Acute acalculous cholecystitis of viral etiology--a rare condition in children?

Cholecystitis due to gallbladder volvulus in a child

Gallbladder volvulus (GV) involves the rotation of the gallbladder along its axis, resulting in torsion. This pathology is rare, more commonly found in elderly females, but can occasionally occur in pediatric patients. Diagnosis is challenging due to often atypical symptoms, with imaging and laboratory findings typically nonspecific. Prompt surgical intervention is necessary when GV is suspected to prevent significant systemic illness. Laparoscopic cholecystectomy has proven to be safe and effective in pediatric cases. In this report, we present a pediatric case of GV, initially misdiagnosed as viral-induced acalculous cholecystitis, which was effectively managed using laparoscopic cholecystectomy.

Is conservative management a safe approach for patients with acute acalculous cholecystitis presenting with an acute abdomen?

Patients with acute acalculous cholecystitis (AAC) often present with acute abdominal symptoms. However, recent clinical studies have suggested that some patients with AAC and an acute abdomen, especially when caused by viruses or rheumatic disease, may not require cholecystectomy and that conservative treatment is adequate. Whether cholecystectomy is superior to conservative treatment for patients with AAC presenting with a severe acute abdomen is still uncertain. This was a case series study of AAC-related literature published between 1960 and 2022. In total, 171 cases (104 viral infection-associated AAC and 67 rheumatic disease-associated AAC) were included. The prognoses of patients receiving cholecystectomy or conservative treatment were compared. To account for confounding factors, etiological stratification and logistic regression were performed. The prognosis was similar for patients undergoing cholecystectomy and conservative treatment (P value .364), and virus infection-associated AAC had a better prognosis than rheumatic disease-associated AAC (P value .032). In patients with AAC caused by viruses or rheumatic disease, the acute abdomen can be adequately managed by conservative treatment of the underlying etiology and does not mandate surgical intervention.

Epstein Barr Virus Hepatitis-A Mild Clinical Symptom or a Threat?

The present study aimed to characterize pediatric patients diagnosed with hepatitis associated with primary Epstein-Barr Virus (EBV) infection. We described the changes in liver aminotransferases activity during the disease, and we analyzed the results of abdominal ultrasonography. A retrospective study was performed by analyzing the medical records of 166 immunocompetent children diagnosed with primary EBV hepatitis hospitalized at the Department of Children's Infectious Diseases, Medical University of Warsaw, Regional Hospital of Infectious Diseases in Warsaw, between August 2017 and March 2023. Elevated alanine aminotransferase (ALT) activity was noted in the first three weeks of the disease. In 46.3% of patients, ALT values exceeded five times the upper limit of the laboratory norm in the first week of illness. Aspartate aminotransferase activity increased from the first to fourth week from the onset of symptoms and showed two peaks in the first and third weeks. The changes over time of mean AST activity demonstrated significance. Transient cholestatic liver disease was the predominant type of hepatic involvement in 10.8% of children; 66.6% of them were older than 15 years. Clinical and ultrasound criteria of acute acalculous cholecystitis (AAC) were met in three female patients over 16 years of age. Hepatitis associated with primary EBV infection is usually a mild and self-limiting condition. Significantly elevated values of liver enzymes with features of cholestatic liver disease may occur in patients with a more severe course of the infection.

Acalculous Cholecystitis in a Seven-Year-Old Girl With Epstein-Barr Virus Infection

Epstein-Barr virus (EBV) infection with associated acute acalculous cholecystitis (AAC) has been reported in 18 pediatric patients. Our case is that of a seven-year-old girl with acute EBV infection and associated AAC.

Coronavirus Disease and Abdominal Pain: Mechanism, Diagnostic, and Treatment

BACKGROUND: On March 11, 2020, the General Director of the World Health Organization has announced that according to the organization, the level of spread and severity of symptoms of coronavirus disease (COVID-19) is becoming alarming and because of that, it can be characterized as a pandemic. The assessment of the World Health Organization stimulated more urgent and belligerent actions from the governments as the number of case reports and studies on COVID-19 symptoms and treatment increased dramatically. AIM: In this paper, the aim is to make a review of the studies and case reports/series that indicate that abdominal pain is one of the manifestations of COVID-19. METHODS: A search was performed on two electronic databases: PubMed Central and Google Scholar, using the key words “COVID-19 and abdominal pain.” Case reports and case series in adults and children were included regardless of the language, region, or the publication date. The methods of synthesis and comparison were also used. RESULTS: In general, it can be noted that the manifestation of the COVID-19 infection on the digestive tract and the consequences on the same are not fully examined. CONCLUSION: The conclusion of the analyzed papers is that clinical practitioners in COVID-19 pandemic should carefully distinguish abdominal pain and other GI symptoms from COVID-19 manifestations and should exclude acute surgical condition.

Acute Acalculous Cholecystitis Due to a Primary Epstein Barr Virus Infection in a Pediatric Patient

Epstein-Barr virus (EBV) is estimated to infect more than 98% of adults worldwide and is one of the most common human viruses. Acute acalculous cholecystitis (AAC) of the gallbladder is an atypical complication of infectious mononucleosis caused by EBV. Conservative management has been described in the context of AAC caused by EBV. A surgical approach must be considered in the case of acute complications such as perforation or gallbladder gangrene. We present the case of a 10-year-old female patient with AAC due to infectious mononucleosis syndrome caused by primary EBV infection.

Gallbladder wall thickening on bedside ultrasound in a child with Epstein-Barr virus infection

Gallbladder wall thickening (GBWT) is rarely reported in children with acute Epstein-Barr virus (EBV) infection. We present a child with EBV infection who was found on point-of-care ultrasound to have GBWT without signs of cholecystitis that subsequently resolved without intervention. We expect the proliferation of mobile and handheld sonography to increase the number of bedside examinations in febrile children. This, in turn, will increase the incidence of GBWT found in patients with EBV infection and without right upper quadrant pain. Prospective study is needed to define the incidence of GBWT in children with EBV infection.

Acalculous acute cholecystitis during the course of an enteroviral infection

Gallbladder diseases are uncommon in children. Acalculous acute cholecystitis, although rare, is the most frequent form of acute cholecystitis in childhood. In acalculous acute cholecystitis, clinical presentation and laboratory findings are unspecific, making the diagnosis challenging. Abdominal ultrasonography is the first-line exam. Most cases of paediatric acalculous acute cholecystitis have been described in critically ill patients, but can occur in previously healthy children, without underlying diseases or severe conditions. The authors present a clinical report of a child with acalculous acute cholecystitis and enteroviral infection. Diagnosis, treatment, clinical course and prognosis are described. Pathophysiology, aetiology, diagnosis and treatment of acalculous acute cholecystitis are also discussed.

Acute acalculous cholecystitis in children

Acute acalculous cholecystitis (AAC) is the inflammatory disease of the gallbladder in the absence of gallstones. AAC is estimated to represent at least 50% to 70% of all cases of acute cholecystitis during childhood. Although this pathology was originally described in critically ill or post-surgical patients, most pediatric cases have been observed during several infectious diseases. In addition to cases caused by bacterial and parasitic infections, most pediatric reports after 2000 described children developing AAC during viral illnesses (such as Epstein-Barr virus and hepatitis A virus infections). Moreover, some pediatric cases have been associated with several underlying chronic diseases and, in particular, with immune-mediated disorders. Here, we review the epidemiological aspects of pediatric AAC, and we discuss etiology, pathophysiology and clinical management, according to the cases reported in the medical literature.

Infectious mononucleosis - not always a benign condition: a case report of infectious mononucleosis-associated acute acalculous cholecystitis

Infectious mononucleosis is typically a self-limited viral infection of adolescence and early adulthood that resolves in a period of weeks, causing no major sequelae. We describe a case of a healthy 18-year-old female diagnosed with infectious mononucleosis who also presented with right upper quadrant abdominal pain, moderate transaminitis, and cholestatic biochemistry. An ultrasound revealed acute acalculous cholecystitis, generally a condition seen in the context of critical illness. Further investigating emergency department patients with infectious mononucleosis is often not indicated, but may be important for those who present atypically.

Conservative Management of Acalculous Cholecystitis in a Seven-year-old Child

Acute acalculous cholecystitis is an uncommon disease in children and is usually associated with trauma, burns, and infections. Whereas acute acalculous cholecystitis is only seen in 10% of cholecystitis in adults, it is uncommon in the paediatric population.

A seven-year-old male presented to the emergency department of a regional hospital with a 36-hour history of right-upper-quadrant abdominal pain. He had associated symptoms of anorexia, nausea, and vomiting. He was septic with raised white cell count and inflammatory markers. Diffuse gallbladder wall thickening without intraluminal sludge or calculi was seen on abdominal ultrasound. He was found to have a concurrent right-upper lobe pneumonia on further investigation. The patient was treated with antibiotics and responded well to supportive and conservative management with close radiological monitoring.

Acute acalculous cholecystitis is associated with a high mortality rate (30%) and significant complications such as gangrene, empyema, and perforation in 40% of adult cases. Acute surgical management has been traditionally advocated, however, surgery is not without risks; studies have suggested that non-operative intervention may be appropriate for selected critically ill children with an underlying cause.

Herein, we discuss the safe and effective conservative treatment of acute acalculous cholecystitis in lieu of operative management and highlight the importance of recognising this disease in paediatric patients with acute abdominal pain and coexisting infection.

Risk factors for poor outcomes of children with acute acalculous cholecystitis

BACKGROUND

Acute acalculous cholecystitis (AAC) is generally considered to be a mild disease in children; however, if left untreated or treated without caution, AAC can lead to severe outcomes, such as death. The objectives of this study were to present the clinical features and identify the predictors of mortality in pediatric AAC.

METHODS

Patients diagnosed with AAC between 2005 and 2012 were enrolled. AAC was defined by the presence of fever and an echo-proven thickened gallbladder wall exceeding 4 mm. A poor health outcome was defined as death. Further information related to the demographics, clinical manifestations, laboratory results, ultrasound findings, and pathogens present in the AAC patients was also collected. Predictors of mortality were identified by association analyses and confirmed by multivariate logistic regression.

RESULTS

A total of 147 pediatric AAC patients (male/female = 1.01, mean age = 5.2 years) were included in this retrospective study. The most common clinical presentation was an elevated C-reactive protein level (84%) followed by hepatomegaly (80%) and anorexia (78%). AAC in children was associated with various diseases, including infectious diseases (70%), systemic diseases (13%), and malignancy (11%). Fourteen of the 147 (9.25%) patients died during the study period. The presences of thrombocytopenia, anemia, gallbladder sludge, hepatitis, and/or sepsis plus hepatitis were found to be the important predictors of AAC mortality.

CONCLUSIONS

The factors associated with AAC mortality were anemia, thrombocytopenia, gallbladder sludge, hepatitis, and sepsis plus hepatitis. These predictors are likely to help clinicians identify patients who are at a high risk of poor prognoses and make appropriate clinical decisions.

Age, Predisposing Diseases, and Ultrasonographic Findings in Determining Clinical Outcome of Acute Acalculous Inflammatory Gallbladder Diseases in Children

We evaluated clinical factors such as age, gender, predisposing diseases and ultrasonographic findings that determine clinical outcome of acute acalculous inflammatory gallbladder diseases in children. The patients were divided into the four age groups. From March 2004 through February 2014, clinical data from 131 children diagnosed as acute acalculous inflammatory gallbladder disease by ultrasonography were retrospectively reviewed. Systemic infectious diseases were the most common etiology of acute inflammatory gallbladder disease in children and were identified in 50 patients (38.2%). Kawasaki disease was the most common predisposing disease (28 patients, 21.4%). The incidence was highest in infancy and lowest in adolescence. The age groups were associated with different predisposing diseases; noninfectious systemic disease was the most common etiology in infancy and early childhood, whereas systemic infectious disease was the most common in middle childhood and adolescence (P = 0.001). Gallbladder wall thickening was more commonly found in malignancy (100%) and systemic infection (94.0%) (P = 0.002), whereas gallbladder distension was more frequent in noninfectious systemic diseases (60%) (P = 0.000). Ascites seen on ultrasonography was associated with a worse clinical course compared with no ascites (77.9% vs. 37.7%, P = 0.030), and the duration of hospitalization was longer in patients with ascites (11.6 ± 10.7 vs. 8.0 ± 6.6 days, P = 0.020). In conclusion, consideration of age and predisposing disease in addition to ultrasonographic gallbladder findings in children suspected of acute acalculous inflammatory gallbladder disease might result in better outcomes.

Acute Acalculous Cholecystitis by Epstein-Barr Virus Infection: A Rare Association

Acute acalculous cholecystitis (AAC) is a rare complication of Epstein Barr virus (EBV) infection, with only a few cases reported among pediatric population. This clinical condition is frequently associated with a favorable outcome and, usually, a surgical intervention is not required. We report a 16-year-old girl who presented with AAC following primary EBV infection. The diagnosis of AAC was documented by clinical and ultrasonographic examination, whereas EBV infection was confirmed serologically. A conservative treatment was performed, with a careful monitoring and serial ultrasonographic examinations, which led to the clinical improvement of the patient. Pediatricians should be aware of the possible association between EBV and AAC, in order to offer the patients an appropriate management strategy.

Ultrasonographic Gallbladder Abnormality of Primary Epstein-Barr Virus Infection in Children and Its Influence on Clinical Outcome

The incidence of pediatric acute inflammatory gallbladder (GB) disease without gallstone such as acute acalculous cholecystitis has increased with the development of improved diagnostic modalities. Although Epstein-Barr virus (EBV) infection is common in general population, only few cases of GB diseases caused by EBV infection have been reported. This study analyzed ultrasonographic characteristics of primary EBV infection in children and evaluated the influence of EBV-associated GB disease on clinical course and outcome of EBV infection.Between March 2004 and January 2013, 94 of 287 pediatric patients with EBV infection underwent abdominal ultrasonography (USG); clinical features, laboratory data, and USG findings were collected and analyzed retrospectively.Of 94 children, ultrasonographic thick GB wall was observed in 24 (25.3%). Platelet counts were lower in the thickened GB wall group than in the normal GB wall thickness group (P = 0.004). Direct bilirubin, alanine aminotransferase, and γ-glutamyl transferase levels were higher in the thickened GB wall group (P = 0.000, P = 0.041, and P = 0.001, respectively). The duration of hospitalization was longer in patients with thickened GB wall (P = 0.043).Radiologic findings of acute acalculous inflammatory GB disease such as thickened GB wall caused by primary EBV infection are more common than previously reported. Consideration of EBV infection in the differential diagnosis of children suspected with acute acalculous GB diseases may avoid unnecessary surgical intervention.

Acute acalculous cholecystitis in a patient with primary Epstein-Barr virus infection: a case report and literature review

Epstein-Barr Virus (EBV) infection can lead to infectious mononucleosis syndrome with the typical symptoms of fever, pharyngitis, and lymphadenopathy. Self-limited mild to moderate elevation of liver enzymes and hepatosplenomegaly are common. However, cholecystitis is not usually considered part of a primary EBV infection and ultrasound scan (USS) of the liver and gallbladder is not routinely performed. Acute acalculous cholecystitis (AAC) caused by etiologies other than primary EBV infection is often associated with severe illness and antibiotic treatment and surgery may be needed. We present a case with primary EBV infection and AAC and a literature review. Our patient was a 34-year-old woman with clinical, biochemical and serological signs of primary EBV infection (lymphocytes 7.6×10˄9/l, monocytes 2.6×10˄9/l, positive early antigen IgM test and 14 days later positive early antigen IgG test). During admission, increasing liver function tests indicated cholestasis (alanine aminotransferase 61 U/l, alkaline phosphatase 429 U/l and bilirubin 42μmol/l). USS revealed a thickened gallbladder wall indicating cholecystitis but no calculus. All other microbiological tests were negative. The literature search identified 26 cases with AAC and acute EBV infection; 25 cases involved females. Sore throat was not predominant (six reported this), and all cases experienced gastrointestinal symptoms. Our and previous published cases were not severely ill and recovered without surgical drainage. In conclusion primary EBV infection should be considered in cases of AAC, especially in young women. In cases associated with EBV infection neither administration of antibiotics nor surgical drainage may be indicated.

Acalculous Acute Cholecystitis in Previously Healthy Children: General Overview and Analysis of Pediatric Infectious Cases

Acute acalculous cholecystitis (AAC) is an inflammation of the gallbladder, which does not appear to be associated with the presence of gallstones. AAC is estimated to represent more than 50% of cases of acute cholecystitis in the pediatric population. Although this pathology was initially described in critically ill patients, actually most pediatric cases have been observed during several infectious diseases. Particularly, here we reviewed pediatric infectious acute acalculous cholecystitis and analyzed the pathophysiological and clinical aspects of bacterial and viral forms.

Acute acalculous cholecystitis, a rare complication of Epstein-Barr virus primary infection: report of two cases and review

We described two cases of acalculous cholecystitis (AAC), due to EBV primary infection in two young Caucasian women and we reviewed other reported cases. In contrast with AAC of other etiologies, antibiotics and surgery are not useful in the management of AAC secondary to EBV.

Epstein-barr virus infection with acute acalculous cholecystitis

Acute acalculous cholecystitis (AAC) is an inflammation of the gallbladder in the absence of demonstrated stones. AAC is frequently associated with severe systemic inflammation. However, the exact etiology and pathogenesis of AAC still remain unclear. Acute infection with Epstein Barr virus (EBV) in childhood is usually aymptomatic, whereas it often presents as typical infectious mononucleosis symptoms such as fever, cervical lymphadenopathy, and hepatosplenomegaly. AAC may occur during the course of acute EBV infection, which is rarely encountered in the pediatric population. AAC complicating the course of a primary EBV infection is usually associated with a favorable outcome. Most of the patients recover without any surgical treatment. Therefore, the detection of EBV in AAC would be important for prediction of better prognosis. We describe the case of a 10-year-old child who presented with AAC during the course of primary EBV infection, the first in Korea, and review the relevant literature.

Hepatobiliary risk factors for clinical outcome of Kawasaki disease in children

Background

Kawasaki disease (KD) is an acute febrile vasculitis that causes coronary artery abnormality (CAA) as a complication. In some patients, an association has been noted between elevated liver enzymes or an abnormal gallbladder (GB) and hepatobiliary involvement in KD. In this study, we aimed to evaluate clinical, laboratory, and ultrasonographic (USG) risk factors of hepatobiliary involvement for the intravenous immunoglobulin (IVIG) resistance and the development of CAA in children with KD.

Methods

From March 2004 through January 2013, clinical features, laboratory data, echocardiographic findings, and USG findings were retrospectively reviewed regarding the response to IVIG treatment and coronary artery complications in 67 children with KD. Acute acalculous cholecystitis (AAC) was diagnosed based on USG criteria.

Results

Among all factors, only the prothrombin time international normalized ratio was significantly different between the IVIG-response and IVIG-resistance groups (p = 0.024). CAA was statistically more frequent in the AAC group (n = 24) than in the non-AAC group (n = 43) (23.3% vs. 58.3%, p = 0.019). Among the laboratory factors, segmented neutrophil percentage, total bilirubin level, and C-reactive protein were significant in children with CAA (p = 0.014, p = 0.009, and p = 0.010). Abnormal GB findings on USG were significantly more frequent in children with CAA than in those without CAA (p = 0.007; OR = 4.620; 95% confidence interval [CI]: 1.574–13.558). GB distension on USG was the only significant risk factor for CAA (p = 0.001; OR = 7.288; 95% CI: 2.243–23.681) by using multiple logistic regression analysis.

Conclusion

For children in the acute phase of KD, USG findings of the GB, especially GB distension, may be an important risk factor for CAA as a complication.

Acute acalculous cholecystitis associated with severe EBV hepatitis in an immunocompetent child

Acute acalculous cholecystitis (AAC) is an inflammation of the gallbladder in the absence of demonstrated stones, which is rarely seen in paediatric population. The diagnosis is accomplished mainly through abdominal ultrasonography in the appropriate but usually non-specific clinical picture. Complicated cases need surgical intervention; the medical management is mainly constituted by supportive and antibiotic therapy, as most AAC are observed in the setting of systemic bacterial or parasitic infections. However, AAC has been rarely reported in association with Epstein-Barr virus (EBV) infection, where the gastrointestinal involvement is often mild and thus unrecognised. We report a case of EBV-related AAC associated with unusually severe hepatitis in an immunocompetent and otherwise healthy patient. We describe its benign clinical course, despite the serious liver impairment, by a medical management characterised by the prompt discontinuation of broad-spectrum antibiotics, as soon as EBV aetiology is ascertained, and by the appropriate analgesia and fluid resuscitation.

Epstein-Barr virus-associated acute cholecystitis in a teenager

A 14-year-old girl was admitted to hospital with fever, headache, sore throat and abdominal pain. Her blood lymphocyte count and inflammatory markers were raised. Acute Epstein-Barr virus (EBV) infection was suspected and confirmed serologically and by measuring the viral load. On day 7, she developed jaundice with abnormal liver function tests. An abdominal ultrasound scan revealed thickening of the gallbladder and bile duct walls without calculi suggesting acute acalculous cholecystitis. The patient improved slowly with symptomatic treatment, and a repeat ultrasound scan six months later was normal. Acalculous cholecystitis is a rare complication of EBV infection and usually has a good prognosis.

Acute acalculous cholecystitis in children with Epstein-Barr virus infection: a role for Gilbert's syndrome?

Acute acalculous cholecystitis (AAC) in association with acute Epstein-Barr virus (EBV) infection has rarely been described in childhood. In the literature, there are only four reported pediatric cases of AAC associated with isolated primary EBV infection. We present two cases (one new, one retrospectively reviewed) of children with Gilbert's syndrome (GS) who presented with AAC during the course of primary EBV infection. Antibiotics were not used and AAC subsided gradually as the infection regressed. The co-occurrence of GS might have played a contributory role in the pathogenesis of AAC during acute EBV infection.