Age, Predisposing Diseases, and Ultrasonographic Findings in Determining Clinical Outcome of Acute Acalculous Inflammatory Gallbladder Diseases in Children

Acalculous Cholecystitis From Kawasaki Disease in a Three-Month-Old Girl: A Rare Sign at an Uncommon Age

We report a case of a previously healthy three-month-old girl who presented with acute fever, watery diarrhea, and right upper abdominal guarding. Abdominal ultrasonography findings were compatible with acute acalculous cholecystitis. Initially, antibiotics were administered for a total of eight days without improvement. Hence, atypical Kawasaki disease (KD) was suspected despite the absence of classical disease manifestations and her uncommon age. The diagnosis was made using alternative diagnostic criteria and echocardiography. After KD was diagnosed, high-dose intravenous immunoglobulin G and aspirin were administered on day 9 of disease onset. Her clinical condition significantly improved within 24 hours, and she recovered well without complications during the 1.5 years of follow-up.

Hepatitis A virus induced acute acalculous cholecystitis diagnosed postoperatively: Case report

INTRODUCTION

acute acalculous cholecystitis (AAC) is defined as gallbladder inflammation without the presence of stones. Contrary, hepatitis A virus (HAV) can present with different symptoms; however, HAV causing and presenting as AAC is rare.

CASE PRESENTATION

41-year-old previously healthy patient presented with right upper quadrant abdominal pain. The pain was persistent and associated with vomiting and laboratory tests showed elevated bilirubin. Laparoscopic cholecystectomy showed inflamed gallbladder with no stones and intraoperative cholangiography showed no abnormalities. Day one post-operation, while the pain resolved, labs showed elevated liver function tests and hepatitis workup showed acute HAV infection attributing her presentation to HAV induced AAC.

DISCUSSION

AAC is usually caused by stasis of the gallbladder due to different causes; however, HAV induced AAC has been rarely reported. While cholecystectomy is the mainstay treatment for AAC, this might not be the case for HAV induced AAC. For instance, unless there is necrotic gallbladder or persistence of symptoms, AAC can be managed conservatively in this case. Even though our diagnosis was cleared post-operatively, had we knew the diagnosis of HAV induced AAC before, we would have still opt for surgery due to the severity and persistence of pain.

CONCLUSION

More cases should be reported and more studies should be done to further define the presentation and management of HAV induced AAC.

Kawasaki Disease With Acute Acalculous Cholecystitis: A Case Report

Acute acalculous cholecystitis (AAC) is an inflammatory disease of the gallbladder in the absence of gallstones. AAC has been linked to various systemic illnesses including Kawasaki disease (KD). We report a case of a five-year-old male brought to the emergency department (ED) with a history of fever and vomiting for four days. He was admitted as a case of KD. Then, we discovered that he had AAC, which was well managed by intravenous immunoglobulin (IVIG) as the fever subsided, C-reactive protein (CRP) decreased, and repeated abdominal ultrasound showed a decrease in gallbladder thickness without any evidence of coronary artery aneurysms.

Is conservative management a safe approach for patients with acute acalculous cholecystitis presenting with an acute abdomen?

Patients with acute acalculous cholecystitis (AAC) often present with acute abdominal symptoms. However, recent clinical studies have suggested that some patients with AAC and an acute abdomen, especially when caused by viruses or rheumatic disease, may not require cholecystectomy and that conservative treatment is adequate. Whether cholecystectomy is superior to conservative treatment for patients with AAC presenting with a severe acute abdomen is still uncertain. This was a case series study of AAC-related literature published between 1960 and 2022. In total, 171 cases (104 viral infection-associated AAC and 67 rheumatic disease-associated AAC) were included. The prognoses of patients receiving cholecystectomy or conservative treatment were compared. To account for confounding factors, etiological stratification and logistic regression were performed. The prognosis was similar for patients undergoing cholecystectomy and conservative treatment (P value .364), and virus infection-associated AAC had a better prognosis than rheumatic disease-associated AAC (P value .032). In patients with AAC caused by viruses or rheumatic disease, the acute abdomen can be adequately managed by conservative treatment of the underlying etiology and does not mandate surgical intervention.

A scoping review on acute gastrointestinal surgical complications in immunocompromised pediatric patients

Background

Gastrointestinal complications are becoming increasingly more common and pose a significant risk on the health of children with compromised immunity caused by various etiologies such as chemotherapy and posttransplantation immunosuppression. We aim to review abdominal complications in immunocompromised children and their respective management.

Main body

This is a scoping review of the literature. PubMed, MEDLINE, Google Scholar, and Scopus libraries were searched for relevant articles. Extracted data included the etiologies of immunocompromised immunity, gastrointestinal and abdominal complications in immunocompromised children, diagnosis, and treatment of these pathologies. Examples of gastrointestinal complications in immunocompromised children include, but not limited to, neutropenic enterocolitis, acute appendicitis, bowel perforation, acalculous cholecystitis, and acute pancreatitis. Our literature review showed that bacterial and fungal infections are the major causes of exacerbation and mortality. The main cause of immunosuppression in children with neutropenic enterocolitis and acute pancreatitis is chemotherapy, and management of these pathologies using intravenous fluids, antibiotic therapy, and granulocyte-stimulating factors is the current standard of care. Surgical intervention is uncommon and reserved for complicated cases. That said, in acute appendicitis and bowel perforation, laparoscopy is the mainstay treatment. However, in systemic infections, nonsurgical interventions such as transfusion and bowel rest are the gold standard. As for acalculous cholecystitis, percutaneous cholecystectomy is superior to laparotomy and other surgical interventions.

Conclusion

Timely diagnosis and management of gastrointestinal complications in the immunocompromised children is key in reducing mortality and morbidity. Both surgical and nonsurgical interventions are needed and should be further studied in order to improve outcomes.

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.

Acute Acalculous Cholecystitis Due to a Primary Epstein Barr Virus Infection in a Pediatric Patient

Epstein-Barr virus (EBV) is estimated to infect more than 98% of adults worldwide and is one of the most common human viruses. Acute acalculous cholecystitis (AAC) of the gallbladder is an atypical complication of infectious mononucleosis caused by EBV. Conservative management has been described in the context of AAC caused by EBV. A surgical approach must be considered in the case of acute complications such as perforation or gallbladder gangrene. We present the case of a 10-year-old female patient with AAC due to infectious mononucleosis syndrome caused by primary EBV infection.

Acute acalculous cholecystitis in child with systemic juvenile idiopathic arthritis, unreported manifestation

Acute acalculous cholecystitis is a gallbladder wall inflammation without gallstones. It was not reported before as a manifestation of systemic juvenile idiopathic arthritis. Here, we describe a 13-month-old boy presented with prolonged intermittent fever, skin rash, arthritis, serositis, and hepatomegaly. After workup, he was diagnosed with systemic juvenile idiopathic arthritis and acute acalculous cholecystitis based on an ultrasound abdomen showing thick gallbladder wall with free fluid. After treatment with three days of intravenous pulse methylprednisolone, he improved dramatically, and repeated ultrasounds showed normal gallbladder. This suggests that Acute acalculous cholecystitis can be a part of systemic juvenile idiopathic arthritis and hypothesised that surgical intervention can be avoided with the use of corticosteroids.

Laparoscopic Cholecystectomy for Symptomatic Cholecystic Disease in Children: Defining Surgical Timing

Background: Laparoscopic cholecystectomy (LC) is the standard of care for gallbladder (GB) pathologies. We evaluated clinical, ultrasonographic (US) data as well as histopathological findings in children affected with symptomatic cholecystic disease (SCD) who underwent LC, with the aim of defining surgical timing. Methods: We reviewed our cases who underwent elective LC (ELC) or urgent LC (ULC). Clinical, US, surgical and histological features were used to create different risk scores. Results: We considered 26 children (17 ELC/9 ULC). US signs were not different in the two groups (p > 0.05). Operating times were longer in ELC than in ULC (p = 0.01). Histopathological evaluation revealed fibrosis and atrophy in both ELC and ULC. The clinical risk score was higher in ELC compared to ULC (p < 0.001). An increased operative risk score was noted in patients with systemic inflammatory signs (OR1.98), lithotherapy (OR1.4.3) and wall thickening ≥3 mm (OR2.6). An increased histopathological risk score was detected in children with symptom duration >7 days (OR3.61), concomitant hematological disease (OR1.23) and lithotherapy (OR3.61). Conclusion: Criteria adopted in adults cannot be adopted to detect the severity of GB damage in children. A dedicated clinical and US score is mandatory to define the most appropriate surgical timing.

Kawasaki Disease Presenting as Acute Acalculous Cholecystitis

Acute acalculous cholecystitis (AAC) is a rare, potentially serious disease that has been associated with Kawasaki disease (KD) in children. Studies suggest that patients presenting with severe abdominal symptoms secondary to KD have increased resistance to intravenous immunoglobulin (IVIG), and a higher rate of coronary artery aneurysms. We describe an eight-year-old boy who presented to the emergency department with severe abdominal pain and was diagnosed with AAC and KD. He was treated with IVIG and high-dose aspirin, achieving good response with complete symptom resolution. He had no coronary artery aneurysms or further complications and was discharged after three days.

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.

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.