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

Acalculous Cholecystitis in COVID-19 Patients: A Narrative Review

Acute acalculous cholecystitis (AAC) represents cholecystitis without gallstones, occurring in approximately 5-10% of all cases of acute cholecystitis in adults. Several risk factors have been recognized, while infectious diseases can be a cause of cholecystitis in otherwise healthy people. Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has spread worldwide, leading to an unprecedented pandemic. The virus enters cells through the binding of the spike protein to angiotensin-converting enzyme 2 (ACE2) receptors expressed in many human tissues, including the epithelial cells of the gastrointestinal (GI) tract, and this explains the symptoms emanating from the digestive system. Acute cholecystitis has been reported in patients with COVID-19. The purpose of this review is to provide a detailed analysis of the current literature on the pathogenesis, diagnosis, management, and outcomes of AAC in patients with COVID-19.

Clinical analysis of infectious mononucleosis complicated with acute acalculous cholecystitis

Objective

This study aimed to investigate specific clinical diagnostic methods for children with infectious mononucleosis (IM) complicated by acute acalculous cholecystitis (AAC).

Methods

We conducted a retrospective analysis of 171 cases of IM diagnosed in the infectious disease ward of Children's Hospital of Nanjing Medical University between January 2020 and December 2020. All IM patients underwent abdominal ultrasound examinations to assess the liver, gallbladder, and spleen. Fourteen patients with symptoms of AAC underwent a follow-up assessment one week later.

Results

The estimated incidence of AAC in hospitalized IM children was 8.2%. Both groups of patients presented with fever, abdominal pain, and eyelid edema upon admission. Characteristic radiological findings of AAC were observed, including gallbladder (GB) distention, increased GB wall thickness and increased common bile duct diameter. Analysis of laboratory results revealed no statistically significant differences in leukocyte, absolute lymphocyte count, CD3+, CD3 + CD4+, CD3+ CD8+, Aspartate Aminotransferase (AST), Alanine Aminotransferase (ALT), or Gamma-Glutamyl Transferase (GGT) levels between the AAC(+) and AAC(-) groups on admission. However, these parameters were not significant risk factors for AAC. After discharge, relevant indicators in non-AAC patients gradually decreased to normal levels, while those in AAC(+) patients did not show a significant decrease.

Conclusion

While cases of IM complicated by AAC are relatively uncommon, the utilization of abdominal ultrasound offers a reliable tool for confirming this diagnosis. Routine abdominal ultrasound examinations are recommended for IM patients to improve early detection and treatment of associated conditions.

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).

Acute acalculous cholecystitis in an infant after gastroschisis closure

Gastroschisis is a common type of congenital anterior abdominal wall defect with intraabdominal organs exposed outside the abdominal cavity. With modern neonatology and surgical practices, the overall prognosis for infants with gastroschisis is excellent. However, a subset of infants with gastroschisis will develop complications, requiring repeat surgical interventions. We present a case of a female infant with complicated gastroschisis who developed acute perforated acalculous cholecystitis, which was accurately diagnosed with abdominal ultrasound and successfully treated with medical management and a percutaneous cholecystostomy tube.

ANOTHER FACE OF EPSTEIN-BARR VIRUS INFECTION: ACUTE ACALCULOUS CHOLECYSTITIS WITH CHOLESTASIS IN A PREVIOUSLY HEALTHY FIVE-YEAR-OLD GIRL WITH PRIMARY INFECTION

Acute acalculous cholecystitis (AAC) is a rare disease, particularly in children. The clinical and laboratory presentation of AAC is variable. The diagnosis is based on radiological criteria. AAC is an atypical and rare complication of Epstein-Barr virus (EBV) infection, therefore we present a girl with AAC and cholestasis due to EBV primary infection. Conservative treatment and careful monitoring was followed by clinical, radiological and laboratory improvement, and finally complete recovery. Our aim was to highlight the importance of recognizing AAC as a differential diagnosis in children with abdominal pain and/or acute cholestasis.

Rare But Fatal: Hemophagocytic Lymphohistiocytosis (HLH) With Acute Acalculous Cholecystitis

Acalculous cholecystitis is an acute inflammatory disease of the gall bladder with high morbidity and mortality rate. It can be seen in trauma, burns, sepsis, total parenteral nutrition, prolonged fasting, and autoimmune diseases. However, there are very few reports of acalculous cholecystitis with macrophage activation syndrome (MAS) and hemophagocytic lymphohistiocytosis (HLH) in patients with underlying rheumatic/autoimmune disorders. Here we report a 23-year-old male with a past medical history of granulomatosis with polyangiitis who presented with fever, weight loss, and pancytopenia. A comprehensive infectious evaluation was done including bacterial cultures and viral and fungal serologies. Repeat abdominal imaging obtained later due to developing abdominal pain raised concerns for acute acalculous cholecystitis. Despite aggressive management of sepsis, the patient continued to decline clinically. HLH was suspected when the patient was found to meet the clinical criteria with fever, splenomegaly, cytopenia, hypertriglyceridemia, elevated liver function tests, hypofibrinogenemia, and ferritin of 22K ng/mL, absent NK cell activity, and elevated soluble CD25 receptor levels. Bone marrow biopsy did not reveal hemophagocytosis. Intravenous methylprednisolone was started and the patient showed remarkable clinical improvement with a decrease in all inflammatory markers and did not require any surgical intervention. On the review of the literature, we were able to identify four female patients with underlying adult-onset Still's disease and Kikuchi disease who presented with HLH along with acalculous cholecystitis likely triggered by flare. Our male patient presented with HLH and acute acalculous cholecystitis. He had a history of granulomatosis polyangiitis (GPA) that remained in remission. Hypersecretion of pro-inflammatory cytokines and cytotoxic cells in HLH promotes ischemia of the gall bladder wall. Early initiation of immunosuppressive therapy under careful observation can prevent surgical intervention and mortality in these patients.

Acute acalculous cholecystitis in a pediatric dengue hemorrhagic fever patient: A case report, lesson learned from limited resource setting

INTRODUCTION

Dengue fever (DF) is endemic in numerous regions of Indonesia with primary clinical features such as high fever as well as pullout of intravascular fluid and albumin leakage, which provokes pleural effusion, hypoproteinemia, and blood hemoconcentration. However, the incidence of abdominal pain as a clinical manifestation of DF, which refers to acalculous cholecystitis, is rare.

CASE PRESENTATION

An 11-year-old female was admitted to the to hospital with fever, headache, and myalgia. Blood examination resulted in low platelet coua nt and positive IgM Dengue antibody test. On the third day, the patient felt sharp abdominal pain. Abdominal ultrasound showed cholecystitis, cholestasis, pleural effusion, ascites, and laboratory finding showed increased C-reactive protein. The management was conservative and discharged at the 7th day.

DISCUSSION

The acalculous cholecystitis in Dengue Fever/Dengue Hemorrhagic fever (DF/DHF) is challenging in diagnose due to atypical presentations. Several proposed mechanisms are critical illness, including direct invasion of the gallbladder epithelial cells, vasculitis, stasis of biliary flow, obstruction of the biliary tree, ischemia, and sequestration. The actual mechanism of the dengue virus has been proposed that direct viral incursion of the gallbladder may yield edema and exudation. Abdominal ultrasonography is considered to diagnose acute acalculous cholecystitis (AAC) in children.

CONCLUSION

Understanding pathophysiology of the acalculous cholecystitis in DF/DHF patients and atypical presentation of sharp abdominal pain help physicians for early diagnosis and management both in monitoring and patient care management. Abdominal ultrasonography can help physicians to diagnose AAC.

Cholecystitis secondary to Salmonella typhi: a rare pathology with an unreported management option—a case report and literature review

Background

This report describes the presentation and course of treatment for one of the youngest reported cases of empyema of the gallbladder. Given the rare occurrence of this disease process, we elected to proceed with a systematic review of the literature. This is only the 7th case series discussing pediatric empyema of the gallbladder due to Salmonella typhi in the literature, and the second case ever reported in the USA.

Case presentation

We report a case of a previously healthy 13-month-old girl who presented with diffuse peritonitis and equivocal imaging studies. Diagnostic laparoscopy revealed purulent peritonitis. The gallbladder was distended with intraluminal pus. Laparoscopy was converted to laparotomy to facilitate exposure, and a cholecystostomy tube was placed. Cultures from the fluid were positive for Salmonella typhi. The patient received a 14-day course of intravenous Ceftriaxone followed by 14 days of oral amoxicillin and clavulanate. A cholangiogram performed 8 weeks after surgery confirmed normal biliary anatomy. The cholecystostomy tube was removed. The patient recovered uneventfully and is doing well over 9 months later.

Conclusion

There is no consensus on treatment with options reported ranging from medical management with antibiotic therapy to more invasive procedures such as cholecystostomy tube or cholecystectomy. Less invasive management options are an alternative for Salmonella cholecystitis.

Advances in the Study of Acute Acalculous Cholecystitis: A Comprehensive Review

BACKGROUND

Acute acalculous cholecystitis (AAC) is characterized by acute necrotizing inflammation with no calculi and is diagnosed based on imaging, intraoperative, and pathological examinations.

KEY MESSAGE

Although AAC has been studied clinically for a long time, it remains difficult to diagnose and treat. The pathogenesis of AAC is still not fully understood, and it is often regarded as a relatively independent clinical disease that is different from acute calculous cholecystitis (ACC). Pathological studies suggest that AAC is the manifestation of a critical systemic disease, while ACC is a local disease of the gallbladder.

SUMMARY

Concerning the pathogenesis, diagnosis, and treatment of AAC, we reviewed the research progress of AAC, which will enhance the understanding of the early diagnosis and treatment of AAC.

The Influence of Pre-Procedural Imaging and Cystic Duct Cholangiography on Endoscopic Transpapillary Gallbladder Drainage in Acute Cholecystitis

Endoscopic transpapillary gallbladder drainage (ETGBD) for acute cholecystitis is challenging. We evaluated the influence of pre-procedural imaging and cystic duct cholangiography on ETGBD. Patients who underwent ETGBD for acute cholecystitis were retrospectively examined. The rate of gallbladder contrast on cholangiography, the accuracy of cystic duct direction and location by computed tomography (CT) and magnetic resonance cholangiopancreatography (MRCP), and the relationship between pre-procedural imaging and the technical success of ETGBD were investigated. A total of 145 patients were enrolled in this study. Gallbladder contrast on cholangiography was observed in 29 patients. The accuracy of cystic duct direction and location (proximal or distal, right or left, and cranial or caudal) by CT were, respectively, 79%, 60%, and 58% by CT and 68%, 55%, and 58% by MRCP. Patients showing gallbladder contrast on cholangiography underwent ETGBD with a significantly shorter procedure time and a lower rate of cystic duct injury. No other factors affecting procedure time, technical success, and cystic duct injury were identified. Pre-procedural evaluation of cystic duct direction and location by CT or MRCP was difficult in patients with acute cholecystitis. Patients who showed gallbladder contrast on cholangiography showed a shorter procedure time and a lower rate of cystic duct injury.

Antibiotics for adults with acute cholecystitis or acute cholangitis or both

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the benefits and harms of antibiotics treatment versus placebo, no intervention, or another antibiotic for people with cholecystitis or cholangitis, or both.

Mycoplasma pneumoniae-related hepatitis in children

Mycoplasma pneumoniae (M. pneumoniae) is a small bacterium characterized by the absence of cell wall. It is a human pathogen causing upper and lower respiratory infections, both in adults and children. However, it is also considered to be implicated in the pathogenesis of several types of extra-respiratory diseases, including some gastrointestinal disorders. The liver involvement in children during or after M. pneumoniae infections is analyzed and discussed in this review. Through a systematic literature search, it is evidenced that M. pneumoniae is not infrequently associated with alteration of liver function, but rarely causes acute and severe hepatitis in children. M. pneumoniae should be considered as an unusual cause of acute hepatitis in children, whenever the most common hepatotropic viruses have been excluded. The pathogenesis of M. pneumoniae-related hepatitis is likely to be immune-mediated: both the innate and adaptive immune responses may play a fundamental role. However, the exact pathological mechanisms have to be elucidated yet. Further clinical studies are needed in order to understand the actual relevance of this microorganism in liver disease and its pathogenesis.

Epstein-Barr virus infection with acute acalculous cholecystitis in previously healthy children

BACKGROUND

Acute acalculous cholecystitis (AAC), an inflammatory process of the gallbladder (GB) in the absence of gallstones, typically occurs in seriously ill patients. AAC can complicate primary Epstein-Barr virus (EBV) infection, but it is an atypical clinical presentation.

AIM

The aim of our study was to analyse AAC occurrence in children with primary symptomatic EBV infection who had been admitted to the hospital.

METHODS

We retrospectively evaluated the medical documentation of 181 children with EBV infection who were diagnosed based on the presence of viral capsid antigen IgM antibodies. All EBV-positive patients underwent transabdominal ultrasonography of the liver in the supine and right anterior oblique positions. Fifteen children who presented with AAC symptoms, including abdominal pain and a positive Murphy's sign, were analysed as a subsample and re-evaluated after 2-3 months.

RESULTS

The incidence of AAC in children hospitalised with infectious mononucleosis (IM) was estimated at 8.3%. Analysis of the laboratory results confirmed that the C-reactive protein (CRP) concentration was the only parameter which was higher in children who presented with AAC symptoms. The mean number of leucocytes and monocytes and liver enzyme activities were not significantly higher. The radiological findings of AAC were evident: increased GB wall thickness, non-shadowing echogenic sludge and pericholecystic fluid collection.

CONCLUSION

AAC during primary EBV infection appears to be a more common pathology than previously suspected. Its relatively mild nature and the lack of laboratory abnormalities mean that ultrasonographic examination is required for diagnosis. This might explain why the prevalence in children is underestimated.

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.

Beware of the Zebra: Nine-year-old with Fever

An otherwise healthy nine-year-old female who spoke only French presented with abdominal pain, vomiting, intermittent fevers, fatigue, and headache. She then quickly became febrile and altered requiring intubation. When treating a healthy child, the physician may initially develop a differential that includes common illnesses. Yet, as emergency medicine providers, we must be thinking about the “zebras” in order to not miss potentially deadly, curable diseases.

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.

Pediatric Biliary Interventions in the Native Liver

Biliary disease in infants and children frequently presents diagnostic and therapeutic challenges. Pediatric interventional radiologists are often involved in the multidisciplinary teams who care for these patients. This article reviews several notable causes of biliary disease in children who have not undergone liver transplantation, describes the role of percutaneous interventional procedures in managing these conditions, and details applicable biliary interventional techniques.

Gallbladder disease in children

Biliary disease in children has changed over the past few decades, with a marked rise in incidence-perhaps most related to the parallel rise in pediatric obesity-as well as a rise in cholecystectomy rates. In addition to stone disease (cholelithiasis), acalculous causes of gallbladder pain such as biliary dyskinesia, also appear to be on the rise and present diagnostic and treatment conundrums to surgeons.

So-called Acute Acalculous Cholecystitis in Macrophage Activation Syndrome

Acute acalculous cholecystitis (AAC) is a severe disease seen in critically ill patients, including those with autoimmune diseases. We herein report the case of a 41-year-old female who developed macrophage activation syndrome (MAS) accompanied by a recurrence of Kikuchi disease. Abdominal imaging revealed marked thickening of the gallbladder wall and pericholecystic fluid, typically found in AAC. Treatment with intravenous pulse methylprednisolone induced in a significant improvement in the gallbladder wall, resulting in no need for surgical intervention. We should consider that patients with MAS may therefore sometimes develop AAC and that early immunosuppressive therapy can be effective in AAC cases associated with rheumatic or autoimmune diseases.