Gallstone disease in children. Indian Pediatr. 2010;47:945-953. [PMID: 21149901 DOI: 10.1007/s13312-010-0159-2]

The natural history of fetal gallstones: a case series and updated literature review

INTRODUCTION

The incidence of fetal gallstones is estimated at 0.45% and its clinical relevance after birth remains unknown. This study aimed to describe the natural history of fetal gallstones and their clinical sequelae after birth.

METHODS

We queried a database of fetuses referred for second and third trimester sonograms performed for high-risk pregnancies, and identified cases with fetal gallstones (1996-2019). Demographics, prenatal/postnatal imaging findings, and clinical sequelae were collected. A literature review was performed according to PRISMA guidelines.

RESULTS

We screened approximately 200,000 obstetric sonograms; 34 fetuses were found to have cholelithiasis. The median gestational age at the time of sonogram was 35 weeks (range 22-38). Fifty-six percent were female and 11.8% were twin pregnancies with one affected fetus. Median maternal age was 28 years (range 17-42). Eight fetuses underwent postnatal imaging and 4 had persistent cholelithiasis. There was one case of in utero demise. Two patients had structural anomalies (renal and cardiac) by sonogram. A subset of 17 patients was followed long-term (range 3-20 years), and none developed clinical sequelae from cholelithiasis.

DISCUSSION/CONCLUSIONS

No child developed postnatal clinical sequelae related to cholelithiasis identified in utero. Fetal cholelithiasis can be managed expectantly without follow-up imaging in asymptomatic patients.

The Laparoscopic Cholecystectomy and Common Bile Duct Exploration: A Single-Step Treatment of Pediatric Cholelithiasis and Choledocholithiasis

BACKGROUND

In recent years, complicated biliary tract diseases are increasingly diagnosed in children. Laparoscopic exploration of the common bile duct (LCBDE) followed by laparoscopic cholecystectomy has gained popularity in children. The aim of this study was to investigate the outcomes of LCBDE in children and compare them with the treatment outcomes of previously used endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

From January 2000 to January 2022, a total of 84 children (78.5% female) underwent laparoscopic cholecystectomy with a median follow-up of 11.4 (IQR 8, 14) years. Of these, 6 children underwent laparoscopic cholecystectomy (LC) + ERCP and 14 children underwent LCBDE for choledochiothiasis. The primary end point of the study was the success of treatment in terms of the incidence of complications, recurrence rate, and rate of reoperation. Secondary endpoints were stone characteristics, presenting symptoms, duration of surgery, and length of hospital stay.

RESULTS

The majority of patients were female in both groups (83.5% vs. 85.7%), mostly overweight with a median BMI of 27.9 kg/m² and 27.4 kg/m², respectively. Obstructive jaundice, colicky pain, acute pancreatitis, and obstruction of the papilla were the most common symptoms in both groups. The majority of patients (68%) had one stone, whereas two or more stones were found in 32% of patients. The median diameter of the common bile duct was 9 mm in both groups. The procedure was successfully completed in all patients in the ERCP group. In the group of patients treated with LCBDE, endoscopic extraction of the stone with a Dormia basket was successfully performed in ten patients (71.4%), while in the remaining four patients (28.6%) the stones were fragmented with a laser because extraction with the Dormia basket was not possible. The median operative time was 79 min in the LCBDE group (IQR 68, 98), while it was slightly longer in the ERCP group, 85 min (IQR 74, 105) (p = 0.125). The length of hospital stay was significantly shorter in the LCBDE group (2 vs. 4 days, p = 0.011). No complications occurred in the LCBDE group, while two (40%) complications occurred in the ERCP group: pancreatitis and cholangitis (p = 0.078). During the follow-up period, no conversions, papillotomies, or recurrences were recorded in either group.

CONCLUSIONS

Exploration of the common bile duct and removal of stones by LCBDE is safe and feasible in pediatric patients for the treatment of choledocholithiasis. Through this procedure, choledocholithiasis and cholelithiasis can be treated in a single procedure without papillotomy or fluoroscopy. Compared with LC + ERCP, LCBDE is associated with a shorter hospital stay. The incidence of complications was rather low but not statistically significant.

Pediatric biliary calculus disease: clinical spectrum, predisposing factors, and management outcome revisited

Background

Biliary calculus disease (BCD) is one of the most prevalent diseases and poses a significant burden to the health care system in adults. The prevalence of BCD in children and adolescents is about 0.1% and 0.6%, respectively. Although many factors have been attributed to BCD in children, exact etiopathogenesis is not clear. BCD has been extensively studied in adults, but not much literature is available in children. The current review was undertaken to study BCD in children focusing on the objectives like predisposing factors, various modes of presentation, and management outcome of BCD in children in the northern part of India.

Results

Out of 42 children, two children had a history of ceftriaxone therapy. Two underwent ileal resection. The mean reticulocyte count was 1.79%. None had G6PD deficiency or abnormal osmotic fragility test. Clinical presentation was right upper quadrant pain (n = 42, 100%), calculous cholecystitis (n = 8, 19.0%), and jaundice (n = 3, 7.14%). The majority (n = 26, 61.92%) were overweight. Only 16.6% (n = 7) children had normal body mass index (BMI), and 9.3% (n = 4) were obese. The mean BMI was 26.3 kg/m2. 85.5% of children frequently consume junk foods. The majority of calculi were GB calculi accounting for 92.8% (n = 39) whereas 7.1% (n = 3) children had CBD calculi. Thirty-five were managed by laparoscopic cholecystectomy, three were managed by non-operative management, and one was managed by open cholecystectomy; among the three cases of CBD calculi, two were managed by endoscopic retrograde cholangiopancreatography (ERCP), stenting, and CBD exploration and one was managed by ERCP sphincterotomy.

Conclusion

Diet and overweight both appear to be important risk factors for pediatric BCD. Drug-induced calculi can be safely observed.

Echogenicities in the fetal gallbladder: Prevalence, sonographic findings, and postnatal outcomes

PURPOSE

To investigate the prevalence of echogenicity in the fetal gallbladder (EFG) and to present prenatal sonographic findings and their postnatal outcomes.

MATERIALS AND METHODS

We performed a retrospective study within 17420 pregnant women during a 66-month period. Fetuses with an incidental finding of EFG in their 2nd or 3rd trimester of pregnancy were followed until birth per two weeks with sonographic examinations.

RESULTS

Out of 5977 fetuses, 44 fetuses were found to have EFG with a prevalence of 0.74%. Nine (20%) of 44 fetuses had single echogenicity, 25 (56%) had multiple echogenicities, 10 (22%) had sludge-like echogenicities. In Doppler sonography, 28 fetuses with EFG exhibited twinkling artifacts; however, none of the echogenicities had obvious acoustic shadowing. All of the cases were resolved either in utero or after birth before 10 months of age.

CONCLUSION

EFG is a late third-trimester phenomenon with a prevalence of 0.74%. Most EFGs presented as twinkling artifacts, suggesting they had a cholesterol component.

Asymptomatic Cholelithiasis in Children: Management Dilemma

Aims and Objectives:

The incidence of cholelithiasis is now increasing in children. Besides hemolytic diseases, there are also nonhemolytic conditions and idiopathic group. A large number of children belong to asymptomatic group who do not present with gallstone-related symptoms. There is no consensus in the management of these children. The aim of this study is to evaluate the role of elective cholecystectomy in asymptomatic cases to prevent complications which leads to more morbidity.

Materials and Methods:

One hundred and seventy-eight children were treated over a period of 12 years and they were divided into two groups according to their age at presentation. Sixty-four children below 5 years belonged to Group A and 114 children between 5 and 12 years belonged to Group B. About 71.8% of children of Group A and 49.1% of children of Group B were asymptomatic. Cholecystectomy was advised in all cases of Group B and all symptomatic cases of Group A. In Group A asymptomatic cases, ursodeoxycholic acid (UDCA) was given for 6–12 months and followed up.

Results:

Laparoscopic cholecystectomy was performed in all cases except in five cases where conversion to open surgery was done as there was gross adhesions due to previous laparotomy. Of 46 asymptomatic cases of Group A, the stone disappeared in seven cases, 12 children developed symptoms, and there was no change in 27 patients. Stone reappeared again in three of seven children who were managed by cholecystectomy. Cholecystectomy was also performed in 12 cases that developed symptoms. In the rest of the 27 children, cholecystectomy was advised after 1 year trial of UDCA. Cholecystectomy was advised in both symptomatic and asymptomatic cases of Group B. Sixteen of 56 asymptomatic cases did not agree for cholecystectomy and 12 of them returned with complications. Endoscopic retrograde cholangio-pancreaticography (ERCP) and stone extraction was performed in four cases. In all the acute cases, cholecystectomy was performed after a period of conservative management.

Conclusion:

UDCA can be tried in the smaller age group below 5 years, but there is a chance of recurrent stone formation. Elective laparoscopic cholecystectomy should be the choice in all asymptomatic cases to prevent complications.

Cholelithiasis and cholecystitis in children and adolescents: Does this increasing diagnosis require a common guideline for pediatricians and pediatric surgeons?

Background

In contrast to adults, for whom guidelines on the cholelithiasis treatment exist, there is no consistent treatment of pediatric patients with cholelithiasis throughout national and international departments, most probably due to the lack of evidence-based studies.

Methods

We evaluated the German management of pediatric cholelithiasis in a dual approach. Firstly, a retrospective, inter-divisional study was established, comparing diagnostics and therapy of patients of the pediatric surgery department with the management of patients aged < 25 years of the visceral surgery department in our institution over the past ten years. Secondarily, a nation-wide online survey was implemented through the German Society of Pediatric Surgery.

Results

Management of pediatric patients with cholelithiasis was primarily performed by pediatricians in the retrospective analysis (p < 0.001). Pediatric complicated cholelithiasis was not managed acutely in the majority of cases with a median time between diagnosis and surgery of 22 days (range 4 days–8 months vs. 3 days in visceral surgery subgroup (range 0 days–10 months), p = 0.003). However, the outcome remained comparable. The hospital’s own results triggered a nation-wide survey with a response rate of 38%. Primary pediatric medical management of patients was confirmed by 36 respondents (71%). In case of acute cholecystitis, 22% of participants perform a cholecystectomy within 24 h after diagnosis. Open questions revealed that complicated cholelithiasis is managed individually.

Conclusions

The management of pediatric cholelithiasis differs between various hospitals and between pediatricians and pediatric surgeons. Evidence-based large-scale population studies as well as a common guideline may represent very important tools for treating this increasing diagnosis.

Supplementary information

The online version contains supplementary material available at 10.1186/s12876-021-01772-y.

Risk factors, manifestations, diagnosis and treatment of cholelithiasis in children

Cholelithiasis in children refers to cholelithiasis or choledocholithiasis in newborns, infants and adolescents, including a series of symptoms and complications related to stones. The incidence rate of cholelithiasis in children is far lower than that in adults. However, the detection rate of cholelithiasis in children has risen in recent years. The aetiology of cholelithiasis in children is complex, and the pathogenesis is still unclear. According to existing studies, cholelithiasis in children may be related to sex and hormones, obesity, drugs, haemolytic diseases, genetic factors, chemokines, abnormal biliary tract formation, ileal surgery, total parenteral nutrition and other factors. In addition, there is a large occurrence of idiopathic cholelithiasis in children with unknown aetiology. The clinical manifestations of cholelithiasis in children are not completely the same as those in adults, mainly due to the different ages and causes. At present, there is no consensus on the clinical treatment of cholelithiasis in children. Follow-up and observation, drug dissolution and surgical treatment are all treatment methods for children with cholelithiasis. This study reviewed the related literature reports of cholelithiasis in children and summarized the risk factors, clinical manifestations, diagnosis and treatment of cholelithiasis in children to improve the understanding, diagnosis, and treatment of cholelithiasis in children.

Ceftriaxone-associated biliary pseudolithiasis in children: do we know enough?

Ceftriaxone is an antibiotic agent frequently used in paediatric hospital practice for the treatment of severe bacterial infections. The use of this agent can result in cholelithiasis and/or biliary sludge, more commonly in children than in adults. This systematic review was aimed at analysing available literature concerning ceftriaxone-associated biliary pseudolithiasis in paediatric patients, with a special emphasis on the clinical aspects. A literature analysis was performed using Medline and Embase electronic databases (articles published in English up to December 2019), with the search terms and combinations as follows:'ceftriaxone', 'cholelithiasis', 'biliary sludge' 'gallstones' 'neonates' 'children' 'clinical aspects' 'management'. Several case reports, case series and prospective/retrospective studies have documented a relationship between ceftriaxone treatment and biliary pseudolithiasis in the paediatric population, even though literature data regarding neonates and infants are scarce. Ceftriaxone-associated biliary pseudolithiasis is dose-dependent and usually asymptomatic but, sometimes, it may present with abdominal pain, nausea and emesis. Abdominal ultrasonography should be performed when this complication is suspected. Generally, ceftriaxone-associated cholelithiasis resolves over a variable period of time (days to months) after cessation of therapy. Therefore, a conservative approach to this condition is advocated, but a prolonged follow-up may be necessary. A personalized assessment of factors predisposing to ceftriaxone-associated biliary pseudolithiasis before prescribing the drug can allow to minimize the risk of developing it, with significant advantages in terms of human and economic costs.

Symptomatic Cholilithiasis and Cholecystectomy for a 9-Month-Old Infant: A Case Report

BACKGROUND

Symptomatic cholilithiasis is rare in children. Thus, a high degree of suspicion is required for diagnosis. Once a child is diagnosed with symptomatic cholilithiasis, cholecystectomy is required to relieve the symptoms and prevent complication.

CASE DETAILS

A 9-month-old infant from Addis Ababa presented to the Pediatric Department of ZewdituMemorial Hospital on January 30, 2015 with irritability, abdominal pain. On workup, she was found to have gall stones, and her condition was at last attributed to biliary colic after months of follow-up in the Department of Pediatrics. She underwent cholecystectomy on the 31st of July 2015 and discharged with improved results. This is the first report of symptomatic cholilithiasis and cholecystectomy in Ethiopia at 9 months of age.

CONCLUSION

Cholilithiasis is rare in infants, and one should have a high index of suspicion for diagnosis. Cholecystectomy should be done as in adults if symptomatic.

Risk factors, complications and outcome of cholelithiasis in children: A retrospective, single-centre review

AIM

The aim of this study was to evaluate the clinical presentation, risk factors, complications, treatment and outcomes of cholelithiasis in children.

METHODS

Children with cholelithiasis were reviewed for demographic information, predisposing factors, presenting symptoms, laboratory findings, complications, treatment and outcome, retrospectively.

RESULTS

A total of 254 children with cholelithiasis (mean age: 8.9 ± 5.2 years) were recruited to the study. Girls (52.8%) were significantly older than boys (P < 0.001). Symptomatic patients (59%) were significantly older than asymptomatic patients (P = 0.002). Abdominal pain was the most frequent symptom. No risk factors were identified in 56.6% of the patients. Ceftriaxone (20%) was the most commonly associated risk factor. At presentation, at least one of the following complications was seen in 14.1% of patients: cholecystitis (10.9%), obstructive jaundice (2.7%), pancreatitis (1.96%) and cholangitis (1.2%). There was no relationship between gallstone size and symptoms, aetiological factors and complications. The cholelithiasis dissolution rate was higher in younger children (P = 0.032), in those with biliary sludge (P < 0.0001) and ceftriaxone-related cholelithiasis (P < 0.001). Haemolytic anaemia (P = 0.001) and older age (P = 0.002) were associated with stable stones. Ursodeoxycholic acid was administered to 94.4% of patients at presentation. Twenty-nine patients underwent cholecystectomy, and seven patients underwent endoscopic retrograde cholangiopancreotography. Patients who were symptomatic at presentation had significantly more frequent symptoms at follow-up (P < 0.001) CONCLUSIONS: Dissolution rate of cholelithiasis was higher in younger children, biliary sludge formation and ceftriaxone-related cholelithiasis but lower in older children and haemolytic anaemia-related cholelithiasis.

Laparoscopic cholecystectomy in a 2 year old male child with choleilithiasis and recurrent right hypochondrial pain: Case report and review of literature

•

The probability of gallstone disease infants and young children should not be ignored.

•

Gall stones should always be considered as a differential diagnosis when young patients present with complaints of abdominal pain.

Introduction

Gallstone disease has been considered an uncommon entity in children and infants, but its incidence is reportedly increasing which may be attributed to widespread use of diagnostic imaging (ultrasonography).

Presentation of case

An apparently healthy 2 year old male child presented to our Outpatient department with chief complaint of recurrent abdominal pain. The episodes of pain were acute in onset and associated with vomiting. As per the complete examination and findings, a diagnosis of chronic calculous cholecystitis was made. A four port laparoscopic cholecystectomy was done.

Discussion

The incidence of gallstones in children in India has not been sufficiently studied. The incidence of gallstone disease in India was found to be 0.3% with the incidence in age group 0–10 being less than 0.1%. In contrast to adult gallstone disease, it has been found that there is no female preponderance in gallstone diseases of infancy. Also, the majority of children having increased haemoglobin turnover develop pigment stones only after 5 years of age.

Conclusion

The probability of gallstone disease in infants and young children should not be ignored. Gall stones should always be considered as a differential diagnosis when young patients present with complaints of abdominal pain.

Prevalence of Gallstones Compared in Children With Different Intravenous Lipids

OBJECTIVE

The aetiology of biliary liver disease in children with intestinal failure treated with long-term parenteral nutrition (PN) is multifactorial. Risks include the lipid component of PN. The aim of the study was to compare prevalence and outcome of gallstones with different types of intravenous lipids.

METHODS

Liver and biliary tract imaging and relevant clinical details were reviewed in 71 patients (37, 52% boys) treated with PN for >3 months. Types of lipid infused were compared with regard to hepatobiliary abnormalities.

RESULTS

In total 369 abdominal ultrasounds were performed in 71 patients of age between 3 months and 17 years. Underlying diagnoses were short bowel syndrome in 20 (28%), small intestinal enteropathy in 34 (48%), and motility disorder in 17 (24%). A total of 67 (94%) children had 362/369 scans on lipid-containing PN. Of the total, 15 (21%) patients had gallstones, 8 (11%) had sludge, and both were detected in 7 (10%) children. The gallstones/sludge resolved in 7 patients (10%) and persisted in 10 (13%). In 6 patients, sludge progressed to form discrete gallstones, and in 9 children, gallstones led to biliary duct dilatation. Four (6%) patients underwent cholecystectomy. Fewer children had abnormalities with the newer mixed lipid emulsion (P = 0.005). There was a higher prevalence of sludge (P = 0.01) on pure soya lipid. Predictors for sludge were young age at PN (P = 0.001), lack of enteral feed (P < 0.001), and motility disorder with stoma (P = 0.002).

CONCLUSIONS

Hepatobiliary pathology is common in children on PN. The use of mixed lipid was associated with less biliary complications and should be the first choice of treatment in children.

Laparoscopic techniques for safe and successful removal of common bile duct stones in pediatric patients

BACKGROUND/PURPOSE

Choledocholithiasis is uncommon in the pediatric population. Techniques for common bile duct stone extraction are still not well established. This article aims to describe safe and applicable techniques for pediatric common bile duct exploration.

MATERIALS AND METHODS

This was a retrospective review of a prospectively maintained database of two pediatric surgeons for patients undergoing laparoscopic common bile duct exploration at two tertiary-care centers from April 2008 to March 2012.

RESULTS

For 39 patients under 15 years of age undergoing laparoscopic cholecystectomy, 10 cholangiograms were performed, and 8 were found to have filling defects. Seven patients underwent successful laparoscopic common bile duct exploration with documentation of stone clearance, and 1 patient was sent for postoperative endoscopic retrograde cholangiopancreatography with stone extraction. Eleven patients had cholecystectomy performed by single-incision laparoscopic surgery, but none of these had cholangiograms or common bile duct explorations. Various methods of stone clearance were used, including the use of saline flush, balloon catheters, nitinol stone extractors, and the aide of glucagon. Depending on patient size, a choledochosope or a ureteroscope was used. There were no complications and no conversions to open surgery.

CONCLUSIONS

Laparoscopic common bile duct exploration is feasible in the pediatric population, using many of the instruments readily available in the standard operating room. With an armamentarium of tools and techniques, the method of stone extraction can be tailored to the patient and situation.

Calcified gallstone in a 3 year-old boy: a case report

BACKGROUND

Gallstones are relatively rare in children. At-risk populations include patients suffering from hemolysis syndromes. Regardless of etiology, these patients usually will present with postprandial abdominal pain, and ultrasonography is the mainstay of diagnosis. However, some gallstones are radiopaque and can be visualized on plain abdominal radiography.

CASE PRESENTATION

We present the uncommon but classic plain x-ray finding of a calcified gallstone in a 3 year-old Hispanic boy. He was treated with elective laparoscopic cholecystectomy.

CONCLUSIONS

Cholelithiasis is rare in children, and calcified stones that will appear on plain abdominal x-rays are even rarer. If symptomatic, cholecystectomy by a pediatric surgeon is the treatment of choice. We discuss some of the recent developments in treatment of this condition in this patient population.

Concept of the pathogenesis and treatment of cholelithiasis

Gallstone disease (GD) is a chronic recurrent hepatobiliary disease, the basis for which is the impaired metabolism of cholesterol, bilirubin and bile acids, which is characterized by the formation of gallstones in the hepatic bile duct, common bile duct, or gallbladder. GD is one of the most prevalent gastrointestinal diseases with a substantial burden to health care systems. GD can result in serious outcomes, such as acute gallstone pancreatitis and gallbladder cancer. The epidemiology, pathogenesis and treatment of GD are discussed in this review. The prevalence of GD varies widely by region. The prevalence of gallstone disease has increased in recent years. This is connected with a change in lifestyle: reduction of motor activity, reduction of the physical load and changes to diets. One of the important benefits of early screening for gallstone disease is that ultrasonography can detect asymptomatic cases, which results in early treatment and the prevention of serious outcomes. The pathogenesis of GD is suggested to be multifactorial and probably develops from complex interactions between many genetic and environmental factors. It suggests that corticosteroids and oral contraceptives, which contain hormones related to steroid hormones, may be regarded as a model system of cholelithiasis development in man. The achievement in the study of the physiology of bile formation and the pathogenesis of GD has allowed expanding indications for therapeutic treatment of GD.