Clinical presentations and predisposing factors of cholelithiasis and sludge in children

Diseases of bile duct in children

Several diseases originate from bile duct pathology. Despite studies on these diseases, certain etiologies of some of them still cannot be concluded. The most common disease of the bile duct in newborns is biliary atresia, whose prognosis varies according to the age of surgical correction. Other diseases such as Alagille syndrome, inspissated bile duct syndrome, and choledochal cysts are also time-sensitive because they can cause severe liver damage due to obstruction. The majority of these diseases present with cholestatic jaundice in the newborn or infant period, which is quite difficult to differentiate regarding clinical acumen and initial investigations. Intraoperative cholangiography is potentially necessary to make an accurate diagnosis, and further treatment will be performed synchronously or planned as findings suggest. This article provides a concise review of bile duct diseases, with interesting cases.

Are children with gallstone disease more overweight? Results of a matched case-control analysis

INTRODUCTION

Gallstone disease (GD) is increasingly common among children, possibly caused by an unhealthy food environment and the associated unhealthy lifestyle. In this study, we investigate the association between body weight and gallstone risk in a cohort of prospectively recruited children with GD.

METHODS

We analysed 188 children with gallstones (50.0% girls, median age 9.8 years) and 376 children without stones who were age- and gender-matched to cases in a ratio of 2:1. Cases were prospectively recruited at three Polish university centres (Warsaw, Katowice and Bialystok). Gallstones were diagnosed by either abdominal sonography or by a history of cholecystectomy. Matched controls without gallstones were selected from 22,412 children taking part in nationally representative Polish health surveys (OLA and OLAF studies) which provided height and weight data for randomly selected pre-school (2.5-6 years) and school aged (7-18 years) children and adolescents.

RESULTS

Analysis of the age- and gender-matched cases and controls demonstrated that patients with GD had significantly higher BMI (P = 0.02) and BMI z-score (P < 0.01) than children without stones. Children with gallstones were more frequently overweight (35.6%, P < 0.01) and obese (12.2%, P < 0.01) than controls (18.4% and 6.7%, respectively). Regression analyses showed that BMI, BMI z-score, overweight and obesity were all associated with increased GD risk (all P < 0.05).

CONCLUSIONS

Overweight and obesity are common in children with cholelithiasis. Given the epidemic of obesity in children we should expect an increasing prevalence of gallstones and stone-related complications in youths and in adults.

Treatment of asymptomatic gallstones in children with hereditary spherocytosis requiring splenectomy

BACKGROUND

Gallstones are common in hereditary spherocytosis (HS) and other chronic hemolytic diseases, with most affected patients being asymptomatic. Whether and how asymptomatic gallstones should be treated is controversial.

METHODS

We conducted a retrospective cohort study of pediatric patients with HS and asymptomatic gallstones to compare the clinical outcomes between the observation group (followed up with gallstones in situ) and the intervention group (cholecystectomy or cholecystolithotomy). The primary outcome was the composite of adverse outcomes, including gallstone-associated, gallbladder surgery-associated, and splenectomy-associated events. Secondary outcomes included the changes in the size and number of gallstones and the recurrence of gallstones.

RESULTS

Fifty-two patients were included (38 in the observation group and 14 in the intervention group), with a mean follow-up length of 5.2 years. Patients in the intervention group had a lower incidence of primary outcomes (7.1% vs. 42.1%) than patients in the observation group (OR, 0.12; 95%CI, 0.01-0.99). Patients with gallstones >5 mm in diameter had the highest risk of adverse events (47.4%). In the observation group, gallstone growth, disappearance, and stability were observed in 19.4%, 29.0%, and 51.6% of splenectomized HS patients, respectively. Small gallstones (diameter ≤5 mm) or sludge were more likely to be associated with disappearance (P = 0.04).

CONCLUSIONS

Most asymptomatic gallstones grow or persist in splenectomized HS patients for an extended period. Surgical treatment of asymptomatic gallstones in HS patients requiring splenectomy is associated with a lower risk of adverse outcomes.

LEVELS OF EVIDENCE

III (retrospective comparative study).

Post-cholecystectomy syndrome in pediatric patients: Occurrence and spectrum of symptoms

BACKGROUND

Post-cholecystectomy syndrome (PCS) refers to persistent or new abdominal symptoms after cholecystectomy. As there are very few reports on PCS in pediatric patients, we aimed to examine whether it was a frequent finding and which symptoms the affected children experienced.

METHOD

This is a retrospective cross sectional study of pediatric patients, who underwent cholecystectomy during 2003-2019 at Oslo University Hospital. The PedsQL™ gastrointestinal symptoms scale questionnaire and a self-designed questionnaire exploring satisfaction after surgery and current medical conditions were mailed to all eligible patients. Patient/parental consent and approval from the local data protection officer (19/09054) were obtained.

RESULTS

Questionnaires were sent to 82 patients of whom 44 (54%) answered. There were no significant demographic differences between the responders and the non responders. We identified 16 (36.7%) patients to have PCS. The most common symptoms were diarrhea (25%), bloating (16%), and heartburn/reflux (16%). Overweight was more common in patients with PCS (31%) than in patients without PCS (4%) (p = 0.014). Altogether 34/44 (77.3%) patients were satisfied with the result of the cholecystectomy; 92,6% of patients without PCS and 56.6% of those with PCS (p = 0.012).

CONCLUSION

PCS is not uncommon in pediatric patients, and they report a wide range of gastrointestinal symptoms. We identified overweight as a potential risk factor for developing PCS. Nonetheless, most patients got total relief of abdominal pain and were satisfied with outcome after cholecystectomy.

LEVEL OF EVIDENCE

Level 3.

Age- and sex-specific rates of gall bladder disease in children with sickle cell disease

BACKGROUND

Children with sickle cell disease (SCD) have an increased risk for gallstones due to chronic hyperbilirubinemia from hemolysis. Although gallstones are a known complication, there is variability in estimates of disease burden and uncertainty in the association between sex and gall bladder disease (GBD).

METHODS

This was a retrospective cohort study of children with SCD using administrative claims data (January 1, 2014-December 31, 2018). Population-averaged multivariable panel-data logistic regression models were used to evaluate the association between GBD clinical encounters (outcome) and two exposures (age and sex). Annual GBD risk was calculated using predictive margins, adjusting for disease severity, transfusion frequency, and hydroxyurea exposure.

RESULTS

A total of 13,745 individuals (of 21,487 possible) met inclusion criteria. The population was evenly split across sex (49.5% female) with predominantly Medicaid insurance (69%). A total of 946 individuals (6.9%) had GBD, 432 (3.1%) had a gallstone complication, and 487 (3.5%) underwent cholecystectomy. The annual risk of GBD rose nonlinearly from 1 to 5% between ages 1 and 19 years with no difference between males and females. Cholecystectomy occurred primarily in individuals with GBD (87%), and neither age nor sex was associated with cholecystectomy in this population. High disease severity (compared with low) more than doubled the annual risk of GBD at all ages.

CONCLUSIONS

GBD is associated with age but not sex in children with SCD. Neither age nor sex is associated with risk of cholecystectomy. High disease severity increases the rate of GBD at all ages.

Gallstones in patients with severe motor and intellectual disability

BACKGROUND

Asymptomatic gallbladder stones may be detected with ultrasound; some gallstones produce symptomatic diseases, such as cholecystitis, cholangitis, or pancreatitis. Identifying the clinical features of symptomatic gallstones may help prevent severe complications by providing intervention for asymptomatic gallstones. We aimed to investigate risk factors associated with developing symptomatic disease in pediatric patients with severe motor and intellectual disabilities (SMID).

METHODS

This retrospective study enrolled 30 patients with SMID who were treated at the Nara Medical University between March 2016 and March 2019. We examined the prevalence of gallstones, and the rate at which associated symptoms of gallstones were observed in patients. Furthermore, we compared the clinical features of patients with and without gallstones.

RESULTS

Among 30 patients with SMID, 7 (23%) had gallstones, with 6 (86%) of them being symptomatic: 3 patients had acute pancreatitis and 3 had cholecystitis or cholangitis. Among 23 patients without gallstones, 2 had acute pancreatitis and 2 had biliary sludge. Patients with gallstones had significantly lower daily calorie intake than those without gallstones (P = 0.042). Furthermore, the incidence of gallstones was higher in patients who received total parenteral nutrition than in those who did not (P = 0.031). Comparative analysis between symptomatic and asymptomatic patients was not performed because almost all cases were symptomatic.

CONCLUSION

Gallstones were detected in 23% of patients with SMID. The gallstones were symptomatic at a very high rate. Considering this fact, patients with SMID should be surveyed for gallstones; careful management may be needed in such patients.

Cholelithiasis in children and adolescents with sickle cell disease: Experience in a resource-limited setting

Background

Sickle cell disease (SCD) remains prevalent in Nigeria and can be complicated by cholelithiasis even in children. There is still a dearth of knowledge about the occurrence of cholelithiasis in these children. The present study is aimed to determine the prevalence of cholelithiasis in pediatric SCD in Lagos and documents relevant socio-demographic and clinical correlates.

Subjects and Methods

This was a cross-sectional study of children and adolescents aged 1-19 years with SCD attending the Paediatric Haematology Clinic of the Lagos University Teaching Hospital. One hundred and forty-seven children were consecutively recruited into the study over 3 months and they all had sonographic examination of the gall bladder. The association between cholelithiasis, sociodemographic data, clinical symptoms, laboratory parameters, and the use of hydroxyurea was also documented.

Results

The median age (range) of the study participants was 9.0 (1-19) years and majority were males (59.9%). The prevalence of cholelithiasis was 13.6% and the condition was most prevalent in adolescents (21.4%) compared to the younger children (6.5%). All the children with cholelithiasis were asymptomatic. Age and the frequency of crisis were significantly associated with cholelithiasis on multivariate analysis (P = 0.03, 0.045, respectively). The use of hydroxyurea was not significantly related to the occurrence of cholelithiasis.

Conclusion

The prevalence of cholelithiasis observed in this study is high. Routine screening of older children and adolescents with SCD, especially with the frequent crisis is suggested. Longitudinal studies to establish the relationship between hydroxyurea and cholelithiasis is also advocated.

Choledocholithiasis-a new clinical pathway

The incidence of cholecystectomy in children has increased considerably since the early 1990s. Management of gallbladder disease in children must include an awareness of choledocholithiasis treatment strategies. Both endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct exploration (open or laparoscopic) are accepted management techniques for choledocholithiasis. Laparoscopic cholecystectomy with preoperative or postoperative ERCP is at least a two-procedure process while cholecystectomy with laparoscopic common bile duct exploration (LCBDE) can provide definitive treatment in a single procedure under one anesthetic. Despite this, the trend over the last decade continues towards less LCBDE utilization in favor of ERCP. This trend has resulted in decreased familiarity with LCBDE by adult and pediatric surgeons and their trainees. Access to the necessary tools and education on the technical aspects can allow for successful single-stage treatment of choledocholithiasis by surgeons during laparoscopic cholecystectomy. This may include a pre-defined stepwise algorithm and understanding of all the equipment and resources necessary to perform a LCBDE. Ultimately, increased understanding of the equipment and procedural steps necessary for LCBDE will result in widened adoption of the technique and thus confer advantages to the patient such as decreased length of stay and fewer required anesthetics.

SYMPTOMATIC CHOLELITHIASIS AS THE PRESENTATION OF PEDIATRIC PRIMARY SCLEROSING CHOLANGITIS - CASE SERIES AND LITERATURE REVIEW

BACKGROUND

Primary sclerosing cholangitis (PSC) is a rare hepatobiliary disorder, whose etiology remains not fully elucidated. Given how rare PSC is in childhood, until the recent publication of a multicenter international collaboration, even data on its characteristics and natural history were scarce. Symptomatic cholelithiasis has not been previously reported as the presentation of PSC.

OBJECTIVE

The aim of this study was the diagnosis of PSC following the initial unusual presentation with symptomatic cholelithiasis, that followed an atypical clinical course that could not be explained by cholelithiasis alone. A literature review was also conducted.

METHODS

We conducted a retrospective chart review of three patients, who were diagnosed and/or followed at the Clinics Hospital, University of Campinas - Sao Paulo/ Brazil, between 2014 and 2020. Data analyzed included gender, age of presentation, past medical history, imaging findings, laboratory results, endoscopic evaluation, response to medical therapy and follow-up.

RESULTS

Age at time of presentation with cholelithiasis varied from 10 to 12 years. In two of the cases reported, a more subacute onset of symptoms preceded the episode of cholelithiasis. Two patients were managed with cholecystectomy, not followed by any surgical complications, one patient was managed conservatively. Percutaneous liver biopsy was performed in all three cases, showing histological findings compatible with PSC. Associated inflammatory bowel disease (IBD) was not seen in any of the patients. The patients have been followed for a mean time of 3.4 years.

CONCLUSION

PSC and cholelithiasis are both rare in the pediatric population. This study reports on symptomatic cholelithiasis as a presentation of PSC and raises the importance of suspecting an underlying hepatobiliary disorder in children with cholelithiasis without any known predisposing factors and/or that follow an atypical clinical course for cholelithiasis alone.

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.

Conjugated Hyperbilirubinemia in Infants: Is There Still a Role for ERCP?

Over a twenty-year period, we performed 255 ERCP procedures in infants aged up to 1 year. ERCP was indicated in cholestatic infants with suspicion of biliary obstruction. The most common diagnosis was biliary atresia (48%), choledochal cysts (13%), and choledocholithiasis (4%). The procedure complication rate was 13.7%. Hyperamylasemia occurred in 12.9%. More severe complications were rare-0.8% of ERCP procedure. There were no cases of postprocedural pancreatitis or death. Our study has proved that ERCP is a safe and reliable method in this age group. Its high specificity and negative predictive value for extrahepatic biliary atresia can prevent unnecessary surgeries in patients with normal bile ducts or endoscopically treatable pathologies.

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.

Gallstone Frequency in Children With Celiac Disease

Introduction

Celiac disease (CD) is a chronic autoimmune systemic disease caused by the T cell-driven immune mechanism, which is triggered by gluten in cereals such as wheat, barley, and rye in individuals who have a genetic predisposition. The purpose of the present study was to investigate the frequency of gallstones in children with CD.

Methods

A total of 120 patients who were diagnosed with CD and who were followed-up by the pediatric gastroenterology clinic of the hospital and 100 healthy children were included in the study. The age, gender, hemogram, biochemistry, and abdominal ultrasonography images of the patients were compared. Cases that had gallstones were evaluated in terms of fasting serum lipids, glucose-6-P dehydrogenase, and pyruvate kinase, osmotic fragility, hemoglobin electrophoresis, and peripheral smears. Cases diagnosed with a hematological or metabolic disease were excluded from the study. Celiac serology was examined in terms of CD diagnosis in cases who had gallstones for the first time.

Results

The median age of the patients with CD who were included in the study was eight years (5-12), and the median age of the control group was 10 years (6-13). A total of 48% of the Control Group was female, and 52% were male. No significant differences were detected between the age and gender distribution of the cases. There were no differences between hemogram and biochemical parameters. Gallstones were detected in six (5%) of CD-diagnosed cases, and in three (3%) of the cases in the control group. Two (2/160; 1.3%) of the patients who were referred to our clinic with the diagnosis of gallstones were diagnosed with CD.

Conclusions: Early diagnosis and treatment of CD is important to avoid gallstone development because a gluten-free diet corrects enteropathy significantly in CD. CD must be considered in cases with gallstones.

Choledochal cyst as an important risk factor for pediatric gallstones in low-incidence populations: A single-center review

BACKGROUND

Gallstones are uncommon in infants and children and Asian children are thought to have very low risk. Diagnoses have increased in recent years with the widespread use of ultrasonography (USG). This study aimed to review our experience with risk factors, complications, and treatment of pediatric gallstones in low-incidence populations.

METHODS

We retrospectively reviewed patients younger than 18 years old diagnosed with gallstones using USG between November 2006 and December 2012 in a tertiary referral hospital in Taiwan. Demographic information including age and sex, follow-up period, USG findings, predisposing factors, complications, treatment approaches and outcomes were recorded.

RESULTS

Ninety-eight children with gallstones diagnosed with USG were enrolled and reviewed in our study. Females comprised 55% of patients, with no specific gender tendency. No risk factor could be identified in 30.8% of patients. The most common risk factors were cephalosporin (CS) use, presence of a choledochal cyst (CC), and spherocytosis. CS use was not associated with a higher dissolution rate. The presence of type IVa CC implied a high rate of gallstone recurrence after Roux-en-Y hepaticojejunostomy. Complications were seen in 22.4% of patients, but only two needed emergency stone removal. Expectant management was performed in 61% of patients and 62.5% of them achieved spontaneous resolution; the stone dissolution rate was not lower than in the group treated with ursodeoxycholic acid (UDCA). Stone size was significantly decreased after UDCA use if resolution did not occur.

CONCLUSIONS

Pediatric gallstones showed high resolution rate, and the clinical course was largely benign. CS use was the most common risk factor and did not predict a higher dissolution rate. Type IVa CC was also an important risk factor associated with a high recurrence rate. Conservative treatment and oral UDCA may be reasonable strategies in most patients, unless complications are present.

Cholecystectomy is Feasible in Children with Small-Sized or Large Numbers of Gallstones and in Those with Persistent Symptoms Despite Medical Treatment

PURPOSE

We investigated the clinical features and factors affecting the choice of treatment modality and the course of pediatric gallstone (GS) disease.

METHODS

We retrospectively analyzed the medical records of 65 patients diagnosed with GS using imaging studies between January 2009 and December 2017 were included.

RESULTS

This study included 65 patients (33 boys and 32 girls; mean age, 8.5±5.3 years; range, 0.2-18 years) who primarily presented with abdominal pain (34%), jaundice (18%), and vomiting (8%). Idiopathic GS occurred in 36 patients (55.4%). The risk factors for GS included antibiotic use, obesity, hemolytic disease, and chemotherapy in 8 (12.3%), 7 (10.8%), 6 (9.2%), and 4 patients (6.2%), respectively. We observed multiple stones (including sandy stones) in 31 patients (47.7%), a single stone in 17 (26.2%), and several stones in 17 (26.2%). GS with a diameter of <5 mm occurred in 45 patients (69.2%). Comorbidities included hepatitis, choledocholithiasis, cholecystitis, and acute pancreatitis in 20 (30.8%), 11 (16.9%), 11 (16.9%), and 4 patients (6.2%), respectively. Ursodeoxycholic acid (UDCA) was administered to 54 patients (83.1%), leading to stone dissolution in 22 patients (33.8%) within 6 months. Cholecystectomy was performed in 18 patients (27.7%) (mean age, 11.9±5.1 years). Most patients treated surgically had multiple stones (83%) and stones measuring <5 mm in size (89%), and 66.7% of patients had cholesterol stones.

CONCLUSION

Cholecystectomy is feasible in patients with small-sized or large numbers of GS and those with persistent abdominal pain and/or jaundice. UDCA administration with close follow-up is recommended in patients with uncomplicated GS.

Gallstones in Egyptian infants and children: risk factors, complications and outcome: a single center experience

Background

The widespread use of abdominal ultrasonography in children documented increased detection rate of gallstones. The aim of this study was to assess the possible risk factors of gallstones and to detect the complication rate and outcome of the disease in Egyptian infants and children from a hepatologist perspective. This prospective study included 35 cases, with ultrasound-detected gallstones, who presented to the Pediatric Hepatology Unit from July 2015 to October 2017. All patients were initially evaluated by full history, general and abdominal examination, laboratory assessment, and ultrasound findings to detect possible risk factors of gallstones. Management approach was individualized for each patient according to his/her condition, and the patients were followed up at 3 months interval.

Results

The patients’ ages ranged from 3.5 months up to 17 years. The median age of gallstone detection was 2 years. Gallstones were symptomatic in 62.9% with abdominal pain in 51.4%. Complications in the form of choledocholithiasis were detected in 7 patients (20%). Laparoscopic cholecystectomy was done for 7 patients while conservative management was applied for 24 patients. Complete resolution occurred in 8.3% and partial resolution in 33.3%. Chronic hemolytic anemia was the most commonly identified risk factor for gallstones. Patients needed surgical intervention had significant higher serum cholesterol and LDL levels (P = 0.006 and P = 0.002 respectively).

Conclusion

Risk factors for gallstones could be identified in most of pediatric cases. Symptomatic presentation is common among the pediatric population. Conservative management is recommended for asymptomatic cases of gallstones in children. Laparoscopic cholecystectomy is a safe and recommended procedure for complicated and symptomatic cases of gallstones.

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.

Trends in the epidemiology of pediatric acute and chronic cholecystitis-related admissions in the USA: a nationwide emergency department and inpatient sample study

Acute and chronic cholecystitis can be related to gallstone disease, although in childhood acalculous cholecystitis may be the most frequent form. Chronic acalculous cholecystitis is a subtype of pediatric chronic abdominal pain. The overall incidence of cholecystitis in children appears to be increasing. Studies suggest a widely variable but predominant female, Caucasian and late adolescent preponderance to the affected population. The Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP), a national emergency department, pediatric and adult inpatient admission coding-based database was accessed for the population-weighted demographic characteristics related to documented principal diagnoses (International Classification of Diseases, Ninth Revision, Clinical Modification) of acute and chronic cholecystitis; pediatric and adult age range 2006–2012 (emergency department), 1997–2012 (inpatient service). ED-derived data show pediatric admissions at the smallest age category (1%), averaging 3.7/100 000 persons; discharges were highest in the 15–17 age range. Inpatient admission was more likely in older (93% >10 years), female (F:M 3.7:1) children, and patients from lower median household income residences. Over the study period, there was a significant relative increase in males. Mean length of inpatient stay was 3.2 days, tended to be shorter in female and older patients; this pattern was reflected in the overall hospital charges which rose threefold over the study period (1997–2012). Our study establishes the gender distribution of cholecystitis-related diagnoses and as yet poorly understood admission discrepancies based on gender and socioeconomic status. Length of admission has overall decreased but costs have risen threefold over the study period.

"Rendezvous" Procedure in Children with Cholecysto-Choledocholithiasis

Introduction: Cholecysto-choledocolithiasis is a rare entity in children and its management is still challenging and controversial. The laparoendoscopic rendezvous (LERV) procedure, consisting of laparoscopic cholecystectomy and simultaneous endoscopic retrograde cholangiopancreatography for the management of symptomatic choledocholithiasis is well described in adult patients. However, in the literature, few reports about its application in the pediatric population have been recorded. Aim of the Study: The aim of the present study is to report our first successful cases of symptomatic cholecysto-choledocholithiasis LERV treatment. Methods: Two girls suffering of hemolytic disease presented to our third referral center with acute abdominal pain due to cholecysto-choledocholithiasis. Preoperative, perioperative, and postoperative data were retrospectively reviewed. Results: Surgery was performed without complications. The girls were dismissed once re-alimentation and re-canalization were achieved and had no other episodes of biliary cholic. Reported advantages of LERV include: a shorter in-hospital stay, a reduction in the number of procedures and anesthesia, and a reduced overall risk of complications. Conclusions: The promising result with our 2 cases suggest that, when performed in highly specialized centers, LERV is a safe procedure, which leads to considerable benefits, despite logistic and organizational difficulties.

Biliary Tract Disease in Girls and Young Women With Rett Syndrome

OBJECTIVE

We reviewed medical records and conducted a nationwide survey to characterize the clinical features and determine the prevalence of biliary tract disease in girls and women with Rett syndrome (RTT).

METHODS

Sixty-two individuals with RTT and biliary tract disease were identified from the membership of Rett Syndrome Organization and patient files of the principal investigator. Medical records of 46 individuals were reviewed for presenting features, diagnostic tests, and treatment outcomes of biliary tract disease. We designed a questionnaire that probed the frequency of risk factors and treatment outcomes of biliary tract disease in RTT. The questionnaire was completed by 271 parents whose daughters met the clinical criteria for RTT and/or had MECP2 mutations and participated in the Natural History of Rett Syndrome Study.

RESULTS

Presenting symptoms identified by record review included abdominal pain (94%), irritability (88%), weight loss (64%), and vomiting (52%). Biliary dyskinesia, cholecystitis, and cholelithiasis were identified in 90%, 77%, and 70%, respectively, by cholescintigraphy, surgical pathology, and abdominal ultrasound. The prevalence of biliary tract disease was 4.4% (n = 12) in the RTT cohort. Risk factors included older age (P < 0.001) and a positive family history (P < 0.01). Diagnoses included cholecystitis (n = 5), biliary dyskinesia (n = 6), and cholelithiasis (n = 7). Ten individuals underwent surgery; 7 had resolution of symptoms after surgical intervention.

CONCLUSIONS

Biliary tract disease is not unique to RTT, but may be under-recognized because of the cognitive impairment of affected individuals. Early diagnostic evaluation and intervention may improve the health and quality of life of individuals affected with RTT and biliary tract disease.

Standardization of common bile duct size using ultrasound in pediatric patients

BACKGROUND/PURPOSE

The incidence of choledocholithiasis is increasing. The diagnosis of common bile duct (CBD) obstruction is based on abnormal CBD size. Establishing norms for CBD size in children would improve diagnostic accuracy. We analyzed ultrasounds (US) to determine normal pediatric CBD size based on age and then validated this against patients with choledocholithiasis.

METHODS

A retrospective review was conducted for children less than 21 years of age with US defined CBD size. Patients were stratified into age groups by ANOVA statistical analysis. Secondary analysis included patients with confirmed choledocholithiasis in comparison to the normal cohort.

RESULTS

A total of 778 patients had US without pathology. Group 1 (<1 year) had a mean CBD of 1.24±0.54 mm, group 2 (1-10 years) 1.97±0.71 mm, and group 3 (>10 years) 2.98±1.17 mm, p<0.05. Fourteen additional patients were found to have choledocholithiasis with a mean CBD size of 8.1 mm. All patients with choledocholithiasis had CBD sizes outside of our normal range, but only 50% of patients had enlarged CBD size based on adult normal range of values.

CONCLUSION

Normal CBD size in children is less than a normal adult patient. More accurate normal values will aid in determining if a child needs further evaluation for possible obstruction of the CBD.

TYPE OF STUDY

diagnostic Level of evidence: III.

Adolescent gallstones-need for early intervention in symptomatic idiopathic gallstones

BACKGROUND AND AIM

Currently, there is a paucity of the literature describing the natural history of cholelithiasis (CL) and choledocholithiasis (CDL) in adolescent children. This study aims to analyse the changing demographics of paediatric and adolescent gallstones.

METHODOLOGY

Retrospective review of all children (Age 0-18 years) presenting with symptomatic gallstones over the last 15 years (2002-2017) at a single tertiary institution. Demographics, diagnostic and therapeutic information were collected, with a 5-year median follow-up. Statistics were accomplished by Chi-squared analysis of trend and Student t test.

RESULTS AND DISCUSSIONS

188 children were seen with symptomatic CL. In the 0-11-year-old group, there were 13 females and 16 males (0.8: female to male ratio). There were 130 females and 29 males in the 12-18-year-old group (4.5:1 female to male ratio). The mean weight at presentation was 81.78 kg and the median age was 16 years. Idiopathic gallstones were found in 131 patients (82%). 137 required cholecystectomy (86%) and ERCP was required in 32 patients (20%). 48 adolescents (30.2%) with gallstones had an associated CDL, compared to six children (20%). All of the adolescent patients with CDL had idiopathic gallstones. Gallstone pancreatitis was noted in eighteen adolescents (11%) and one child (3%). We analysed the ideal time to operate on adolescent patients with symptomatic gallstones using the relationship between the length of delay from initial diagnosis to definitive management of CDL and incidence of complications. The analysis demonstrated that for every 10 days treatment was delayed, the risk of subsequent presentations with a symptomatic episode was increased by 5% (p = 0.0004).

CONCLUSION

The current trend of gallstones in adolescent children seems to be a disease primarily of adolescent girls. Symptomatic idiopathic gallstones in adolescents are associated with high rates of common bile duct obstruction and pancreatitis and consequently warrant an early cholecystectomy for all adolescents.

LEVEL OF EVIDENCE

Level IV Treatment Study.

Ultrasound findings in paediatric cholestasis: how to image the patient and what to look for

Paediatric biliary tract and gallbladder diseases include a variety of entities with a wide range of clinical presentations. Cholestasis represents an impaired secretion of bilirubin by hepatocytes, manifesting with high blood levels of conjugated bilirubin and jaundice. Various causes may be involved, which can be recognised analysing blood tests and hepatobiliary imaging, while sometimes liver biopsy or surgery may be necessary. High-resolution real-time ultrasonography is an important tool for differentiation of obstructive and non-obstructive causes of jaundice in infants and children. In this paper, we briefly review the normal anatomy and the ultrasound aspects of main pathologies affecting gallbladder and biliary tree in neonatal and paediatric age.

Risk Factors of Cholelithiasis Unrelated to Hematological Disorders in Pediatric Patients Undergoing Cholecystectomy

Background

Pediatric cholelithiasis unrelated to hematological disorders is an increasing disease. We analyzed our experience in the surgical treatment of these cases to evaluate risk factors, clinical presentation, intervention and follow-up.

Methods

From January 2010 to December 2016, we retrospectively recorded all data (hematological study, familiarity, use of lithogenic drugs and parenteral nutrition) of cholecystectomies for cholelithiasis not related to hematological diseases. The body mass index (BMI) was calculated (obesity if > 25), medical treatment, surgery and follow-up were evaluated. All patients underwent ultrasound for diagnosis and major biliary tract assessment prior to surgery. All patients had a 1-year follow-up.

Results

There were twenty-four cases (eight males), with a median age of 11.2 years. Predisposing factors were familiarity in 19, use of lithogenic drugs in 5 and total parental nutrition (TPN) in 3. Median BMI was 19.8 kg/m², with BMI > 25 kg/m² in eight cases. Regarding the clinical presentation, 14 had acute pain in the right upper quadrant, 5 had cholecystitis and 5 had non-specific abdominal pain. The medical treatment lasted 6 months in all, except for five (three operated after 2 months and two after 12 months). Preoperative ultrasound did not show stones in the biliary tract. MRI was performed in three cases for suspected malformation of the biliary tract (negative). Laparoscopic cholecystectomy was performed in all cases: mean intervention time was 95 min. A case of postcolecystectomy syndrome was found. At follow-up, all were asymptomatic, except two (recurrent abdominal pain).

Conclusion

Main predisposing factors are familiarity and obesity. Preoperative ultrasound in our series replaced the intraoperative study of the biliary tract. Laparoscopic cholecystectomy is the gold standard.

A newborn with combined pituitary hormone deficiency developing shock and sludge

A male neonate was born at 41 weeks of gestation with a birth weight of 3320 g. Artificial respiratory management was required due to respiratory disturbance 1 h after birth, and subsequently catecholamine-refractory low cardiac output-induced shock occurred. Severe combined pituitary hormone deficiency (CPHD) was considered based on the presence of his respiratory disturbance, hypoglycemia and micropenis. After hydrocortisone (HDC) administration, circulatory dynamics rapidly improved. Brain magnetic resonance imaging (MRI) showed aplasia of the anterior pituitary gland and ectopic posterior gland. γ-Glutamyltranspeptidase (γ-GTP) increased from day 10 after birth and direct bilirubin increased from day 18. On ultrasonography, sludge filling the common bile duct and gall bladder was observed. After initiating treatment with both ursodeoxycholic acid and recombinant human growth hormone (rhGH), cholestasis improved and the sludge disappeared at 3 months after birth. In newborns with CPHD, severe central adrenal insufficiency might induce cardiogenic shock after birth. Early diagnosis and intervention are necessary.

Optimal timing of cholecystectomy in children with gallstone pancreatitis

BACKGROUND

Little data exist regarding the recurrence of pancreatitis in pediatric patients with gallstone pancreatitis awaiting cholecystectomy. This study evaluates the recurrence rate of pancreatitis after acute gallstone pancreatitis based on the timing of cholecystectomy in pediatric patients.

MATERIALS AND METHODS

A retrospective chart review of all patients admitted with gallstone pancreatitis from 2007 to 2015 was performed. Children were divided into the following five groups. Group 1 had surgery during the index admission. Group 2 had surgery within 2 wk of discharge. Group 3 had surgery between 2 and 6 wk postdischarge. Group 4 had surgery 6 wk after discharge, and group 5 patients had no surgery. The recurrence rates of pancreatitis were calculated for all groups.

RESULTS

Forty-eight patients with gallstone pancreatitis were identified in this study. The 19 patients in group 1 had no recurrence of their pancreatitis. Of the remaining 29 patients, nine (31%) had recurrence of pancreatitis or required readmission for abdominal pain prior to their cholecystectomy. In group 2, two of the eight patients (25%) had recurrent pancreatitis. In group 3, three of eight patients (37.5%) developed recurrent pancreatitis. In group 4, three of five patients (60%), and in group 5, one of eight. No children in group 5 had demonstrable gallstones at presentation, only sludge in their gallbladder.

CONCLUSIONS

Cholecystectomy during the index admission is associated with no recurrence or readmission for pancreatitis. Therefore, we recommend that cholecystectomy be performed after resolution of an episode of gallstone pancreatitis during index admission.

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.

Cholelithiasis in children with CHD: is it a problem?

BACKGROUND

An association of heart disease and its treatment with biliary calculi is popularly accepted. We sought determine the prevalence and risk factors of paediatric gallstone disease in the presence of CHD and analyse the treatment options. We evaluated the role of open-heart surgery in the development of gallstones in patients with CHD. Patients and methods In a 10-year, retrospective, chart review (2005-2014), patients with CHD and cholelithiasis were identified and reviewed.

RESULTS

In all, 19 of 4729 children with CHD had cholelithiasis (0.4%); eight patients underwent cardiac surgery before diagnosis of cholelithiasis (group 1), whereas 11 of them had not (group 2). The prevalence was 0.3% in group 1 and 0.5% in group 2. In nine asymptomatic patients, gallstones were found incidentally. Children with cholecystolithiasis (n=17) received ursodeoxycholic acid. A resolution of gallstones was found in four cases; two patients underwent biliary surgery, and the others (15/17) were successfully managed non-operatively.

CONCLUSION

Despite an accumulation of risk factors, prevalence of gallstones is not as high as expected in children with CHD. Open-heart surgery with a heart-lung machine plays a minor role as an aetiological factor. In about half of the cases, cholelithiasis is an incidental finding and patients stay asymptomatic. Prophylactic administration of ursodeoxycholic acid is not indicated in children undergoing open-heart surgery for CHDs. Biliary surgery is reserved for patients with recurrent symptoms or cholestasis. In children with CHD, cholelithiasis is a minor and manageable co-morbid condition.

Pediatric cholecystectomy for symptomatic gallstones unrelated to hematologic disorder

BACKGROUNDS/AIMS

Gallstones are being increasingly diagnosed in pediatric patients. The purpose of this study was to determine characteristics of pediatric patients who underwent cholecystectomy because of symptomatic gallstone disease unrelated to hemolytic disorder.

METHODS

We reviewed cases of pediatric patients (under 18 years old) who underwent cholecystectomy between May 2005 and December 2015.

RESULTS

A total 20 pediatric patients (under 18 years old) underwent cholecystectomy during the study period. One patient was excluded because cholecystectomy was performed due to gall stones caused by hemolytic anemia. The 19 cases comprised 9 male (47.3%) and 10 female (52.7%) subjects. The mean age was 14.9 years (range, 5-18), and 66.7% of patients were older than 12 years of age. Mean body weight was 65.0 kg (range, 13.9-93.3), and mean body mass index was 21.7 kg/m² (range, 12.3-35.1), with 26.37% of patients being overweight. All 19 patients underwent laparoscopic cholecystectomy. There were no postoperative complications and no mortality. Comparison between overweight and non-overweight patients indicated that significantly more overweight patients had cholesterol stones (5/5 vs. 7/14, p=0.036) and were classified as complicated disease (3/5 vs. 1/14, p=0.037).

CONCLUSIONS

The more frequent occurrence of complications such as choledocholithiasis or gallstone pancreatitis, in overweight patients indicates the need for more careful evaluation and management in these patients. Pediatricians and surgeons should always consider gallstone disease in pediatric patients despite difficulty in suspecting symptomatic gallstones in cases who present with abdominal pain that is rarely clear-cut.

Gallstones in childhood: etiology, clinical features, and prognosis

AIM

The aim of this study was to determine demographic and clinical features in children diagnosed with gallstones, risk factors for gallstone formation, the effectiveness of ursodeoxycholic acid therapy, and the course of the disease.

MATERIALS AND METHODS

Patients aged 0-18 years were followed up for at least 6 months after the diagnosis of gallstones with ultrasonography and were evaluated retrospectively. Patients were evaluated with respect to age, sex, presenting symptoms, BMI, facilitating factors, accompanying diseases, family history of gallstones, history of ceftriaxone use, laboratory tests, ultrasonography findings and follow-up, and therapeutic approaches and results.

RESULTS

The study was completed with 70 patients. Thirty-nine (55.7%) patients were females. The mean age of the patients was 9.3±5.29 (0.3-18) years. The mean age among females was statistically significantly higher than that among males (P=0.007).No risk factor for stone formation was encountered in 50% of cases, whereas a family history of gallstones was present in 17.1%. Use of ceftriaxone was present in 8.6% of cases, total parenteral nutrition in 10%, obesity in 5.7%, hereditary spherocytosis in 4.3%, and Down's syndrome in 4.3%. The probability of dissolution of stones was 3.6 times higher in patients with stone sizes up to 5 mm [odds ratio (OR): 3.65, P=0.020], 3.9 times higher in those aged younger than 2 years (OR: 3.92, P=0.021), and 13.9 times higher in those with a single stone (OR: 13.97, P=0.003).

CONCLUSION

Our findings show that unknown causes are still prevalent in stone formation and that ursodeoxycholic acid exerts no effect on stone dissolution; however, diagnosis at younger than 2 years of age, a single stone, and small size of stone are factors affecting dissolution.

Neonatal Gallstones Serendipitously Discovered by Point-of-Care Ultrasound in the Pediatric Emergency Department

Cholelithiasis in children was once thought to be uncommon, but the prevalence has increased in recent years. We present a case of a 3-month-old infant brought to the pediatric emergency department for vomiting and increased fussiness. A point-of-care ultrasound was performed to rule out pyloric stenosis but revealed multiple stones within the gallbladder. Ultrasound findings and a review of technique for ultrasound of the gallbladder are presented.

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.

Ultrasonography: Applications in Pediatric Abdomen

Ultrasonography (US) is a valuable imaging tool for evaluation of different clinical conditions in children, in general and abdominal conditions, in particular. The interest in US derives primarily from the lack of ionizing radiation exposure, low cost, portability, real-time imaging and Doppler capabilities. In addition, US application requires no preparation or sedation, making it particularly attractive in the pediatric population. Because of these advantages, US has been adopted as the primary imaging tool for evaluation of a number of pediatric abdominal conditions that would have involved the use of ionising radiation in the past, e.g., pyloric stenosis, intussusception and various renal and bladder abnormalities, to name a few. Certain limitations, however, are inherent to US including large body habitus, excessive bowel gas, postoperative state and the learning curve. In addition, pediatric US is particularly challenging as the children are frequently unable to co-operate for breath holding and many of them are crying during the scanning. In the present review, the authors discuss the various applications of US in the evaluation of pediatric abdomen.

The increasing incidence of gallbladder disease in children: A 20year perspective

OBJECTIVE

The incidence of cholecystectomy in the pediatric population has increased over the last 20years but has not been described in a Canadian population. We conducted the first province-wide study to describe the incidence of cholecystectomy in children in Ontario.

STUDY DESIGN

A population-based, retrospective cohort using administrative databases in Ontario, Canada, was conducted. We included patients less than 18years of age who underwent cholecystectomy from 1993 to 2012. Trends in rates of cholecystectomy were assessed with the Cochrane-Armitage test.

RESULTS

There were a total of 6040 pediatric cholecystectomies performed over the study period in Ontario. The mean age was 14.3years, and 79.6% of patients were females. The crude incidence per 100,000 person-years increased from 8.8 to 13.0 (p<0.001) from 1993 96-2009-12, respectively. The sex-specific incidence showed a larger increase in the female population from 14.7 to 21.1 per 100,000 person-years (p<0.001). The vast majority (82%) of surgeries were performed in 13-17year olds and were largely performed in the community (>75%).

CONCLUSIONS

There has been a significant rise in the incidence of pediatric cholecystectomy in Ontario over the last 20years. The majority of surgeries are performed in the community, and pediatricians will likely see an increase of gallbladder disease in practice.

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.

Pediatric Cholecystectomy: Clinical Significance of Cases Unrelated to Hematologic Disorders

PURPOSE

Cholecystectomy is rarely performed in the child and adolescent. However, it is associated with several conditions. This study was conducted to describe the characteristics of pediatric patient who underwent cholecystectomy unrelated to hematologic disorders, and then to suggest its clinical significance in management by comparing a simple and complicated gallbladder disease.

METHODS

We reviewed cases of cholecystectomy in pediatric patients (under 18 years old) at a single institution between January 2003 and October 2014. There were 143 cases during the study period and 24 were selected as the subject group.

RESULTS

There were 7 male (29.2%) and 17 female (70.8%) patients. The mean age was 13.1 years old, and 66.6% of patients were older than 12 years. Mean body weight was 52.7 kg, and body mass index was 21.7 kg/m(2), with 41.7% of patients being overweight or obese. We could identify a female predominance and high proportion of overweight or obesity in a complicated disease. There were also significantly increased levels of aspartate transaminase (AST), alanine transaminase (ALT), alkaline phosphatase (ALP) and bilirubin in this group. Most patients (87.5%) underwent laparoscopic cholecystectomy.

CONCLUSION

Cholecystectomy for diseases unrelated to hematologic disorders is rarely performed in the child and adolescent. In general, female patients who are overweight or obese, and those older than 12 years old, require laparoscopic cholecystectomy owing to multiple gallstones. This condition has a tendency to show a complicated gallbladder disease and significantly increased levels of AST, ALT, ALP, and bilirubin.

Prevalence, clinical investigation, and management of gallbladder disease in Rett syndrome

AIM

This study determined the prevalence of cholelithiasis and/or cholecystectomy in Rett syndrome, described gallbladder function in a clinical cohort, and identified recommendations for assessment and management of gallbladder disease.

METHOD

The incidence of cholelithiasis/cholecystectomy was estimated from data describing 270 and 681 individuals with a pathogenic MECP2 mutation in the Australian Rett Syndrome Database and the International Rett Syndrome Phenotype Database respectively. Gallbladder function in 25 females (mean age 16y 5mo, SD 20y 7mo, range 3y 5mo-47y 10mo) with Rett syndrome (RTT) was evaluated with clinical assessment and ultrasound of the gallbladder. The Delphi technique was used to develop assessment and treatment recommendations.

RESULTS

The incidence rate for cholelithiasis and/or cholecystectomy was 2.3 (95% confidence interval [CI] 1.1-4.2) and 1.8 (95% CI 1.0-3.0) per 1000 person-years in the Australian and International Databases respectively. The mean contractility index of the gallbladder for the clinical sample was 46.5% (SD 38.3%), smaller than for healthy individuals but similar to children with Down syndrome, despite no clinical symptoms. After excluding gastroesophageal reflux, gallbladder disease should be considered as a cause of abdominal pain in RTT and cholecystectomy recommended if symptomatic.

INTERPRETATION

Gallbladder disease is relatively common in RTT and should be considered in the differential diagnosis of abdominal pain in RTT.

Biliary dyskinesia and symptomatic gallstone disease in children: two sides of the same coin?

BACKGROUND

Despite lack of consensus criteria, biliary dyskinesia (BD) is an increasingly accepted pediatric diagnosis.

AIMS

We compared patient characteristics, outcomes, and resource utilization (before and after surgery) between children with BD and symptomatic cholecystolithiasis (LITH).

METHODS

Data from the electronic medical record were abstracted for children diagnosed with BD or LITH between December 1, 2002, and November 30, 2012, at Children's Hospital of Pittsburgh.

RESULTS

Four hundred and ten patients were identified (BD: 213 patients, LITH: 197 patients). Patients with BD had significantly lower BMI, longer symptom duration, more dyspeptic symptoms, and were more likely to present with other symptoms. Forty-one patients (13.8%) with BD underwent cholecystectomy despite a normal gallbladder ejection fraction (GB-EF). In 32 of these, sincalide triggered pain compared to 75 of the 155 patients with low GB-EF. After surgery, patients with BD more commonly visited gastroenterology clinics and had more GI-related hospitalizations, while emergency room visits decreased in both groups. Only the nature of biliary disease independently predicted continuing pain after surgery, which in turn was the best predictor for higher resource utilization after cholecystectomy.

CONCLUSIONS

A large percentage of children with BD did not meet the adult diagnostic standards. Compared to those with LITH, children with BD have more widespread symptoms and continue to use more clinical resources after surgery. These findings suggest that despite its benign prognosis, BD is increasingly treated like other potentially acute gallbladder diseases, although it has the typical phenotype of FGIDs and should be treated using approaches used in such disorders.

Paediatric ultrasonography of the liver, hepatobiliary tract and pancreas

In the field of paediatric radiology ultrasonography (US) is the most versatile imaging tool available. Children in general, by virtue of their body composition, are excellent candidates for US exams in whom abdominal anatomy and pathology can be visualised in great detail. The fact that during the US study a clinical history can be obtained strongly adds to the value of the US exam. This does require investment in time and expertise and ideally a paediatric radiologist performing the exam. In this review the role of ultrasonography (US) of the liver, biliary tract and pancreas in children is discussed.

Biliary dyskinesia in pediatrics

Biliary dyskinesia (BD) is a diagnosis that is being made increasingly in children. It is defined by abdominal pain thought to be biliary in nature based on location and character; a completely normal gallbladder on imaging tests, typically ultrasound; and decreased gallbladder contraction in response to a pharmacological stimulus. Unlike other functional gastrointestinal disorders (FGIDs) that are treated with medications, behavioral therapy, and/or dietary modification, current clinical practice has accepted cholecystectomy as the treatment of choice for BD, which now accounts for up to 50% of cholecystectomies in children. Although well-designed trials are missing, accumulating evidence argues against such an approach. First, BD is by definition a benign disorder without risk of truly relevant complications. Second, despite reportedly high rates of satisfaction with postoperative outcomes, most children continue to experience symptoms. Lastly, limited long-term studies have demonstrated comparable benefit of operative and conservative therapy. To summarize, BD should be seen as a more localized manifestation of functional abdominal pain, which may improve over time independent of the type of therapy chosen. Despite the widespread adoption of minimally invasive surgery in pediatrics, a different risk-benefit ratio favors conservative treatment for this benign disorder.

Cholecystectomy in Danish children--a nationwide study

BACKGROUND

An increase in the frequency of cholecystectomy in children has been described during the last decades. Part of the reason is that more cholecystectomies in children are performed for dyskinesia of the gallbladder and not only for gallstone disease. We conducted the first nationwide study to describe outcome of cholecystectomies performed in children in Denmark by using data from the national Danish Cholecystectomy Database (DCD).

METHODS

In the DCD, two data sources were combined: administrative data from the National Patient Registry (NPR) and clinical data entered into the secure Web site by the surgeon immediately after the operation. In the present analysis, we have included children ≤ 15 years from the five year period January 1, 2006, to December 31, 2010.

RESULTS

In the study period 35,444 patients were operated with a cholecystectomy. Of these, 196 (0.5%) were ≤ 15 years. The median age was 14 years, and 82% were girls. Predisposing medical factors for gallstones (despite obesity) were found in only 5%. More than 50% were overweight, and one third were obese. Ninety-seven percent of the operations were completed laparoscopically, and the conversion rate was 0. 5%. Nearly half of the operations (45%) were performed as same day surgery, and 80% of the children stayed in hospital 0-1 day without readmission. 91% were discharged within 3 days and not readmitted. Morbidity was low, and no bile duct lesions occurred. The 30 day mortality was zero.

CONCLUSION

Our nationwide outcome results indicate good quality with 91% of the patients discharged within 3 days without readmission, no bile duct injuries, and no mortality. All patients except two were operated for symptomatic gallstone disease in accordance to the Danish national guidelines. We have not experienced a demand or a need to expand the indications for cholecystectomy beyond gallstone disease.

An unusual case of an icteric infant with abdominal distention

BACKGROUND

Jaundiced infants are uncommon in most emergency departments (EDs). Biliary rupture remains one of the more rare and less described causes of this condition.

CASE REPORT

A 5-month-old male presented to our ED with scleral icterus, increasing abdominal distention, and increased irritability. A bedside ultrasound revealed a moderate amount of ascites and further imaging suggested he had a rupture of his common bile duct. Surgical exploration confirmed this and revealed the presence of choledocholithiasis, which was the likely cause of the rupture. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Biliary rupture remains a rare but serious condition in very young patients. Emergency physicians should consider bedside ultrasound as an adjunct in undifferentiated abdominal distention or jaundice in this patient population.