Gallstone disease in children
Section snippets
Physiology
The function of bile is largely 2-fold. It facilitates the absorption of lipids and fat-soluble vitamins (A, D, E, and K) from the gastrointestinal tract (nutritional role) and actively transports substances, such as bilirubin and cholesterol, from the hepatocyte to the gastrointestinal tract (excretory role). The latter is achieved by a mixture of bile acids and fatty acids, which solubilize cholesterol by formation of micelles, facilitating transport across the biliary canalicular membrane
Classification of gallstones
Four types of gallstones have been described in children: cholesterol, black pigment, brown pigment, and calcium carbonate stones.18, 19 Cholesterol stones contain between 70% and 100% cholesterol, the remaining constituents being bilirubin, protein, and calcium carbonate. Black pigment stones are composed of calcium bilirubinate (calcium salt of unconjugated bilirubin) and are associated with hemolysis20 and parenteral nutrition.21 Brown pigment stones are much rarer, associated with biliary
Risk factors for development of cholelithiasis
Gallstone disease in children is evolving and can be attributed to multiple conditions and physiological stresses that predispose to the development of all types of gallstones (Table 2).
Firstly, there is increasing survival of a cohort of critically ill neonates that have had lithogenic interventions, such as long-term parenteral nutrition after bowel resections for necrotizing enterocolitis or congenital short bowel because of gastroschisis or intestinal atresias. Secondly, there has been a
Clinical features
Gallstones in children present in a similar way to that of adults, although there seems to be a delay from onset of symptoms to diagnosis/definitive treatment. For instance, the median time from onset of symptoms to surgical treatment in children operated at the Astrid Lindgren Children's Hospital in Sweden during 2006-2008 was 3.5 years (unpublished observation).
Gallstones may present in a variety of ways:
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Asymptomatic (17%-50%): these are usually detected on ultrasonography while assessing
Management
The aim of treatment is to provide long-term relief from the symptoms of gallstones and to minimize the possibility of complications and recurrence. A number of strategies have evolved, largely from adult experience.
There have been no prospective randomized controlled trials that compare medical and surgical treatment of gallstone disease in children. An Italian multicenter study has shown that there is a difference in treatment depending on the specialty of the center. If patients are treated
Open versus laparoscopic cholecystectomy in children
The first elective open cholecystectomy (OC) was performed by Carl Langenbuch, a surgeon working in Berlin, Germany in 1882.99 Although there is still some dispute in the literature, the first laparoscopic cholecystectomy (LC) is now also credited to a German surgeon, Erich Mühe in 1985.100 The first laparoscopic cholecystectomies in children were reported in 1991.101, 102
Two retrospective cohort studies have shown that LC in children results in a shorter hospital stay, reduced analgesia
Postcholecystectomy syndrome
Postcholecystectomy syndrome can be defined as the persistence or recurrence of symptoms similar to those experienced before the cholecystectomy,132 but can also involve new symptoms like intolerance to fasting. Colicky or noncolicky pain is most often present, but there may also be intolerance of fatty foods, bloating, flatulence, nausea, and vomiting.133 There have been no reports about the incidence of postcholecystectomy syndrome in children. Ure et al133 put forward an algorithm suggesting
Association with malignancy
After cholecystectomy, bile flows continually to the duodenum. This leads to an increased formation of secondary bile acids (deoxycholic and lithocholic acid) because of an increase of the enterohepatic circulation and degradation of primary bile acids by intestinal flora. Such secondary bile acids seem to have a carcinogenic effect on colonic mucosa. There have been numerous epidemiological studies trying to estimate the scale of this increased risk.134, 135, 136
The largest has been reported
Conclusions
The prevalence of gallstone disease in children appears to be increasing. The etiology behind this is certainly multifactorial, but there is good evidence to support that a rise in childhood obesity, awareness of emerging genetic factors, and improved diagnostic modalities certainly play a role. Asymptomatic or incidental gallstones do not require surgical intervention, but if indicated, the laparoscopic approach is the preferred approach. There appears to be a minimal role for the use of
References (140)
- et al.
Prevalence and ethnic differences in gallbladder disease in the United States
Gastroenterology
(1999) - et al.
Changing spectrum of cholelithiasis and cholecystitis in infants and children
Am J Surg
(1989) - et al.
Cholecystectomy is becoming an increasingly common operation in children
Am J Surg
(1999) - et al.
Water handling and aquaporins in bile formation: Recent advances and research trends
J Hepatol
(2003) - et al.
Biliary lipids and cholesterol gallstone disease
J Lipid Res
(2009) - et al.
Gallstone composition: Are children different?
J Pediatr
(2003) - et al.
Calcium carbonate gallstones in children
J Pediatr Surg
(2007) - et al.
Does total parenteral nutrition induce gallbladder sludge formation and lithiasis?
Gastroenterology
(1983) Critical tables for calculating the cholesterol saturation of native bile
J Lipid Res
(1978)- et al.
Pathogenesis of gallstones: A genetic perspective
Best Practice Res Clin Gastroenterol
(2006)
Gallstones: Pathogenesis
Lancet
Outcomes for children with gallbladder abnormalities and sickle cell disease
J Pediatr
Hereditary spherocytosis
Lancet
Coinheritance of Gilbert syndrome increases the risk for developing gallstones in patients with hereditary spherocytosis
Blood
Enterohepatic cycling of bilirubin: A putative mechanism for pigment gallstone formation in ileal Crohn's disease
Gastroenterology
Quantitative infrared spectroscopy of common bile duct gallstones
Gastroenterology
Microlithiasis, endoscopic ultrasound, and children: Not just little gallstones in little adults
J Pediatr Surg
Gallstone disease: Microlithiasis and sludge
Best Practice Res Clin Gastroenterol
Reversible ceftriaxone-associated biliary pseudolithiasis in children
Lancet
Defect of multidrug-resistance 3 gene expression in a subtype of progressive familial intrahepatic cholestasis
Hepatology
The wide spectrum of multidrug resistance 3 deficiency: From neonatal cholestasis to cirrhosis of adulthood
Gastroenterology
ABCB4 heterozygous gene mutations associated with fibrosing cholestatic liver disease in adults
Gastroenterology
ABCB4 gene mutation-associated cholelithiasis in adults
Gastroenterology
The genetic background of gallstone formation: An update
Biochem Biophys Res Commun
Prevalence and trends of severe obesity among US children and adolescents
Acad Pediatr
Underdiagnosis of pediatric obesity and underscreening for fatty liver disease and metabolic syndrome by pediatricians and pediatric subspecialists
J Pediatr
A genomewide search finds major susceptibility loci for gallbladder disease on chromosome 1 in Mexican Americans
Am J Hum Genet
Biliary dyskinesia: The most common indication for cholecystectomy in children
Surgery
Functional gallbladder disorder: Gallbladder dyskinesia
Gastroenterol Clin North Am
Predictors of successful outcome after cholecystectomy for biliary dyskinesia
J Pediatr Surg
Pathologic changes in biliary dyskinesia
J Pediatr Surg
Efficacy of laparoscopic cholecystectomy in the pediatric population
J Pediatr Surg
A comparison of cholecystectomy and observation in children with biliary dyskinesia
J Pediatr Surg
Gallbladder motor function in gallstone patients: Sonographic and in vitro studies on the role of gallstones, smooth muscle function and gallbladder wall inflammation
J Hepatol
Abnormal processing of the human cholecystokinin receptor gene in association with gallstones and obesity
Gastroenterology
Cholelithiasis in newborns and infants
J Pediatr Surg
Cholelithiasis in infancy: A study of 40 cases
J Pediatr
The role of endoscopic retrograde cholangiopancreatography in infants with cholestasis
J Pediatr Surg
Hepatoprotective bile acid ‘ursodeoxycholic acid (UDCA)' property and differences as bile acids
Hepatol Res
Is there a place for medical treatment in children with gallstones?
J Pediatr Surg
Cholecystectomy versus cholecystolithotomy for cholelithiasis in childhood: Long-term outcome
J Pediatr Surg
Scenes from the past: Multidetector CT study of gallbladder stones in a wrapped Egyptian mummy
Radiographics
The biliary system through the ages
Int Surg
Gallstone prevalence and gallbladder volume in children and adolescents: An epidemiological ultrasonographic survey and relationship to body mass index
Am J Gastroenterol
Prevalence of gallstone disease in a general population of Okinawa, Japan
Am J Epidemiol
Clinical presentations and predisposing factors of cholelithiasis and sludge in children
J Pediatr Gastroenterol Nutr
Gallbladder disease and cholelithiasis
Risk factors, complications, and outcomes of gallstones in children: A single-centre review
J Pediatr Gastroenterol Nutr
Clinical characteristics and risk factors for symptomatic pediatric gallbladder disease
Pediatrics
Gallbladder disease in childhood
Am J Dis Child
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Cholelithiasis in childhood: Report of two cases from Afghanistan and literature review
2023, International Journal of Surgery OpenAre children with gallstone disease more overweight? Results of a matched case-control analysis
2023, Clinics and Research in Hepatology and GastroenterologyCholecystectomies performed in children by pediatric surgeons compared to general surgeons in North Carolina are associated with higher institutional charges
2023, American Journal of SurgeryCitation Excerpt :Symptomatic cholelithiasis or biliary dyskinesia are also indications for laparoscopic cholecystectomy, a safe and effective treatment.5,6 Since the 1960s, the number of cholecystectomies in children has steadily increased, particularly with the application of laparoscopy in children and improvement in diagnostic modalities such as ultrasound or hepatobiliary scintigraphy.7–9 These factors have allowed for more timely diagnosis and treatment of symptomatic cholelithiasis.
Nationwide Evolution of Pediatric Endoscopic Retrograde Cholangiopancreatography Indications, Utilization, and Readmissions over Time
2021, Journal of PediatricsCitation Excerpt :Pediatric biliary pathology was previously rare and highly associated with congenital or hemolytic disorders; however, the incidence of pediatric gallstone disease has increased in parallel with the emerging pediatric obesity epidemic.20,23 Recent estimates have indicated a prevalence of pediatric cholelithiasis as high as 4%,20 and consequently, the prevalence of pediatric choledocholithiasis and need for pediatric ERCPs have increased as well.22,24 The relatively high proportion of ERCPs performed in females is consistent with some recent reports of a female predominance of pediatric obesity, as well as an increased prevalence of gallstone disease in adolescents taking oral contraception.25
Choledochal cyst as an important risk factor for pediatric gallstones in low-incidence populations: A single-center review
2020, Pediatrics and NeonatologyPancreatic Problems in Infants and Children
2019, Shackelford's Surgery of the Alimentary Tract: 2 Volume Set