs to a pregnant woman? Are we afraid that she will take so much that the fetus becomes dependent? Slim chance!

 

[epidural man]

other than the fact that this is sort of way off the beaten path, i have yet to see a good argument for not placing an epidural here. we do thoracic epidurals all the time, don't we? i cant think of a great physiologic reason why a thoracic epidural is absolutely contraindicated in a first trimester parturient. fetal exposure to narcotics/LAs is probably less. risk of wet tap? not increased and, okay, if it happens not a big deal. decreased catechols, decreased maternal stress--better for the baby. risk of fetal demise? can't see why it would be increased from 72 hours of a thoracic epidural.

obviously if something goes wrong, you are probably on an island by yourself...what if she had multiple rib fractures from an mva and had an sao2 in the low 90s from splinting, and you were being asked to place one for pain control to improve respiratory function?

Everything decision we make has a consequence. Treating with something other than an epidural has consequences.

I like the idea of treating this temporary pain with a temporary regional technique that may work very well.

I would have thought seriously about doing it....

Medicines are poisons. The amount of 'poison' you need through an epidural is very minimal, and physiologically, has a lot of benefits. Hell, maybe the sympathectomy dilates the duct and fixes the problem.

 

[Idiopathic]

I've considered doing this for renal colic, so i wont argue that it cant or shouldn't be done, just that i probably wouldn't do it without a more definitive plan to address what I assume will be a chronic problem over the next 30 weeks.

 

[B-Bone]

I've considered doing this for renal colic, so i wont argue that it cant or shouldn't be done, just that i probably wouldn't do it without a more definitive plan to address what I assume will be a chronic problem over the next 30 weeks.

this.

there was a recent thread about regional anesthesia/analgesia in chronic pain. sure you can help for a few hours/days, but are you going to leave an epidural in until she delivers and gets her gall bag out? regional analgesia isn't going to solve the problem.

 

[nitroglycerine]

I can only address the surgeon's decision since I'm not an anesthesia pro, but I want to point out that laparoscopic cholecystectomy during pregnancy is very safe, and our old practices of waiting until the 2nd trimester, or even post-partum, to operate are probably outdated.

I've done reviews of the literature, and the general rule of thumb is that it's safe if necessary, so any patient with gallstone pancreatitis or cholecystitis should have cholecystectomy regardless of trimester, as the risk to the fetus is probably greater from the disease process than from the surgery.

If the patient has mild symptomatic cholelithiasis, it's wise to wait until the second trimester to operate, as organogenesis is over, miscarriage rates are lower, etc. You can put the preggo on a low-fat diet with prn narcotics.

However, if the patient's symptoms are so severe that she needs inpatient admission, and an anesthesia consult for a possible epidural, then she probably needs an operation. I think the stress of the pain plus anorexia/poor PO intake is more risky to the fetus than a laparoscope.

On a side note, if the patient has severe, constant pain (i.e. not colicky and not resolving) that's lasted long enough to contact anesthesia for an epidural, then it's probably not simple biliary colic. It's either cholecystitis or some completely other diagnosis.

I hope that helps.[/QUOTE
Thanks again.
Our surgeon would also opeate an emergency an any trimester. He did not want to take her to the OR because she had a dilated CBD on the CT scan and apparently needed ERCP which are not done in our local hospital. Her LFTs were not elevated. I think the plan now is to transfer her to a teaching hospital 100km away for the ERCP.

 

[Ketafol20]

Thanks again.
Our surgeon would also opeate an emergency an any trimester. He did not want to take her to the OR because she had a dilated CBD on the CT scan and apparently needed ERCP which are not done in our local hospital. Her LFTs were not elevated. I think the plan now is to transfer her to a teaching hospital 100km away for the ERCP.

this doesn't make sense. The only reason to not operate is if they have choleangitis or pancreatits. If it's choleangitis then she needs ERCP first but that is the only time you need to do ERCP first. Dilated CBP does not need ERCP first.

 

[sevo85288]

you can take care of the pain but how long do you plan keep this epidural in? Until after delivery? Can you use it for labor

I think the pain is not the issue but the bad gb.

 

[periopdoc]

We know that opiates are very safe in pregnancy. In fact, despite the infectious complications, heroin is probably the safest drug of abuse during pregnancy. The only real risk to the fetus is dependency which can easily, though not cheaply, be treated after delivery. Anyone have any idea what the risk of prolonged LA infusion in the first trimester might be? NMDA blockade in the first trimester? Are you serious?

Sure these techniques may be safe, but if Johnny comes out with a VSD and an attention span not quite up to snuff, guess who they are coming after.

Not to mention the increased risk of epidural hematoma from venous engorgement.

- pod

 

[jetproppilot]

If you were asked on the boards why you you would not place it, what would you say?

If she has not had opiates titrated to effect, I may say that she has lower-risk interventions that may prove effective

What would you guys say?

I'd say we need to put the girl to sleep so the surgeon can take the gallbladder out.

 

[IN2B8R]

bad idea. would need close to a T4 level, maybe not even then. Also, if the diaphragm is irritated then the shoulder pain will be unmanageable with epidural.

i dont blame him, i wouldnt want to do it either, and its elective as long as no cholecystitis. sounds like dietary modification, opiates and tylenol are in her immediate future!

edit: i know you can do GB surgery with epidural, but I think to do this, you would need to guarantee that you can get rid of the visceral pain of an acute attack, which I dont think could be accomplished safely with an epidural.[/QUOTE]

Would you please care to elaborate: why would a thoracic epidural not cover the "visceral," non-referred, pain of an acute GB attack? Thank you.

 

[Idiopathic]

i just think that with an acute attack of cholelithiasis you can have activity of higher thoracic fibers than you care to block, and also you can have a significant amount of referred pain from diaphragmatic irritation. do you want to do an epidural so someone can sit in the hospital with 5/10 pain as opposed to 10/10 pain? thats why i would have pause.

as an analogy, ive had some excellent success with low thoracic (T9-10) epidurals for exploratory laparotomy but every once in a while someone will have severe migratory abdominal pain due to ileus or just due to bowel gas, while their incisional pain is 0/10. conceptually similar to patients who complain of pain and discomfort with uterine exteriorization during cesarean section, even with a T4 spinal. im no expert on this matter, i just think the classical interpretation of innervation doesnt always match up with clinical observation. id love for someone whos done an epidural for acute cholelithiasis to tell me that its very effective,

however, knowing that she could get ERCP/lap chole in the next few days, might change my mind. id have a problem with simply temporizing this patient with an epidural for many reasons, just one of which that Im not sure how effective it would be,

 

[Idiopathic]

I'd say we need to put the girl to sleep so the surgeon can take the gallbladder out.

probably the best plan, this document lets us know that ERCP is probably not the best idea for the 11 week fetus, as well.

 

[dhb]

Not to mention the increased risk of epidural hematoma from venous engorgement.

- pod

Little contradiction her since we're talking about 1st trimester

 

[SLUser11]

Thanks again.
Our surgeon would also opeate an emergency an any trimester. He did not want to take her to the OR because she had a dilated CBD on the CT scan and apparently needed ERCP which are not done in our local hospital. Her LFTs were not elevated. I think the plan now is to transfer her to a teaching hospital 100km away for the ERCP.

Well, if she has a dilated CBD but normal LFTs, specifically normal Tbili, then I think a Lap Chole with IOC would be the best first approach. If the cholangiogram shows stones that can't be laparoscopically removed, then moving on to an ERCP would be the logical next step. If the IOC is negative, then you're done, sans an extra procedure.

Flouroscopy definitely has more radiation than plain x-rays, and so intra-op cholangiogram and ERCP should not be taken lightly, but if a preggo has an impacted CBD stone, she's got bigger problems than 3-8 RADS from the fluoro machine. I guess you could just do a one-shot flat plate x-ray for IOC, but those aren't easy.

I do want to mention that some of the good GI docs can do ERCPs with very minimal fluoro time and good fetal shielding, so it's not off the table completely.

Either way, it sounds like the surgeon did the right thing by transferring to a facility where ERCP was available.

probably the best plan, this document lets us know that ERCP is probably not the best idea for the 11 week fetus, as well.

Great find.

 

[periopdoc]

Little contradiction her since we're talking about 1st trimester

Are you sure?

The Fiberscopic Findings of the Epidural Space in Pregnant Women

- pod

 

[IN2B8R]

i just think that with an acute attack of cholelithiasis you can have activity of higher thoracic fibers than you care to block, and also you can have a significant amount of referred pain from diaphragmatic irritation. do you want to do an epidural so someone can sit in the hospital with 5/10 pain as opposed to 10/10 pain? thats why i would have pause.

as an analogy, ive had some excellent success with low thoracic (T9-10) epidurals for exploratory laparotomy but every once in a while someone will have severe migratory abdominal pain due to ileus or just due to bowel gas, while their incisional pain is 0/10. conceptually similar to patients who complain of pain and discomfort with uterine exteriorization during cesarean section, even with a T4 spinal. im no expert on this matter, i just think the classical interpretation of innervation doesnt always match up with clinical observation. id love for someone whos done an epidural for acute cholelithiasis to tell me that its very effective,

however, knowing that she could get ERCP/lap chole in the next few days, might change my mind. id have a problem with simply temporizing this patient with an epidural for many reasons, just one of which that Im not sure how effective it would be,

I will chime in: first off, I would not advocate the utilization of an epidural in this scenario. Rather, I would ask the surgeon to remove the source of the inflammation, i.e., the GB itself. Second, inflammation of viscera, the GB in this case, is what leads to the referred pain. This order of events is relevant and important, as this specific site of inflammation is what actually leads to what is called 'viscero-somatic convergence,' which is what is responsible for the "referred thoracic/shoulder" pain that you are alluding to. Based on this reasoning, one should assume that placing a thoracic epidural that covers the "visceral inflammed fibers" of the GB should alleviate any referred thoracic/shoulder pain. We know this to be factual, since when the surgeon actually removes the GB, these people never re-experience their referred pain. By placing your thoracic epidural, you would be "pharmacologically" removing the GB, or atleast the signals from this inflammed site that lead to the referred pain. In my practice, I have gotten consults to place short term epidurals (no more than four days) before an inflammed viscera can be surgically excised (mainly due to surgeon scheduling and patient optimization reasons....). Once placed, these people never had any referred pain after epidural placement. Keep in mind that if there is visceral hyperalgesia due to a chronic inflammatory state, then the referred pain may not be alleviated, as at this stage the culprit behind the referred pain is increased central sensitization. This is an important piece of information that must be obtained from the H&P and documented in the consult note: if the inflammaiton is chronic (IBS patients, for example), then any and all referred pain may be due to central sensitization and, even after surgery and removal of the "inflammed visceral fibers," these patients can still very much have referred pain.... Linked, for your review pleasure, is a review of the sensory pathways.

Regards

 

[IN2B8R]

I will chime in: first off, I would not advocate the utilization of an epidural in this scenario. Rather, I would ask the surgeon to remove the source of the inflammation, i.e., the GB itself. Second, inflammation of viscera, the GB in this case, is what leads to the referred pain. This order of events is relevant and important, as this specific site of inflammation is what actually leads to what is called 'viscero-somatic convergence,' which is what is responsible for the "referred thoracic/shoulder" pain that you are alluding to. Based on this reasoning, one should assume that placing a thoracic epidural that covers the "visceral inflammed fibers" of the GB should alleviate any referred thoracic/shoulder pain. We know this to be factual, since when the surgeon actually removes the GB, these people never re-experience their referred pain. By placing your thoracic epidural, you would be "pharmacologically" removing the GB, or atleast the signals from this inflammed site that lead to the referred pain. In my practice, I have gotten consults to place short term epidurals (no more than four days) before an inflammed viscera can be surgically excised (mainly due to surgeon scheduling and patient optimization reasons....). Once placed, these people never had any referred pain after epidural placement. Keep in mind that if there is visceral hyperalgesia due to a chronic inflammatory state, then the referred pain may not be alleviated, as at this stage the culprit behind the referred pain is increased central sensitization. This is an important piece of information that must be obtained from the H&P and documented in the consult note: if the inflammaiton is chronic (IBS patients, for example), then any and all referred pain may be due to central sensitization and, even after surgery and removal of the "inflammed visceral fibers," these patients can still very much have referred pain.... Linked, for your review pleasure, is a review of the sensory pathways.

Regards

http://humanneurophysiology.com/sensorypathways.htm

 

[epidural man]

. Linked, for your review pleasure, is a review of the sensory pathways.

Regards

Uh.....

That wasn't pleasurable at all...kinda boring actually, all those lines and texts and arrows and words like 'ganglia'

 

[IN2B8R]

Uh.....

That wasn't pleasurable at all...kinda boring actually, all those lines and texts and arrows and words like 'ganglia'

Good, glad you enjoyed it!

 

[dhb]

Are you sure?

The Fiberscopic Findings of the Epidural Space in Pregnant Women

- pod

i was waiting for something like that
thanks

 

[Idiopathic]

Are you sure?

The Fiberscopic Findings of the Epidural Space in Pregnant Women

- pod

good read thanks