Successful nonoperative management of neonatal acute calculous cholecystitis

Clinical management of infantile cholelithiasis

PURPOSE

Infantile cholelithiasis is a rare disease process, and management strategies are poorly defined. We therefore examined the risk factors, complications, and management of this disease at our institution.

METHODS

We retrospectively reviewed infants with cholelithiasis diagnosed on ultrasound between 1997 and 2013. Details of the patient's medical history, presentation, imaging findings, laboratory values, and treatment were reviewed and analyzed.

RESULTS

Over the 16-year period, 50 infants were evaluated for cholelithiasis. Thirty-seven (74%) had at least one risk factor for gallstone development which included total parenteral nutrition, diuretic therapy, cephalosporin antibiotic treatment, sepsis, congenital heart disease (CHD), prematurity, or a malabsorptive gastrointestinal condition. Thirteen (26%) infants were symptomatic, most commonly presenting with emesis and jaundice. Complications from gallstones included choledocholithiasis (9), cholecystitis (3), and pancreatitis (1). Nearly half (6/13) of patients with complicated cholelithiasis had CHD. Of infants presenting with complications, 9 had a cholecystectomy, most commonly via a laparoscopic approach, 2 had an ERCP for choledocholithiasis, and 2 were medically managed. In patients managed conservatively, resolution of gallstones occurred in 25%.

CONCLUSIONS

Infantile cholelithiasis has variable outcomes ranging from spontaneous resolution to choledocholithiasis or cholecystitis. While patients with complicated cholelithiasis often undergo an operation, infants <1year of age have higher anesthetic and surgical risks. Conservative management with ERCP or medical treatment can also be successful, which offers an alternative to operative intervention in properly selected patients.

Cholelithiasis and perforated gallbladder in an infant

An infant presented with abdominal distension and failure to thrive. This patient was a 3.5-month-old, ex-26-week premature infant at the time of presentation who required supplemental parenteral nutrition until day 9 of life. Workup found ascites and a complex cystic mass in the porta hepatis. A perforated gallbladder with gallstones was found at laparotomy. The gallstones were removed, and the bed of the gallbladder was drained. Output from the drain was minimal by postoperative day 6, and the drain subsequently was removed. The child did well postoperatively; hematologic and metabolic workups were unrevealing. Perforation of the gallbladder is an exceedingly uncommon finding in infants. Appropriate management includes laparotomy and drainage of the gallbladder bed.

Asymptomatic neonatal cholelithiasis

Cholelithiasis in neonates and infants has been rarely reported. With the current widespread use of diagnostic ultrasonography, more neonates may be found with gallstones and common bile duct stones. We describe a case of asymptomatic gallstones detected incidentally at the age of four days who presented with early onset of neonatal sepsis and dehydration.