Obesity and the risk and prognosis of gallstone disease and pancreatitis

Obesity is a risk factor for the formation of cholesterol gallstones and exposes patients to increased risk of gallstone-related complications and cholecystectomy. Rapid weight loss achieved by very low calorie diets or bariatric surgery is also a risk factor for cholelithiasis in obese patients, and therapy should take into account the higher prevalence of gallstones, the possibility of more frequent complications and the need for prophylactic treatment with oral ursodeoxycholic acid during weight loss. Obesity is also frequent in children and adolescents, and the burden of cholesterol cholelithiasis is increasing in this population. The chance to develop acute pancreatitis and the severity of the disease are higher in obese subjects because of specific pathogenic factors, including supersaturated bile and crystal formation, rapid weight loss, and visceral obesity. All health policies aimed at reducing the incidence of obesity worldwide will decrease the incidence of gallstones and gallstone-related complications. The pathophysiological scenarios and the therapeutic implications for obesity, gallstone disease, and pancreatitis are discussed.     

A population study on the prevalence of gallstone disease: the Sirmione Study

The prevalence of gallstone disease (cholelithiasis and previous cholecystectomy for gallstones) in the population of the town of Sirmione, Italy, examined by ultrasonography, was 6.7% in men and 14.6% in women, ranging from 18 to 65 yr of age (overall prevalence = 11%). The prevalence of cholelithiasis in the same age span was 6.9% (4.5% in men and 8.9% in women). Prevalence of cholelithiasis increased with age in both sexes. Twenty-two percent of gallstone subjects suffered from biliary pain vs. 2% of subjects without gallstones. No difference was observed in the frequency of nonspecific symptoms between subjects with and without gallstones. Of the 132 gallstone subjects, 108 (82%) were not aware of having gallstones prior to the study. Prevalence of gallstone disease was found to be higher in obese and hypertriglyceridemic subjects and to increase with the number of pregnancies.     

Prevention or surgical treatment of gallstones in patients undergoing gastric bypass surgery for obesity

Opinion statement It is well known that obesity is a risk for gallstone formation and biliary sludge. Additionally, it has been clearly shown that rapid weight loss following bariatric surgery is a risk factor for cholesterol cholelithiasis. Multiple serious complications from gallstones such as cholecystitis, cholangitis, gallstone pancreatitis, and cholecystenteric fistulae may occur. Thus, it is necessary to employ medical or surgical methods to prevent or treat gallstones in this group. Therapy should be individualized. Although there is a high incidence of gallstones in this group, only a minority of individuals will develop symptomatic disease. When used in patients who are compliant, ursodeoxycholic acid therapy can be effective to prevent gallstone formation during rapid weight loss. The cost effectiveness of routine ursodeoxycholic acid therapy compared with the potential costs of complicated gallstone disease needs to be further investigated. Combined cholecystectomy with Roux-en-Y gastric bypass surgery is a safe and appropriate therapeutic option in those with preoperatively known gallstones, biliary sludge, and prior episodes of cholecystitis. However, routine cholecystectomy at the time of gastric bypass surgery is not warranted for all patients because of the increased time of operation and postoperative hospitalization, as well as all the potential complications after cholecystectomy. The approach of routine cholecystectomy in this setting subjects many patients to an unnecessary procedure because the majority will not develop symptoms or complications of gallstones. Furthermore, cholecystectomy is technically easier to perform after weight loss occurs.     

Gallstone disease and its complications

Gallstone disease is one of the most common disorders of the gastrointestinal tract, and more cholecystectomies are performed each year in the United States than any other elective abdominal operation. As such, clinicians need a fundamental knowledge of gallstone disease and the common complications that are associated with this disease. Overall, the prevalence of gallstones in the United States is approximately 10% to 15%, of which, approximately 80% are without symptoms. Symptoms will occur in approximately 20% of those with gallstones, and this subgroup is at the highest risk for developing serious complications from their gallstone disease. These complications can range from simple recurrent biliary colic to severe, life-threatening ascending cholangitis and/or pancreatitis. This review will outline the basis for gallstone formation, the underlying mechanisms that result in gallstone-induced symptoms and a rational approach to individuals who present with symptoms consistent with gallstone disease. Current diagnostic and treatment modalities will be discussed, with a particular emphasis on acute cholecystitis and acute biliary pancreatitis.     

Gallstone disease risk in relation to body mass index and waist-to-hip ratio in Japanese men

OBJECTIVE: To examine the relation of body mass index (BMI) and waist-to-hip ratio (WHR) to gallstones and postcholecystectomy risk in middle-aged Japanese men. DESIGN: Cross-sectional study. SUBJECTS: We used 174 men with prevalent gallstones, 104 with postcholecystectomy and 6909 with normal gallbladder in the consecutive series of 7637 men aged 48-59y receiving a preretirement health examination at four hospitals of the Japan Self-Defense Forces between 1986 and 1994. MEASUREMENTS: Gallbladder status was assessed by abdominal ultrasonography after an overnight fast. BMI was calculated as weight in kilogram divided by height in square meters, and WHR was used as a measure of central obesity. Analysis of the WHR was limited to a subset of data for the period 1991-1994 (gallstones 113, postcholecystectomy 66 and normal gallbladder 4410). RESULTS: After adjustment for hospital, rank in the Self-Defense Forces, cigarette smoking, alcohol use and glucose tolerance, BMI was significantly associated with an increased risk of both prevalent gallstones and postcholecystectomy. WHR also showed a significant positive association with each of the two conditions. When BMI and WHR were mutually adjusted for, both of the obesity indices tended to be associated positively with prevalent gallstones and postcholecystectomy. CONCLUSION: These findings indicate that obesity is associated with increased gallstone risk in men.     

Small gallstones are associated with increased risk of acute pancreatitis: potential benefits of prophylactic cholecystectomy?

OBJECTIVES: Pancreatitis is a severe complication of gallstone disease with considerable mortality. Small gallstones may increase the risk of pancreatitis. Our aims were to evaluate potential association of small stones with pancreatitis and potential beneficial effects of prophylactic cholecystectomy. METHODS: Stone characteristics were determined in patients with biliary pancreatitis (115), obstructive jaundice due to gallstones (103), acute cholecystitis (79), or uncomplicated gallstone disease (231). Sizes and numbers of gallbladder and bile duct stones were determined by ultrasonography and endoscopic retrograde cholangiopancreatography, respectively. Effects of prophylactic cholecystectomy were assessed by decision analyses with a Markov model and Monte Carlo simulations. RESULTS: Patients with pancreatitis or obstructive jaundice had more and smaller gallbladder stones than those with acute cholecystitis or uncomplicated disease (diameters of smallest stones: 3 +/- 1, 4 +/- 1, 8 +/- 1, and 9 +/- 1 mm, respectively, p < 0.01). Bile duct stones were smaller in case of pancreatitis than in obstructive jaundice (diameters of smallest stones: 4 +/- 1 vs 8 +/- 1, p < 0.01). Multivariate analysis identified old age and small stones as independent risk factors for pancreatitis. Decision analysis in a representative group of patients with small (相似文献   

Sex differences in the relationships between BMI, WHR and incidence of cardiovascular disease: a population-based cohort study

OBJECTIVE: Body mass index (BMI) is associated with increased incidence of cardiovascular disease (CVD). However, the risk could be very different for individuals with the same body mass. The present study explored whether regional fat distribution, as measured by waist-hip ratio (WHR), could modify the impact of BMI on the risk of CVD in men and women. DESIGN: Prospective population-based study. SUBJECTS: A total of 10 369 men and 16 638 women, 45-73 years old, from general population in Malm?, Sweden.Measurements:All subjects were followed over 7 years for the incidences of first-ever cardiac event (CE) and ischemic stroke in relation to BMI category (<25.0, 25.0-29.9, > or =30.0) and WHR. RESULTS: The prevalence of overweight and obesity was 39.4 and 13.0%, respectively. During follow-up, 1280 subjects suffered a CVD event (750 CE, 530 ischemic stroke). The risk of CVD in women increased with increasing levels of WHR, irrespective of BMI category. In men, WHR (per 1 s.d. increase) was associated with increased incidence of CVD in those with normal weight (relative risk (RR)=1.24; 95% CI: 1.13-1.37) after adjustments for confounding factors. However, WHR was not related to CVD in overweight men (RR=1.06; 95%CI: 0.94-1.20) or obese men (RR=1.04; 95%CI: 0.87-1.24). A significant interaction was observed between sex and WHR on the CVD risk. CONCLUSION: The effect of WHR on incidence of CVD is modified by the overall body weight and by gender. WHR adds prognostic information on the cardiovascular risk in women at all levels of BMI, and in men with normal weight.     

Epidemiology of gallbladder disease: cholelithiasis and cancer

Diseases of the gallbladder are common and costly. The best epidemiological screening method to accurately determine point prevalence of gallstone disease is ultrasonography. Many risk factors for cholesterol gallstone formation are not modifiable such as ethnic background, increasing age, female gender and family history or genetics. Conversely, the modifiable risks for cholesterol gallstones are obesity, rapid weight loss and a sedentary lifestyle. The rising epidemic of obesity and the metabolic syndrome predicts an escalation of cholesterol gallstone frequency. Risk factors for biliary sludge include pregnancy, drugs like ceftiaxone, octreotide and thiazide diuretics, and total parenteral nutrition or fasting. Diseases like cirrhosis, chronic hemolysis and ileal Crohn's disease are risk factors for black pigment stones. Gallstone disease in childhood, once considered rare, has become increasingly recognized with similar risk factors as those in adults, particularly obesity. Gallbladder cancer is uncommon in developed countries. In the U.S., it accounts for only ~ 5,000 cases per year. Elsewhere, high incidence rates occur in North and South American Indians. Other than ethnicity and female gender, additional risk factors for gallbladder cancer include cholelithiasis, advancing age, chronic inflammatory conditions affecting the gallbladder, congenital biliary abnormalities, and diagnostic confusion over gallbladder polyps.     

Changes in gallbladder motility and gallstone formation following laparoscopic gastric banding for morbid obestity.

Morbid obesity is associated with cholesterol gallstone formation, a risk compounded by rapid weight loss. Laparoscopic gastric banding allows for a measured rate of weight loss, but the subsequent risk for developing gallstones is unknown. METHOD: Twenty-six normal-weight volunteers (body mass index [BMI] less than 30) were compared with 14 morbidly obese patients (BMI greater than 40). Gallbladder volumes were measured ultrasonographically, after fasting and following stimulation with intravenous cholecystokinin-octapeptide (CCK-8) RESULTS: Preoperatively, fasting gallbladder volume and residual volume after CCK stimulation were both two times greater in the obese group (P<0.02 versus controls). Per cent gallbladder emptying was not different. Gallbladder refilling was four times higher in the obese patients (P<0.01). By six weeks postoperatively, the obese patients lost 1.4+/-0.1% body weight per week. Gallbladder emptying decreased 18.4% (80.3+/-3.9% to 65.5+/-6.9%; P<0.05); residual volume rose one-third (not significant), and refilling fell 60.5% (0.43+/-0.09 to 0.26+/-0.04 mL/min; P=0.07). Three patients with weight losses of greater than 1.7% per week developed gallstones; gallbladder emptying fell outside the 95 percentile. By six months, weight loss slowed to 0.5+/-0.1% per week; gallbladder motility improved modestly. No further stones developed. CONCLUSION: Rapid weight loss following laparoscopic gastric banding impairs gallbladder emptying and when pronounced, gallstones form by six weeks postoperatively. The accompanying reduction in gallbladder emptying, increased gallbladder residual volume and decreased refilling promote gallbladder stasis and hence stone formation.     

Gallstone Formation after Rapid Weight Loss: A Prospective Study in Patients Undergoing Gastric Bypass Surgery for Treatment of Morbid Obesity

The present study evaluated the incidence of gallstone formation in 105 morbidly obese patients undergoing rapid weight loss after proximal gastric bypass surgery. Intraoperative ultrasonography demonstrated gallstones in 20 (19%) and gallbladder sludge in four (4%) patients. Eighty-one patients had a normal gallbladder ultrasound. After bariatric surgery, these patients were followed prospectively with periodic gallbladder ultrasound examinations. At 6 months, gallstones had developed in 36% and gallbladder sludge in 13% of patients. These percentages remained relatively constant at 12 and 18 months. Body weight declined rapidly after surgery from a mean of 132.3 kg to 95.5, 87.0, and 84.0 kg at 6, 12, and 18 months, respectively. Gallstones developed significantly more often in the white race, and in women. No significant differences in age, body weight, percent ideal body weight, percent weight loss, or percent of excess body weight lost existed between patients who developed gallstones or sludge and those who did not. Patients who developed gallbladder sludge had less cholesterol and lower cholesterol saturation (1.25 +/- 0.42) in their gallbladder bile than persons who developed gallstones (2.00 +/- 0.79). Forty percent (13/32) of patients who developed gallstones became symptomatic; nine (28%) underwent elective cholecystectomy. An attempt to prevent gallstone formation during rapid weight loss appears warranted.     

Relationship of serum leptin concentration and other measures of adiposity with gallbladder disease.

Obesity increases the risk of gallstones, especially in women. Most gallbladder disease studies have used body mass index (BMI) as a measure of overall adiposity, although BMI does not distinguish between fat and lean body mass. Central adiposity may also increase gallstone risk, although this is less well studied. Leptin is a peptide whose serum concentration is highly correlated with total body fat mass. We examined the relationship of gallbladder disease with anthropometric measures and serum leptin concentration in a large, national, population-based study. A total of 13,962 adult participants in the Third National Health and Nutrition Examination Survey underwent gallbladder ultrasonography and anthropometric measurements of BMI, body circumferences, and skinfold thicknesses, and a random subgroup of 5,568 had measures of fasting serum leptin concentrations. Gallstone-associated gallbladder disease was defined as ultrasound-documented gallstones or evidence of cholecystectomy. When controlling for BMI and other gallbladder disease risk factors in multivariate analysis, a test for trend for increasing waist-to-hip circumference ratio and risk of gallbladder disease was statistically significant among women (P =.043) and men (P =.007). BMI remained strongly associated with gallbladder disease among women (P <.001), but was unrelated among men (P =.46). Leptin concentration was associated with gallbladder disease in both sexes (P <.001), but not after controlling for BMI and waist-to-hip circumference in either women (P =.29) or men (P =.65). In conclusion, waist-to-hip circumference ratio was related to gallbladder disease among women and men. Serum leptin concentration was not a better predictor of gallbladder disease than anthropometry.     

Complications of gallstone disease: Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus

Gallstone is a common disease with a 10% prevalence in the United States and Western Europe. However, it is only symptomatic in 20-30% of patients, with biliary pain "colic" being the most common symptom. Complications of asymptomatic gallstone disease are generally rare, with an incidence of <1 %/yr. The most common complications of gallstone disease are acute cholecystitis, acute pancreatitis, ascending cholangitis, and gangrenous gallbladder. Less frequent complications include Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus. Mirizzi syndrome and cholecystocholedochal fistula are two manifestations of the same process that starts with impaction of a gallstone in the gallbladder neck that results in obstruction of the bile duct, causing jaundice. The gallstone may erode into the bile duct, causing cholecystocholedochal fistula. Gallstone ileus refers to small bowel obstruction resulting from the impaction of one or more gallstones after they have migrated through a cholecystoenteric fistula. An accurate diagnosis is essential to the management and prevention of further complications. A variety of imaging and endoscopic modalities are used to make the diagnosis once the condition is suspected clinically. Treatment should be tailored to each individual patient. Management choices include ERCP, lithotripsy (endoscopic or extracorporeal), and surgery. Prognosis is frequently related to early recognition, management of any comorbid conditions, and careful selection of treatment modalities.     

The effect of weight loss on change in waist-to-hip ratio in patients with type II diabetes.

This study sought to determine whether weight loss would alter body fat distribution in obese men and women with type II diabetes. Subjects were 60 women and 33 men who participated in a year-long weight loss program. Weight losses of women and men, respectively, averaged 13.4 kg and 16.8 kg at six months and 11.2 kg and 13.1 kg at one year. WHR decreased significantly in both genders: for women, WHR decreased from 0.95 at baseline to 0.93 at six months and 0.94 at one year; for men WHR decreased from 0.99 at baseline to 0.96 at six months and 0.96 at one year. Subjects with greater upper body obesity at baseline did not lose more weight than subjects with less upper body obesity, but they did have greater reductions in WHR at six months in both genders and at one year in men. The magnitude of WHR reduction was strongly related to the amount of weight lost in men, but was not related to weight loss in women. Improvements in fasting glucose, fasting insulin, and HbA1 were significantly related to weight loss, but not to reductions in WHR. Thus, participation in a weight loss program had beneficial effects on body fat distribution in patients with type II diabetes, but these changes in WHR were not independently associated with improvements in glycemic control.     

Endoscopic gallbladder stent placement for treatment of symptomatic cholelithiasis in patients with end-stage liver disease

OBJECTIVES: Symptomatic cholelithiasis is a common disease in the general population with an increased prevalence in patients with cirrhosis. While cholecystectomy is the procedure of choice for the treatment of symptomatic cholelithiasis, cirrhotics have an increased risk of complications associated with this therapy. We have found that placement of an endoscopic gallbladder stent is an alternative, less invasive treatment for cirrhotic patients with symptomatic gallbladder disease and describe our experience here. METHODS: A retrospective medical record review of 23 patients with cirrhosis who underwent endoscopic retrograde cholangiography with gallbladder stent placement for symptomatic gallbladder disease from July 1994 to August 2004. RESULTS: Indications for stent placement included recurrent biliary colic (56.5%), acute calculous cholecystitis (39%), acalculous cholecystitis (8.6%), and gallstone pancreatitis (8.6%). All patients experienced resolution of their symptoms following stent placement. Twenty patients (87%) were asymptomatic from 5 days to 3 years post-procedure until transplantation, death, or end of study period. Nine patients (39%) underwent liver transplantation, 5 days to 34 months after the procedure. Eleven patients are well, with ten patients awaiting liver transplantation. Three patients developed late complications and were treated successfully with antibiotics. CONCLUSION: Endoscopic stenting of the gallbladder may be a potential treatment for symptomatic gallbladder disease in patients with cirrhosis awaiting liver transplantation, considered to be high-risk for cholecystectomy.     

Prevalence of gallstones in patients with primary immunoglobulin deficiency

In the early 1970s an increased prevalence of gallstones was reported in adults and children with immunoglobulin deficiency. As the advent of ultrasonography has largely changed the diagnostic approach to gallstones, we have reevaluated the prevalence of cholelithiasis in a group including 37 patients with common variable immunodeficiency and seven patients with other forms of primary immunodeficiency. All patients were receiving intravenous gammaglobulin replacement since 1983 or, in more recent cases, soon after the diagnosis was made, and therefore had relatively few infections. All patients underwent a hepatobiliary ultrasonogram and blood sampling. Data were compared, after age and sex standardization, with those obtained by the GREPCO in a free-living population of 1239 men and 1081 women. Only two women with immunoglobulin deficiency had gallstones. One of these was obese and had had one pregnancy. Both were asymptomatic. None of the patients studied had a history of cholecystectomy or evidence of biliary sludge. Thus, the observed prevalence rates of gallstone disease were 8.7% in women and 0% in males, respectively,against expected values of 9.5% and 3.2%. Immunodeficient patients expressed several putative risk factors for gallstones in the low range (body mass index, total and HDL cholesterol, and blood glucose in both sexes, and triglycerides in men). We conclude that gallstone disease is not more frequent in patients with immunodeficiency syndromes undergoing immunoglobulin therapy than in the general population.     

Cholesterol cholelithiasis in pregnant women: pathogenesis,prevention and treatment

Epidemiological and clinical studies have found that gallstone prevalence is twice as high in women as in men at all ages in every population studied. Hormonal changes occurring during pregnancy put women at higher risk. The incidence rates of biliary sludge (a precursor to gallstones) and gallstones are up to 30 and 12%, respectively, during pregnancy and postpartum, and 1-3% of pregnant women undergo cholecystectomy due to clinical symptoms or complications within the first year postpartum. Increased estrogen levels during pregnancy induce significant metabolic changes in the hepatobiliary system, including the formation of cholesterol-supersaturated bile and sluggish gallbladder motility, two factors enhancing cholelithogenesis. The therapeutic approaches are conservative during pregnancy because of the controversial frequency of biliary disorders. In the majority of pregnant women, biliary sludge and gallstones tend to dissolve spontaneously after parturition. In some situations, however, the conditions persist and require costly therapeutic interventions. When necessary, invasive procedures such as laparoscopic cholecystectomy are relatively well tolerated, preferably during the second trimester of pregnancy or postpartum. Although laparoscopic operation is recommended for its safety, the use of drugs such as ursodeoxycholic acid (UDCA) and the novel lipid-lowering compound, ezetimibe would also be considered. In this paper, we systematically review the incidence and natural history of pregnancy-related biliary sludge and gallstone formation and carefully discuss the molecular mechanisms underlying the lithogenic effect of estrogen on gallstone formation during pregnancy. We also summarize recent progress in the necessary strategies recommended for the prevention and the treatment of gallstones in pregnant women.     

Nationwide epidemiological study of severe gallstone disease in Taiwan

Background

Our study aimed to assess the nationwide trends in the incidence of severe gallstone disease in Taiwan among adults aged ≥20.

Methods

A retrospective longitudinal study was conducted using Taiwan National Health Insurance Research Database collected during 1997–2005. Patients with incident severe gallstone disease (acute cholecystitis, biliary pancreatitis, acute cholangitis) and gallstone-related procedures (elective and non-elective cholecystectomy, endoscopic retrograde cholangiopancreatography [ERCP]) that led to hospital admission were identified using ICD-9-CM diagnostic and procedure codes. Annual incidence rates of gallstone-related complications and procedures were calculated and their 95% confidence intervals (CI) were estimated assuming a Poisson distribution.

Results

The hospital admission rate for severe gallstone disease increased with advancing age and the age-standardized rate (95% CI) per 1000 population was 0.60 (0.59–0.60) for men and 0.59 (0.59–0.60) for women. Men had a higher rate of acute cholecystitis, probably due to the substantially lower rate of elective cholecystectomy among men than women. For those aged 20–39, hospital admissions for all gallstone-related complications and procedures increased significantly. For those aged ≥60, incidences of biliary pancreatitis, acute cholangitis, and hospital admission for gallstone receiving ERCP increased significantly without substantial change in the incidence of acute cholecystitis and despite a decreased rate of elective cholecystectomy.

Conclusion

This population-based study found a substantial increase in the rate of admission for severe gallstone disease among those aged 20–39. Concurrently, the incidences of biliary pancreatitis and acute cholangitis have risen among those aged ≥60.     

The Successful Treatment of Chronic Cholecystitis with SpyGlass Cholangioscopy-Assisted Gallbladder Drainage and Irrigation through Self-Expandable Metal Stents

A 34-year-old female with a history of advanced pulmonary sarcoidosis and right-sided heart failure presented with chronic, postprandial right upper quadrant pain, and weight loss. Endoscopic biliary drainage was deemed to be the most appropriate therapeutic option for her chronic cholecystitis. Endoscopic retrograde cholangiopancreatography utilizing the SpyGlass cholangioscopy system allowed us to access the cystic duct through which the gallbladder was ultimately decompressed, via biliary stent placement and gallstone irrigation. This is the first report of SpyScope assisted placement of fully covered self-expandable metal biliary stents into the cystic duct enabling definitive treatment of symptomatic chronic cholecystitis and cholelithiasis without cholecystectomy.     

高血糖与胆石症40例临床报告

目的 分析胆石症和糖尿病发病率之间的关系。讨论糖尿病合并无症状胆石症时是应该手术治疗以及糖尿病病人胆道手术的围手术期处理。方法 对４０例合并高血糖的胆石症病人进行回顾性分析。结果 外科胆石症 ６９３例,其中４０例合并高血糖。男性１４例,女性２６例,平均年龄６０．１岁。确认糖尿病１５例,可疑糖尿病１１例,应激性高血糖１４例。手术治疗３３例,胆囊切除１４例,胆囊切除、胆总管探查１６例,胆肠内引流２例,     

Gallstone disease and pancreatitis in pregnancy.

Controversy exists over whether pregnancy is a risk factor for gallstone formation; however, changes in hepatobiliary function do occur during pregnancy to create a lithogenic environment; these changes include gallbladder stasis and secretion of bile with increased amounts of cholesterol and decreased amounts of chenodeoxycholic acid. In women with existing gallstones, pregnancy may bring out symptoms, including pain and even acute cholecystitis. This may be more common during the postpartum period than during pregnancy itself; however, the overall occurrence of symptomatic biliary disease in association with pregnancy is low. The effects of pregnancy, if any, on pancreatic exocrine function are undefined. Acute pancreatitis can occur during pregnancy but does not appear to do so with either increased or, alternatively, decreased frequency. The concept of pancreatitis caused by pregnancy per se is not valid, although in susceptible women with lipid disorders, hypertriglyceridemia can occur and serve as an etiologic factor. Gallstones are a common cause of pancreatitis, but in contrast to nonpregnant women, alcohol is unusual as a cause. Although the presentation of both acute cholecystitis and acute pancreatitis may be similar to that in the nonpregnant state, the differential diagnosis of both these disorders is expanded because of unique pregnancy-related conditions and the shift of abdominal viscera by the enlarging uterus. The diagnosis is clinical and supported with conventional laboratory studies and ultrasound; management is supportive and in most patients successful. Cholecystectomy is seldom necessary during pregnancy, either for acute cholecystitis or gallstone pancreatitis, but can be safely performed if necessary after the first trimester. Endoscopic papillotomy and stone removal for choledocholithiasis are possible during pregnancy and may be the treatment of choice for this unusual condition. Specific enteral or parenteral nutrition may be necessary in women with pancreatitis associated with hypertriglyceridemia.