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Introduction

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During normal pregnancy, the gastrointestinal tract and its appendages undergo remarkable anatomical, physiological, and functional changes. These changes, which are discussed in detail in Chapter 4 (Gastrointestinal Tract), can appreciably alter clinical findings normally relied on for diagnosis and treatment of gastrointestinal disorders. Moreover, as pregnancy progresses, gastrointestinal symptoms become more difficult to assess. Physical findings are often obscured by a large uterus that displaces abdominal organs and can alter the location and intensity of pain and tenderness.

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General Considerations

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Diagnostic Techniques
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Endoscopy
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Various methods can evaluate the gastrointestinal tract during pregnancy without reliance on x-ray techniques. Fiberoptic endoscopic instruments have revolutionized diagnosis and management of most gastrointestinal conditions, and these are particularly well suited for pregnancy. With endoscopy, the esophagus, stomach, duodenum, and colon can be inspected (Cappell, 2006, 2011). The proximal jejunum can also be studied, and the ampulla of Vater cannulated to perform endoscopic retrograde cholangiopancreatography—ERCP (Fogel, 2014; Kamani, 2012; Tang, 2009). Experience in pregnancy with videocapsule endoscopy for small-bowel evaluation is limited (Storch, 2006).

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Upper gastrointestinal endoscopy is used for management as well as diagnosis of several problems. Common bile duct exploration and drainage are used for choledocholithiasis as described in Chapter 55 (Pancreatic Disorders). It is also used for sclerotherapy as well as placement of percutaneous endoscopic gastrostomy (PEG) tubes. A number of concise reviews have been provided (Cappell, 2011; Fogel, 2014; Gilinsky, 2006).

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Flexible sigmoidoscopy can be used safely in pregnant women (Siddiqui, 2006). In nonpregnant patients, colonoscopy is indispensible for viewing the entire colon and distal ileum for diagnosis and management of inflammatory bowel disease. Except for the midtrimester, reports of colonoscopy during pregnancy are limited, but preliminary results indicate that it should be performed if indicated (Cappell, 2010, 2011). Bowel preparation is completed using polyethylene glycol electrolyte or sodium phosphate solutions. With these, serious maternal dehydration that may cause diminished uteroplacental perfusion should be avoided.

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Noninvasive Imaging Techniques
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The obvious ideal technique for gastrointestinal evaluation during pregnancy is abdominal sonography. Because computed tomography (CT) use is limited in pregnancy due to radiation exposure, magnetic resonance (MR) imaging is now commonly used to evaluate the abdomen and retroperitoneal space (Khandelwal, 2013). One example is magnetic-resonance cholangiopancreatography—MRCP (Oto, 2009). These and other imaging modalities, and their safe use in pregnancy, are considered in more detail in Chapter 46 (Computed Tomography).

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Laparotomy and Laparoscopy
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Surgery is lifesaving for certain gastrointestinal conditions—perforative appendicitis being the most common example. From the Swedish Registry database through 1981, abdominal exploration by laparotomy or laparoscopy was performed in 1331 of 720,000 pregnancies—approximately 1 in every 500 (Mazze, 1989...

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