Choledocholithiasis in a premature neonate

Hyperbilirubinemia and Choledocholithiasis in an Extremely Premature Neonate

Cholestasis affects 2% of newborns admitted to the neonatal intensive care unit and 20% of premature infants and requires a thoughtful evaluation and diagnostic workup.There may be a single responsible etiology, or its development may be multifactorial. Premature neonates are especially predisposed because of their increased risk of infections and acute illness, need for parenteral nutrition, and exposure to certain medications. Clinically, an infant may present with jaundice, evidence of hepatic injury, or worsening hepatic function. Diagnosis may be made in consultation with various pediatric subspecialists including gastroenterology, genetics, and surgery. Treatment depends on the etiology but may include medications or surgical interventions. Timely recognition and intervention improve outcomes. [Pediatr Ann. 2023;52(8):e297-e302.].

Common bile duct stones in infancy: a medical approach

Symptomatic choledocholithiasis in infancy is not common. It usually presents with jaundice and acholic stools and is diagnosed on abdominal ultrasonography. Favourable outcome of conservative management has been reported, but specific management guidelines are not well defined in the literature. We describe three cases using a combination of ursodeoxycholic acid and antibiotics as a treatment paradigm, which could potentially negate more invasive treatment. All three patients had ultrasonography proven choledocholithiasis with concomitant obstructive liver function test. They were treated with a combination of ursodeoxycolic acid and antibiotics. Patient 1 had an Escherichia coli urinary tract infection and was treated with oral bactrim. Intravenous amoxicillin, gentamicin and metronidazole were used for the other two patients. All three patients responded with a return to normal-coloured stools within 48 h of combination treatment. Repeat ultrasonography done within 11 days after the first study for all three patients confirmed complete resolution of choledocholithiasis. It is postulated that this improvement is as a result of a reduction in inflammation and oedema, associated with a low-grade cholangitis, following antibiotic treatment. This is coupled with improved bile flow with ursodeoxycholic acid therapy. The findings suggest the potential application of this safe, non-invasive therapeutic strategy as initial management in infants with this condition. A follow-up prospective randomised controlled trial may be an answer to prove the validity of this observation but due to the rarity of this problem, it would be a challenge to recruit sufficient number of patients.

Balloon sphincteroplasty in the management of choledocholithiasis in a 10-week-old infant

The management of common bile duct stones in neonates has not been clearly fully standardized, although percutaneous image-guided washing of the bile duct is generally adopted as the first-line treatment. We report the case of a 10-week-old infant with a choledocholithiasis in whom anterograde sphincter balloon dilation was achieved by combining image-guided access and flexible gastroduodenoscopy. This mini-invasive strategy may be an alternative to surgery in cases of impacted choledocholithiasis resistant to bile duct washing.

Choledocholithiasis in an infant of extremely low birthweight

A five-month-old infant of extremely low birthweight with choledocholithiasis is reported. A baby girl was delivered at 26 weeks gestation as a second twin, weighing 834 g. At 30 days of age, gallbladder stones were found by routine ultrasonography. She had vomiting at 157 days of age. Ultrasonography revealed calculi in the gallbladder and a dilated common bile duct. She was conservatively treated with scopolamine, antibiotics and dehydrocholic and ursodeoxycholic acids, and the calculi had disappeared by 189 days of age. Although conservative treatment succeeded in this patient, further cases should be analysed to establish how to manage choledocholithiasis in such small infants.

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.