CHOLECYSTITIS IN PREGNANCY TABLE I. Common causes of cholecystitis8 Aerobic Escherichia coli Klebsiella sp. Enterococci Proteus sp. Anaerobic Bacteroides sp. Clostridium sp. Anaerobic cocci E. coli account for 75% of all bacterial strains re- covered during acute cholecystitis. 18 There has been a slow increase in anaerobic isolates which is most likely due to improved culturing techniques. Nevertheless, of the anaerobes recovered, Bacte- roides and Clostridia are among the most com- mon. 18 Although the bacteria of acute cholecystitis are undoubtedly enteric in origin, the route of entry into the biliary tract remains uncertain. Ascending infection would seem to be the most likely expla- nation. However, there is good evidence that he- matogenous spread with direct infection through the thickened gallbladder walls also leads to acute cholecystitis. 18 DIAGNOSIS To effectively treat acute cholecystins you must first recognize the clinical picture. Other than bil- iary disease, the differential diagnosis in a pregnant woman with right upper quadrant pain includes prccclampsia, pyclonephritis, appendicitis, and even gastric ulcer. After initial evaluation excludes these and other less common entities from the dif- ferential diagnosis, the diagnosis of biliary disease should be further investigated. As stated earlier, differentiating cholelithiasis from acute cholecysti- tis can be difficult. This is especially true when pregnancy complicates the clinical picture. Some clinicians argue that differentiating between the two would not affect management. At any rate, the clinical manifestations of acute cholecystitis during pregnancy are essentially the same as the non- pregnant state. HISTORY An episode of biliary pain usually begins with right upper quadrant or mid-epigastric pain which may increase in severity. Biliary colic begins quite sud- denly and may radiate to the interscapular area, to CASEY AND COX the angle of the right scapula, or to the right shoul- der. It may be precipitated by a fatty meal or by consumption of a large meal following a period of fasting. Typically though, biliary colic occurs in a diurnal pattern with pain peaking around midnight. Nausea and vomiting also frequently accompany episodes of colic. Finally, 70-80% of patients will have a history of colic attacks and fatty food intol- erance. 13 Increasing severity of colicky pain, fever, or chills (rigors) usually implies an underlying com- plication, i.e., cholecystitis, pancreatitis, or cholan- gitis. PHYSICAL EXAMINATION Physical examination reveals right upper quadrant tenderness. This is usually associated with an in- crease in pain to palpation upon deep inspiration (Murphy’s sign). Fever and tachycardia may indi- cate an underlying infection. The presence of peri- toneal signs, guarding, rigidity, and rebound, are extremely ominous signs and may reflect rupture of the gallbladder. LABORATORY FINDINGS Laboratory evaluation may provide assistance in di- agnosis but it is clear that the clinical course will dictate the management plan. Laboratory studies commonly performed when evaluating these women include blood leukocyte count, evaluation of hepatic function, serum bilirubin, amylase, li- pase, and alkaline phosphatase. There are numer- ous alterations in several of these laboratory param- eters which normally occur in pregnancy and can limit their usefulness. The blood leukocyte count varies considerably during normal pregnancy. Val- ues can range from 5,000 to 12,000/ml and these values may rise significantly with exercise or labor. Also, alkaline phosphatase activity nearly doubles during normal pregnancy. Finally, postprandial plasma levels of total bile acids progressively in- crease during pregnancy. Therefore, laboratory evaluation will only provide clues in the diagnosis of biliary tract disease during pregnancy. For ex- ample, serum bilirubin may be mildly elevated and leukocytosis may be present. If bilirubin remains elevated with persistent jaundice, common duct stones should be suspected. If there is significant leukocytosis in addition, an underlying infectious process should be considered. Finally, serum amy- INFECTIOUS DISEASES IN OBSTETRICS AND GYNECOLOGY 305