Chronic Acalculous Cholecystitis in Children With Biliary Symptoms: Usefulness of Hepatocholescintigraphy

Evaluation and Management of Biliary Dyskinesia in Children and Adolescents: A Systematic Review From the APSA Outcomes and Evidence-Based Committee

INTRODUCTION

The diagnosis and management of biliary dyskinesia in children and adolescents remains variable and controversial. The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee (APSA OEBP) performed a systematic review of the literature to develop evidence-based recommendations.

METHODS

Through an iterative process, the membership of the APSA OEBP developed five a priori questions focused on diagnostic criteria, indications for cholecystectomy, short and long-term outcomes, predictors of success/benefit, and outcomes of medical management. A systematic review was conducted, and articles were selected for review following Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. Risk of bias was assessed using Methodologic Index for Non-Randomized Studies (MINORS) criteria. The Oxford Levels of Evidence and Grades of Recommendation were utilized.

RESULTS

The diagnostic criteria for biliary dyskinesia in children and adolescents are not clearly defined. Cholecystectomy may provide long-term partial or complete relief in some patients; however, there are no reliable predictors of symptom relief. Some patients may experience resolution of symptoms with non-operative management.

CONCLUSIONS

Pediatric biliary dyskinesia remains an ill-defined clinical entity. Pediatric-specific guidelines are necessary to better characterize the condition, guide work-up, and provide management recommendations. Prospective studies are necessary to more reliably identify patients who may benefit from cholecystectomy.

LEVEL OF EVIDENCE

Level 3-4.

TYPE OF STUDY

Systematic Review of Level 3-4 Studies.

HAV-induced acalculous cholecystitis: A case report and literature review

Hepatitis A virus (HAV) has some life-threatening extrahepatic complications, such as acute acalculous cholecystitis (AAC). We present HAV-induced AAC in a young female, based on clinical, laboratory, and imaging findings, and conduct a literature review. The patient became irritable, which progressed to lethargy, as well as a significant decline in liver function, indicating acute liver failure (ALF). She was immediately managed in the intensive care unit with close airway and hemodynamic monitoring after being diagnosed with ALF (ICU). The patient's condition was improving, despite only close monitoring and supportive treatment with ursodeoxycholic acid (UDCA) and N-acetyl cysteine (NAC).

Celiac Disease and Gallbladder: Pathophysiological Aspects and Clinical Issues

Background: Celiac Disease (CD) is an immune-mediated disorder which primarily affects the small intestine; however, extra-intestinal organs are often affected by the pathological process, too. As regards the digestive system, liver alterations in CD patients have been widely described, which can also extend to the biliary tract. Notably, gallbladder function can be altered in CD patients. In this review, we specifically analyze and summarize the main pathophysiological aspects and clinical evidence of gallbladder dysfunction in CD patients, in order to discuss the potential medical complications and clinical research gaps. In addition to some perturbations of bile composition, CD patients can develop gallbladder dysmotility, which mainly expresses with an impaired emptying during the digestive phase. The main pathophysiological determinant is a perturbation of cholecystokinin secretion by the specific duodenal enteroendocrine cells in response to the appropriate nutrient stimulation in CD patients. This situation appears to be reversible with a gluten-free diet in most cases. Despite this gallbladder impairment, CD patients do not seem to be more predisposed to gallbladder complications, such as calculous and acalculous cholecystitis. However, very few clinical studies have actively investigated these clinical aspects, which may not be completely evidenced so far; alternatively, the substantial improvements in the last two decades regarding CD diagnosis, which have reduced the diagnostic delay (and related dietary treatment), may have lessened the potential clinical consequences of CD-related gallbladder dysfunction. Specific clinical studies focused on these aspects are needed for a better understanding of the clinical implications of gallbladder alterations in CD patients.

Acute acalculous cholecystitis caused by gallbladder metastasis due to the peritoneal dissemination of gastric cancer: A case report

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Acute acalculous cholecystitis is rare, but life threatening disease.

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Metastasis to the gallbladder is infrequent.

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Acute acalculous cholecystitis caused by peritoneal dissemination of gastric cancer is rare and immediate treatment is essential.

Introduction and importance

Acute acalculous cholecystitis (AAC) is associated with a high mortality rate. AAC caused by metastasis to the gallbladder is rare. We report a case of AAC caused by gallbladder metastasis due to the peritoneal dissemination of gastric cancer.

Case presentation

An 84-year-old male visited our hospital because of epigastric pain. Ultrasonography and computed tomography revealed swelling and thickening of the gallbladder wall, but stones were not observed in the gallbladder. We performed emergency surgery with a diagnosis of acute cholecystitis. Laparoscopy revealed the presence of many nodules around the abdominal cavity including the hepatoduodenal ligament. Inflammation of Calot’s triangle was severe, so we performed subtotal cholecystectomy. We also resected one of the peritoneal nodules. Macroscopically, there were no stones in the gallbladder and histopathological examination revealed acute cholecystitis and existence of adenocarcinoma involving the subserosa of the gallbladder wall and the resected peritoneal nodule. After surgery, esophagogastroduodenoscopy revealed Borrmann type II lesions at the antrum and gastric biopsy showed adenocarcinoma. He was diagnosed with advanced gastric cancer with peritoneal dissemination. His postoperative course was good.

Clinical discussion

The cases of AAC caused by gallbladder metastasis have been little reported in the literature. This case is advanced gastric cancer with peritoneal dissemination and AAC was thought to be caused by peritoneal dissemination from operative and histopathological findings. We successfully treated this rare case of AAC with laparoscopic surgery.

Conclusion

Although metastasis to the gallbladder is rare, it is necessary to be aware of this possibility when treating AAC.

Biliary Dyskinesia in Children and Adolescents: A Mini Review

Introduction: While functional gallbladder disorder is a well-recognized and defined condition in adults, its pediatric analog, biliary dyskinesia, lacks uniformity in diagnosis. Yet, biliary dyskinesia is among the most common conditions resulting in cholecystectomy in youth and its frequency continues to rise. The primary aims of the current review were assess the efficacy of cholecystectomy in children diagnosed with biliary dyskinesia and the utility of cholescintigraphy in predicting outcomes. Results: All previous studies assessing outcomes in youth with biliary dyskinesia have been retrospective and therefore of low quality. There is a lack of uniformity in patient selection. Short term follow-up reveals partial response in 63.4-100% with complete resolution in 44.2-100%. Only 4 studies have reported long-term outcomes with complete symptom resolution in 44-60.7%. The published research generally indicates that the gallbladder ejection fraction (GBEF) as determined by cholescintigraphy lacks utility in predicting cholecystectomy outcome utilizing the commonly used cut-off values. There are data suggesting that more extreme cut-off values may improve the predictive value of GBEF. Conclusion: There is a lack of consensus on the symptom profile defining biliary dyskinesia in youth and current literature does not support the use of cholescintigraphy to select patients for cholecystectomy. There is a substantial portion of pediatric patients diagnosed with biliary dyskinesia who do not experience long-term benefit from cholecystectomy. Well-designed prospective studies of surgical outcomes are lacking. Increasing the uniformity in patient selection, including both symptom profiles and cholescintigraphy results, will be key in understanding the utility of cholecystectomy for this condition.