Title : Role of Pregnancy (P) and Breastfeeding on Gallstones (GS) related Acute Pancreatitis (AP)
Abstract:
Parity is associated with GS only in younger mothers. High estrogen levels, mainly in the last trimester, increases cholesterol saturation of bile and high progesterone levels during all P reduce gallbladder contractility, both phenomenon may help sludge and GS precipitation.
In a prospective study of 305 women observed within 3 days after delivery we found sludge and GS in 80/16 women. Age, obesity and oral contraceptive before P were predictors of GS. We followed-up them in the first year after delivery: most of sludge and 2/16 GS spontaneous disappeared (J Hep 1987, Gastroenterology 1988). In another study we enrolled 275 women at the first trimester of P, after delivery we observed an actuarial incidence of new sludge and GS respectively in 31 and 2%. Obesity was a predictor of new sludge, slusge itself was predictor of new GS. In the first year after delivery sludge and GS spontaneous disappeared respectively in 68.3% and 31%. Predictors of spontaneous disapperance were age > 35 yerars old and a small GS diameter (5/12 mm). Slude was asymptomatic, only a few patients with GS had biliary colic (Ann int Med 1993). In a population based case control study at the Olmsted County (Minnesota, USA) we reviewed all women in childbearing age with AP and investigated the prevalence of P in them and in controls (n = 4, from general population): P was not related to AP, but GS AP was more frequent in the first post-partum year (RR 4.78%) and AP was more frequent in younger women ( <35/>35 ; RR 13.95%) (Mayo Clin Proceed. 2000). In a population based cohort sudy on the Sicilian population we observed in 6 years 1885 AP. Incideence in non pregnant and pregnant was respectively 21.61 and 20.02/100,000 w-y. During P incidence decreased from 28.3 in the first trimester to 17.7 in ghee second and 14.1/100,000 w/y in the last .In the post-partum period incidence increased to 95.37/100,000 w/y in the first semester, it was 42.39 in the second semester and 31.79/100,000 w/y in the second year. The incidence returned to control value in the third year (26.05/100,000 w/y). AP was related to GSS in 38% of AP during P, 48.50% in controls and in 70% in post-partum. At the light that most of sludge and GS are at the end of P while AP have lower incidenc it is clear that the restore of gallbladder motility during and after delivery with fast reduction of progesterone has a fundamental role in AP pathogenesis. In the post-partum GS related AP incidence decreases with age, while in controls AP increases with increasing age. (Dig Dis & Sc 2021, Gastroeneterology 2022).
The peculiar natural history of GS and GS AP during and after delivery may be related to a longer amenorrea period and anovulatoy cycles after delivery in older mothers, with lower estrogen levels and lower cholesterol daturation of bile. At the light of this speculation we conducted a population based case control srudy on the Sicilian population to investigate if breastfeeding, which like advanced age, determines longer amenorrea period and anovulatory cicles after delivery may have a role in post-partum AP. We demonstrated at multivariate analysis that breastfeeding at least 3 months has a strong protective role in the risk of post-partum AP.
Cholecystectomy is mandatory after GS-AP to prevent relapsing AP, but during P surgery is a challenge and it is performed only in the second trimester in tertiary hospitals with specific experience in surgery during P. Furthermore, ursodeoxycholic acid therapy (urso) is safe during P and may be more useful with small GS who have chance of spontaneous dissolution. So, we treated 14 consecutive women with small GS AP during or after P who refused cholecystectomy with urso: We found that in 12/14 women urso was effective in dissolving GS and prevent relapsing AP, in one woman we observed a relapse after one month, before urso could dissolve GS, in another patient we observed a relapse of GS and AP dafter 7 years In conclusion we digest to treat with urso women with AP during P to postpone surgery after delivery. In postpartum we suggest breastfeeding at least 3 months and usso only in women refusing surgery, with seriate ultrasonographic exams for late recurrence of GS and new period of urso treatment.
