Successful Management of Acute Cholecystitis in Pregnancy Using Percutaneous Transhepatic Cholangioscopy Under Local Anesthesia: A Case ReportAndrew Liman 1; Master of Clinical Medicine, MBBS; Biliary Surgical Department of West China Hospital; Address: 37th Guoxue Ln, Wuhou District, Chengdu, Sichuan, China. Zip code: 610041.Rongxing Zhou *; MD; Biliary Surgical Department of West China Hospital; Address: 37th Guoxue Ln, Wuhou District, Chengdu, Sichuan, China. Zip code: 610041.*Corresponding author; Email: Rongxingzhou@126.comCase ReportA 31-year-old female at 18 weeks of gestation presented with a 6-day history of persistent lower back and upper abdominal pain, accompanied by abdominal tightness and nausea. She denied fever, chills, or jaundice. Her medical history included a cesarean section 2 years prior, with an uneventful recovery. She had previously undergone percutaneous gallbladder drainage (PTGD) but reported no significant improvement in symptoms following 6 days of conservative antibiotic therapy and PTGD.On physical examination, the patient appeared stable, with no scleral or skin jaundice. The abdomen was distended but soft, with tenderness localized to the right upper quadrant and the xiphoid process. No rebound tenderness was noted, and the rest of the abdomen was non-tender. Hepatomegaly and renal enlargement were absent, but percussion pain was elicited in the right renal area.Laboratory testing revealed a white blood cell count of 7,150/μL (78% neutrophils), elevated C-reactive protein of 103 mg/L (reference: 0–6 mg/L), and hypokalemia with potassium at 3.23 mEq/L (reference: 3.6–5.2 mEq/L). Additional findings included low total protein (54.3 g/L; reference: 65–85 g/L), hypoalbuminemia (29.8 g/L; reference: 40–55 g/L), elevated alkaline phosphatase (130 U/L; reference: 35–100 U/L), and gamma-glutamyltransferase of 56 U/L, increased from a baseline of 45 U/L. Creatinine was slightly below the reference range at 40 μmol/L (reference: 48–79 μmol/L).Ultrasound imaging revealed a 2.2-cm gallstone, gallbladder wall thickening of 1.0 cm, and flocculent weak echogenic deposits within the gallbladder cavity.After consideration and communications with the patient and her family, we decided to perform Percutaneous Transhepatic Cholangioscopy (PTCS) under local anesthesia. Local anesthesia was administered at the 7th and 8th, as well as 8th and 9th, right paravertebral spaces. A combination of 15 mL of 33% ropivacaine and 15 mg dexamethasone was injected to achieve blockade of the intercostal nerves, providing region-specific numbness for the procedure. The PTCS procedure began with dilation of the existing PTGD fistula. A guidewire was advanced along the retained PTGD tube, and local anesthesia was administered at the puncture site using 2% lidocaine. The puncture channel was expanded to gain access to the gallbladder. Once access was achieved, a rigid cholangioscope was inserted to visualize the gallbladder, and fluid was flushed to dislodge smaller gallstones. Larger stones were fragmented using a ballistic lithoclast and retrieved with a lithotripter mesh basket. Intraoperative ultrasound was used to confirm the absence of residual gallstones.DisscussionThis 31-year-old pregnant patient at 18 weeks gestation presented with acute cholecystitis, as evidenced by persistent abdominal pain, elevated inflammatory markers (CRP 103 mg/L, neutrophil-predominant leukocytosis), and imaging findings of a 2.2 cm gallstone with gallbladder wall thickening. Despite 6 days of conservative management, including antibiotics and PTGD, her symptoms persisted, necessitating definitive intervention.Conservative antibiotic therapy, although appropriate as initial management, is insufficient in patients with persistent symptoms and structural abnormalities such as large gallstones. Antibiotics control infection but do not address the obstruction, risking progression to complications like sepsis, gallbladder perforation, or preterm labor. Comparative studies show that non-operative management leads to higher recurrence rates and prolonged morbidity 1 . This approach is inappropriate for this patient, given her ongoing symptoms and elevated inflammatory markers.LC is the definitive treatment for acute cholecystitis and is generally safe during the second trimester 2 . It effectively removes the gallbladder, preventing recurrence. However, general anesthesia poses systemic risks to the mother and fetus, including respiratory depression, hypotension, and uterine relaxation, which could trigger fetal distress 3 . The U.S. FDA has highlighted concerns about potential neurodevelopmental effects of general anesthetics on fetuses 4 . The PANDA and MASK studies associate in utero exposure to anesthesia with adverse behavioral outcomes, including worse Child Behavior Checklist (CBCL) scores 5,6 . Additionally, pregnancy-associated anatomical changes, such as uterine enlargement, increase the risks of trocar injury and surgical complications. While effective, LC’s reliance on general anesthesia makes it less favorable when safer alternatives exist.PTGD offers temporary relief by decompressing the gallbladder but does not resolve the underlying obstruction. Continued monitoring without further intervention increases the risk of disease progression, recurrence, and preterm labor. Delayed definitive management is associated with higher maternal and fetal morbidity 7, making this strategy unsuitable, particularly in symptomatic patients.PTCS presents a minimally invasive and effective alternative for managing acute cholecystitis during pregnancy. Unlike conservative therapy or PTGD, PTCS directly addresses the obstruction by removing gallstones, ensuring complete resolution of the condition8 . Compared to LC, PTCS offers several advantages, particularly in pregnant patients: (a)Avoidance of General Anesthesia: Local anesthesia avoids systemic drug exposure, reducing fetal neurotoxicity risks. It also minimizes cardiovascular and pulmonary stress, maintaining maternal hemodynamic stability. (b)Targeted Intervention: PTCS enables real-time visualization and precise removal of stones. Ultrasound guidance reduces radiation exposure compared to ERCP 9 . Complete resolution of obstruction reduces the need for additional interventions. (c)Lower Maternal and Fetal Risk: PTCS avoids uterine trauma and has a shorter recovery period compared to LC. Fewer complications, such as infection or prolonged hospitalization, are observed. Early intervention reduces the risk of preterm labor. (c)Psychological Benefits: Local anesthesia allows the patient to remain awake, reassured by interaction with the care team, reducing anxiety. (d)Efficiency and Future Planning: PTCS resolves the acute condition during pregnancy, allowing LC to be performed postpartum when it is safer and more practical. This staged approach optimizes maternal and fetal outcomes.The diagnosis is acute cholecystitis with gallbladder obstruction, refractory to conservative management. Among the options, PTCS under local anesthesia is the preferred intervention due to its safety profile and effectiveness. It offers an excellent balance of efficacy and reduced risks, addressing both maternal and fetal concerns while demonstrating significant advantages over LC and other management strategies.This case underscores the value of minimally invasive procedures like PTCS in managing acute conditions during pregnancy.
