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Context Although cholelithiasis is not a common condition in children, recent studies have documented an increasing incidence rate, owing to the development of diagnostic tools. The prevalence of cholelithiasis in children has been reported to be 0.13% - 0.3%, whereas in obese children and adolescents, the prevalence rate has been estimated at 2% - 6.1%. In this study, we aimed to review cholelithiasis in children. The gathered results could be useful in finding a suitable method and proper clinical practice for this complication. Evidence Acquisition For literature review, international databases, including PubMed and Google Scholar, were searched, using keyword combinations, e.g., “cholelithiasis in children”, “gallstone in children”, and “childhood cholelithiasis”, to review diagnostic and therapeutic approaches for cholelithiasis in children from 2006 to 2016. Also, some articles were retrieved through hand searching and reviewing the reference lists of papers, regardless of the date of publication. Abstracts, duplicates, and articles irrelevant to childhood cholelithiasis were excluded. Results A total of 36 out of 93 articles were reviewed. The results showed that the prevalence of childhood cholelithiasis varies in different communities, with a global rate of 1.9%. Most cases of cholelithiasis in children were associated with underlying diseases. Hemolytic diseases, hereditary blood disorders, and cirrhosis were among the main causes of cholelithiasis in children. Cholelithiasis was detected incidentally or via diagnostic evaluations due to the presentation of symptoms. Conclusions Although evaluation of the underlying causes of gallstone formation and appropriate diagnostic/therapeutic implications is still a challenging issue in the management of childhood cholelithiasis, in asymptomatic cases or those with gallstones of certain sizes, it is only recommended to monitor the disease or rule out the underlying causes. It should be noted that long periods of diagnostic and therapeutic approaches can impose stress and tension on families.
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J Pediatr Rev. In Press(In Press):e9114.
Published online 2016 December 6.
doi: 10.17795/jpr-9114.
Review Article
Cholelithiasis in Children: A Diagnostic and Therapeutic Approach
Hasan Karami,1,* Hamid Reza Kianifar,2and Shahryar Karami3
1Department of Pediatric Gastroenterology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, IR Iran
2Department of Pediatric Gastroenterology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
3Departement of Dentistry, Faculty of Dentistry, Mazandaran University of Medical Sciences, Sari, IR Iran
*Corresponding author: Hasan Karami, Department of Pediatric Gastroenterology, Bouali Sina Hospital, Pasdaran bulevard, Sari, Mazandaran Province, IR Iran. Tel:
+98-1133344506, E-mail: dr_hkarami87@yahoo.com
Received 2016 September 24; Revised 2016 November 19; Accepted 2016 November 29.
Abstract
Context: Although cholelithiasis is not a common condition in children, recent studies have documented an increasing incidence rate, owing to
the development of diagnostic tools. The prevalence of cholelithiasis in children has been reported to be 0.13% - 0.3%, whereas in obese children and
adolescents, the prevalence rate has been estimated at 2% - 6.1%. In this study, we aimed to review cholelithiasis in children. The gathered results
could be useful in finding a suitable method and proper clinical practice for this complication.
Evidence Acquisition: For literature review, international databases, including PubMed and Google Scholar, were searched, using keyword combi-
nations, e.g., “cholelithiasis in children”, “gallstone in children”, and “childhood cholelithiasis”, to review diagnostic and therapeutic approaches for
cholelithiasis in children from 2006 to 2016. Also, some articles were retrieved through hand searching and reviewing the reference lists of papers,
regardless of the date of publication. Abstracts, duplicates, and articles irrelevant to childhood cholelithiasis were excluded.
Results: A total of 39 out of 93 articles were reviewed. The results showed that the prevalence of childhood cholelithiasis varies in different commu-
nities, with a global rate of 1.9%. Most cases of cholelithiasis in children were associated with underlying diseases. Hemolytic diseases, hereditary
blood disorders, and cirrhosis were among the main causes of cholelithiasis in children. Cholelithiasis was detected incidentally or via diagnostic
evaluations due to the presentation of symptoms.
Conclusions: Although evaluation of the underlying causes of gallstone formation and appropriate diagnostic/therapeutic implications is still a
challenging issue in the management of childhood cholelithiasis, in asymptomatic cases or those with gallstones of certain sizes, it is only recom-
mended to monitor the disease or rule out the underlying causes. It should be noted that long periods of diagnostic and therapeutic approaches
can impose stress and tension on families.
Keywords: Cholelithiasis, Childhood, Diagnosis, Therapy
1. Context
With the development of diagnostic methods such as
ultrasonography, cholelithiasis in children is being fre-
quently reported. This disease may be either symptomatic
or asymptomatic, even though the asymptomatic presen-
tation is less likely in children (17% - 50%) (1-5). Although
both genders are equally affected in early childhood, most
previous studies have demonstrated a female predomi-
nance in pediatric gallbladder disease, starting from pu-
berty. In fact, most cases of cholelithiasis at young age are
diagnosed in the second decade of life (1,6-8).
Cholelithiasis is sometimes diagnosed in patients in-
cidentally or as silent stones. In some other cases, they
are reported in association with clinical symptoms such
as cholecystitis and cholangitis (9-11). Although hemolytic
diseases are the most common causes of cholelithiasis in
children, some other factors such as obesity, metabolic syn-
drome, prematurity, necrotizing enterocolitis (NEC), con-
genital heart diseases, cystic fibrosis, parenteral nutrition,
use of certain medicines, and anatomic stenosis of bile
ducts should be also considered.
Information about cholelithiasis and bile duct stones
causes stress and anxiety in parents and sometimes leads
to the use of improper diagnostic and therapeutic ap-
proaches by physicians (9,10,12). Evaluation of the
causes of cholelithiasis and utilization of a proper ther-
apeutic method are among the challenges of cholelithia-
sis management in children. Considering the use of gall-
bladder lithotripsy procedures in certain cases and sta-
tus of pharmacological treatments in gallbladder stone
management, we aimed to review different types of
cholelithiasis, clinical symptoms, underlying causes, and
pharmacological/non-pharmacological therapies in chil-
dren.
2. Evidence Acquisition
For the purpose of literature review, international
databases, including PubMed and Google Scholar, were
searched, using keyword combinations, e.g., “cholelithi-
asis in children”, “gallstone in children”, and “childhood
cholelithiasis”, to review diagnostic and therapeutic ap-
proaches for cholelithiasis in children from 2006 to 2016.
Also, some articles were retrieved by hand searching and
reviewing the articles’ references, regardless of the date of
publication. After removing duplicates, abstracts, and ar-
ticles irrelevant to cholelithiasis in children, 39 eligible ar-
Copyright © 2016, Mazandaran University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons
Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in
noncommercial usages, provided the original work is properly cited.
Uncorrected Proof
Karami H et al.
ticles were obtained and reviewed. The qualitative results
are presented in this article.
3. Results
3.1. Epidemiological Review
Generally, the incidence and prevalence of cholelithia-
sis are influenced by age, gender, genetics, race, and geo-
graphical factors (9-12). Epidemiological studies have indi-
cated the involvement of genetic factors in the formation
of cholelithiasis. The effect of a gene on incontinentia pig-
menti chromosome has been confirmed in the formation
of cholelithiasis. In fact, patients with ABCB11 mutations
are at a higher risk of cholelithiasis.
The first report of cholelithiasis in children was pre-
sented by Gibson in 1737. The prevalence of cholelithia-
sis in children is variable, with a global rate of 1.9% in dif-
ferent communities. Children under 26 months of age
constitute 10% of cholelithiasis cases. Sometimes, cases
of fetal cholelithiasis are reported, most of which are
asymptomatic and gradually resolve following the postna-
tal monitoring of newborns (9,10,13,14).
Most cases of cholelithiasis in children are associ-
ated with underlying factors, such as hemolytic diseases,
history of treatment with total prenatal nutrition (TPN),
Wilson’s disease, and cystic fibrosis; also, use of some
medicines should be always considered. Hemolytic causes
appear mostly in one- to five-year-old children. On the
other hand, cholelithiasis in adolescents is usually associ-
ated with obesity, pregnancy, and medication use (10,11,15).
3.2. Pathophysiology
The five main constituents of bile include water, biliru-
bin, cholesterol, bile pigments, and phospholipids; also,
lecithin is the precursor of bile phospholipids. The early
stage of gallstone formation initiates from the sedimen-
tation of insoluble primary components of bile, which
mainly include cholesterol, bile pigments, and calcium
salts (10). Gallstones are mainly categorized in three
groups of cholesterol, pigment, and mixture, among
which the mixture is more common. Imbalance in bile
constituents, such as cholesterol, lecithin, and bile salts, is
the main cause of gallstone formation. As the concentra-
tion of cholesterol increases, the rate of crystallization also
elevates, which gives rise to underlying conditions for gall-
stone formation (15,16).
3.3. Cholesterol Stones
When the bile includes higher levels of cholesterol and
bilirubin, along with lower levels of bile salts, cholesterol
stones are formed. Generally, three factors are involved in
the formation of cholesterol stones: 1) Bile saturates with
cholesterol which creates solid cholesterol; 2) bile kinetics
majorly contribute to cholesterol crystal formation; and
3) cholesterol crystals bind to the central core. It should
be noted that most cholesterol stones are yellow-white in
color (16).
3.4. Pigment Stones
These stones are mostly reported in cases with
hemolytic disease, cirrhosis, bile tract infection, and
hereditary blood disorders, such as spherocytosis and
sickle cell anemia. These stones are black-brown in color
and are more common in adolescents (10,12,16).
3.5. Cholelithiasis in Infants
Bile is more diluted in infants than older children.
Lower concentrations of bile salts, short period of core
formation, and higher levels of cholesterol saturation
may predispose infants to bile deposition and gallbladder
sludge. According to different studies, more than half of
gallstone cases in infancy are resolved spontaneously fol-
lowing the postnatal monitoring of newborns; therefore,
surgical interventions or symptomatic treatments are nec-
essary only in some certain cases (13,16-18). The features of
cholesterol and pigment stones are presented in Table1 (16,
19-22).
3.6. Clinical Symptoms of Cholelithiasis
In most cases, cholelithiasis is asymptomatic in chil-
dren and is incidentally diagnosed in abdominal sonog-
raphy assessments. Cholelithiasis can be symptomatic if
leading to cholestasis, cholecystitis, and cholangitis. The
main clinical symptoms include icterus, abdominal pain,
nausea, vomiting, and Murphy’s sign. In case of any under-
lying factors, the clinical symptoms of the causes of stone
formation should be also included (12,13,16).
3.7. Diagnosis of Cholelithiasis
Diagnostic interventions for cholelithiasis should be
performed to identify the stones and to determine the un-
derlying causes. Liver, gallbladder, and biliary tract ultra-
sonography is the optimal diagnostic method with high
sensitivity and specificity. Deposition of biles due to dif-
ferent pharmacological therapies, fasting of the patients,
and reduced physical activity lead to no posterior opacity
in ultrasonography; however, opacity can appear in cases
of cholelithiasis.
Abdominal plain sonography can be helpful in cases
of pigmented stones, considering the sedimentation of
calcium bilirubinate, whereas it is not effective in cases
with cholesterol or radiolucent stones (12,13,16,23). Along
2J Pediatr Rev. In Press(In Press):e9114.
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Karami H et al.
Table1. The Features of Cholesterol and Pigment Stones
Characteristics Cholesterol Stones Pigment Stones
Black Brown
Color Yellow-white (often with a dark core) Black to brown Brown to orange
Consistency Hard, crystalline, and layered Hard, shiny,and crystalline Soft, greasy,50% amorphous, and
crystalline at rest with inorganic salts
Number and morphology Multiple: 2 - 25 mm, faceted, and smooth,
Solitary: 2 - 4 cm (~ 10%), round, and
smooth
Multiple: < 5 mm, irregular, or smooth Multiple: 10 - 30 mm, round, and smooth
Composition Cholesterol monohydrate > 50%
,glycoprotein, Calcium salts
Bile pigment polymer ~ 40%, Calcium
carbonate or phosphate, salts~ 15%,
Cholesterol ~ 5%, Mucin glycoprotein
~ 20%
Calcium bilrubinate ~ 60%, Calcium
palmitate and ,stearate soaps ~ 15%,
Cholesterol ~ 15%, Mucin glycoprotein
~ 10%
Radiopaque No Yes, ~ 50% No
Location Gallbladder ±common bile duct Gallbladder ±common bile duct Common bile duct, Intrahepatic bile duct
Clinical associations Hyperlipidemia, Obesity,Clofibrate use,
Pregnancy,Cystic fibrosis, Octreotide use
Hemolytic anemia, Cirrhosis, Total
parenteral nutrition (TPN) ,Ileal disease
(after puberty), Ceftriaxone use
Bacterial infection, (Escherichia coli),
Parasitic infection, Bile duct anomaly,Use
of birth control pills
Recurrence Yes No Yes
Sex Female > Male No difference No difference
Age Puberty (increasing with age) Anyage (increasing with age) Any age (increasing with age)
Bacteria No No Yes (consistently found at the core)
Soluble Yes No No (minimally)
with the diagnosis of cholelithiasis, the underlying etiol-
ogy should be also evaluated through medical history tak-
ing and patient examination, as gallstone is a sign indicat-
ing an underlying pathophysiological cause.
The evaluations should include positive history of
hemolytic diseases in the child or his/her family mem-
bers, metabolic syndrome in the child, history of recur-
rent icterus in the child or his/her family members, history
of splenectomy in relatives, anemia, clinical symptoms of
liver dysfunction, symptoms of chronic liver disease in the
child, family history of mortality possibly due to liver dis-
orders (e.g., Wilson’s disease), chronic diarrhea, steator-
rhea, weight loss, severe skin itching in the child (Bayler
disease), obesity, and the underlying causes of gallstone
formation (12,16,19).
Use of ceftriaxone, as a routine prescribed medicine,
as well as clofibrate, is the main pharmacological cause
of stone formation. The results of laboratory tests such
as complete blood count, differential tests, Coombs test,
reticulocyte count, hemoglobin electrophoresis, glucose-
6-phosphate dehydrogenase (G6PD) test, liver functional
tests, evaluation of amylase, lipase, and copper serum lev-
els, Wilson’s disease diagnostic tests, as well as sweat and
stool exams can be helpful in the diagnosis of cholelithia-
sis. Evaluation of patients’ medical history, contributing
factors for gallstone formation, and clinical symptoms of
systemic diseases, along with laboratory findings, can help
determine the etiology of stone formation (12,13,16).
The most common causes of cholelithiasis in children
include idiopathic diseases, TPN, hemolytic disease, malab-
sorption, NEC, hepatobiliary diseases, obesity, abdominal
surgery, epilepsy medications, and acute leukemia (1,5,24-
26). A review of 382 Canadian children with cholelithiasis
reported complications attributable to gallstone disease in
less than 5% of asymptomatic children. Also, about 20% of
the asymptomatic children revealed eventual resolution of
the gallstones. There was a similarly low rate of complica-
tion (8.6%) among infants in this study, and a high rate of
spontaneous resolution of gallstones (34.1%) was reported
among infants who were followed-up via ultrasound.
With this background in mind, expectant manage-
ment seems appropriate, particularly for otherwise
healthy infants and children with stones less than 2 cm in
size. For patients with smaller stones, serial ultrasound
examinations appear warranted to monitor spontaneous
disappearance of stones. Larger stones are more prob-
lematic. Gallstones may play a role in the development of
gallbladder carcinoma, with larger stones (> 2 cm) carry-
ing a greater risk than smaller ones. As larger stones are
unlikely to disappear spontaneously, there is a reasonable
argument for removing the gallbladder in an otherwise
asymptomatic child, given the inherent enhanced risk of
J Pediatr Rev. In Press(In Press):e9114. 3
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Karami H et al.
gallbladder carcinoma, caused by the presence of a stone
in the gallbladder over several decades (5) (Table 2) Friesen
and Roberts, 1989 (12).
Table2. Diagnosis of Cholelithiasis
Age Percentage of TotalCases
0 - 12 months
None 36.4
Total parenteral nutrition (TPN) 29.1
Abdominal surgery 29.1
Sepsis 14.8
Bronchopulmonary dysplasia 12.7
Hemolytic disease 5.5
Malabsorption 5.5
Necrotizing enterocolitis (NEC) 5.5
Hepatobiliary disease 3.6
1 - 5 years
Hepatobiliary disease 28.6
Abdominal surgery 21.4
Artificial heart valve implantation 14.3
None 14.3
Malabsorption 7.1
6 - 11 years
Pregnancy 37.2
Hemolytic disease 22.5
Obesity 8.1
Abdominal surgery 5.1
None 3.4
Hepatobiliary disease 2.7
Total parenteral nutrition (TPN) 2.7
Malabsorption 2.8
3.8. Treatment of Cholelithiasis
Treatment of cholelithiasis is affected by several con-
tributing factors, such as the anatomical status of gall-
stone, rate of symptoms in the child, underlying anatomic
disorders, other underlying causes of stone formation, in-
flammatory changes of the biliary system, and age of the
child. While the gallstone is located in the common bile
duct or around the pupillary sphincter, it can cause cholan-
gitis, obstruction of bile flow, and icterus in the child,
which definitely require stone removal.
Gallstones with diameters less than 10 mm, which
float in the gallbladder and are diagnosed incidentally
in asymptomatic children, should be investigated for
hemolytic diseases and underlying disorders and need to
be treated after diagnosis. On the other hand, one or
more gallstones, a few millimeters in size, floating in the
gallbladder, are mostly asymptomatic and should be only
monitored once every few months (11,17). In case of the oc-
currence of cholecystitis and cholangitis after the adminis-
tration of antibiotics, serum therapy, and vital sign moni-
toring, it is recommended to remove the gallstone (prefer-
ably by laparoscopy) as soon as possible.
In cases receiving TPN, the child should be monitored
due to time limitations on the use of TPN regimens; also,
asymptomatic patients should be assessed (13,27). By dis-
continuation of TPN regimen, onset of an oral nutritional
regimen, and establishment of bile flow, bile sedimenta-
tion and cholelithiasis development would gradually re-
solve. In cases with more severe underlying diseases such
as intestinal pseudo-obstruction or short bowel syndrome,
TPN regimen should be continued and repeated, as there is
no chance for enteral feeding; in these patients, cholecys-
tectomy is a preferable therapeutic approach.
Patients should be monitored to receive ceftriaxone
and clofibrate after completing the therapeutic period. In
most cases, cholelithiasis resolves after several months of
monitoring. However, cholelithiasis is not usually resolved
spontaneously in older children and should be removed
in symptomatic cases. Cholecystectomy is applicable in
cases requiring acute drainage of gallbladder and also se-
vere cases of the disease. Removal of cholelithiasis through
performing cholecystectomy (via laparoscopy) in children
is an alternative, as adopted in adult cases. Non-surgical,
therapeutic approaches for cholelithiasis in children are
increasing, although there are still some controversies in
this context (9,11,15).
3.9. Oral Medications
Ursodeoxycholic acid (Ursobil®) and chenodeoxy-
cholic acid (chenodiol) can be only effective in cholesterol
stones and therapy–resistant cases. However, their admin-
istration is restricted due to the long course of treatment,
different efficacies, and side-effects such as diarrhea
and liver consequences. Administration of hydroxyurea
has been shown to be useful in reducing the frequency
of cholelithiasis in some hemolytic diseases, such as
thalassemia intermedia or major (10,28,29).
Extracorporeal shock–wave lithotripsy is another ther-
apeutic method, which can be applied whenever the
patient is asymptomatic or the gallstone is radiolucent
(1,30); consequently, the best result is obtained in sin-
gle cholelithiasis. The most common complications of
cholelithiasis include cholecystitis and pancreatitis. In
cases with cholesterol stones, methyl tert-butyl ether
4J Pediatr Rev. In Press(In Press):e9114.
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Karami H et al.
Cholecystostomy
Cholelithiasis
Ultrasono
g
ra
p
h
y
K.u13
Diagnosis
Asymptomatic
Symptomatic
Less than 20mm Greater than 20mm
Need to treatment
Follow up Cholecystectomy
Cholecystom ERCP + basket
removal
Laparascopic
cholecystomy
Oral
medication
Electrohydraulic
Lithotripsy
Laser
Lithotripsy
ESWL
Figure 1. Recommended Therapeutic Methods for Childhood Cholelithiasis
should be injected into the gallbladder by a catheter. Al-
though the results in adults seem to be satisfactory, imple-
mentation of this method in children is faced with some
limitations due to its numerous side-effects, such as intra-
venous hemolysis, duodenitis, nausea, and vomiting.
Partial internal biliary diversion can be helpful in
cases with progressive familial cholestasis (Bayler disease).
Weight control in children with obesity, use of hypolipi-
demic drugs in high-risk populations, exercise, early re-
turn to oral nutrition in hospitalized children, and pre-
vention of drug-induced calculi by prescription of proper
medications are suggested. The recommended therapeu-
tic methods are presented in Figure 1 (9,13,31) and Table 3
(24,32-36).
4. Conclusions
Children with gallbladder disease may be either symp-
tomatic or asymptomatic, although the asymptomatic pre-
sentation is less likely in children. The risk factors in chil-
dren vary according to age, geographical localization, eth-
nicity, referral status, and medical facilities. Hemolytic
anemia, family history, oncologic diseases, and ceftriax-
one use were the most frequent risk factors in the asymp-
tomatic group. Non-specific abdominal symptoms, es-
pecially in younger children, may mimic the gallstones;
therefore, more children might have been factitiously clas-
sified in the symptomatic group. Although both genders
are equally affected in early childhood, most previous stud-
ies have demonstrated a female predominance in pediatric
gallbladder disease, starting from puberty. The results
have shown that most gallstones at young age are diag-
nosed in the second decade of life. It seems that evaluation
of the underlying causes of gallstone formation and appro-
priate diagnostic and therapeutic implications is still chal-
Table3. Therapeutic Approaches for Childhood Cholelithiasis
Type Comments
Cholecystectomy Method of choice in most cases
Cholecystostomy Effective for acute gallbladder
drainage (i.e., acalculous
cholecystitis)
Laparoscopic cholecystectomy Effective for severely ill patients (e.g.,
cystic fibrosis), shortening the
length of hospital stay
Endoscopic retrograde
cholangio-pancreatography
Basket removal Bile duct stone removal
Mechanical basket lithotripsy Stone crushing within the bile ducts
Electrohydraulic lithotripsy Stone destruction within the bile
ducts
Laser lithotripsy Stone destruction within the bile
ducts
Extracorporeal shock–wave
lithotripsy
Limited experience (unpublished)
only for cholesterol stones currently
Dissolution
Oral medicine
Ursodeoxycholic acid and
chenodeoxycholic acid
Blockage of HMG-CoA reductase and
reduction of cholesterol synthesis
Contact
Methyl tert-butyl-ether (for
cholesterol stones only)
Bile acid-EDTA solution for pigment
stones (IfRr, experimental)
Preventive measures
Enteral feeding Even small amounts during total
parenteral nutrition (TPN) can
decrease the risk of stone formation
Weight loss For obesity or gradual weight loss
Lovastatin and simvastatin Blockage of HMG-CoA reductase and
reduction of cholesterol synthesis
(experimental)
Cholecystokinin Stimulation of gallbladder
contraction while NPO
(experimental)
lenging in the management of childhood cholelithiasis.
In asymptomatic cases or those with gallstones of certain
sizes, only surveillance of the disease or ruling out the un-
derlying causes is recommended. It should be noted that
long periods of diagnostic and therapeutic approaches can
impose stress and tension on the patients’ families.
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Uncorrected Proof
... Respecto a las características clínicas, se encontró una alta prevalen- y dolor abdominal en hipocondrio derecho (73,8%), hallazgos que difieren significativamente con respecto a la literatura iraní donde se reporta una mayor prevalencia de dolor abdominal (67%) y en menor proporción vómito (35%) (17,18). No obstante, el estudio concuerda con la India donde se reporta que 61,1% de los pacientes presentaron síntomas entre los que resaltan dolor en cuadrante superior derecho (51,4%) como principal síntoma, epigastralgia, náuseas (33,8%) y vómito (28,4%) (19,20). ...
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Objetivo: Determinar prevalencia de sobrepeso en los pacientes pediátricos con colelitiasis atendidos en el hospital San Rafael de Tunja durante los años 2010 - 2019. Materiales y métodos: Estudio observacional, descriptivo, de corte transversal y retrospectivo, donde se evaluó las características de colelitiasis en los pacientes menores de 18 años de edad. Se evaluaron variables sociodemográficas, clínicas, imagenológicos y terapéuticas. Resultados: Se revisaron 84 expedientes clínicos de pacientes con diagnóstico de colelitiasis en un periodo comprendido entre el año 2010 al 2019. El 69,1% de la población de género femenino y el 30,9% al género masculino. La edad promedio de los pacientes fue de 15.07 años, la prevalencia de sobrepeso fue 35,7% y de obesidad 21,4%. Las manifestaciones más frecuentes fueron nauseas 85,71%, vómito 84,52% y signo de Murphy positivo en un 83,33%. en el 76% de los ||||pacientes los cálculos fueron únicos, con un tamaño promedio de 7,45 mm (con un mínimo de 1 mm y máximo 25 mm). El 26,1% recibió tratamiento conservador, mientras que el 73,8% fue tratado mediante cirugía, de estos, en el 50% de los casos la intervención fue abierta y en el restante por vía laparoscópica de los cuales el 2,43% requirió conversión intraoperatoria. Respecto a las complicaciones las más presentadas fueron, el absceso hepático 2,38% y pancreatitis en un 4,76%. Conclusiones: Más de la mitad de los niños con colelitiasis tenían obesidad (21,4%) y sobrepeso (35,7%), lo cual indica un problema de salud pública ya que puede incidir en otras patologías a futuro, además de ser fuerte predictor de la patología a estudio en este artículo.
... Gender is mainly associated with pure cholesterol stone 11 . The development of cholelithiasis in children may be affected by age, sex, genetic constituent, race and geographical influence 12 . Cholecystectomy is recommended in paediatric patients with biliary complaints but is not advocated for those with vague complaints. ...
Article
Introduction: Cholelithiasis is being frequently diagnosed in children, although not as often as in adult. The real aetiology of gallstone formation is poorly understood, but some inciting factors are assumed to be involved in gallstone formation in children. Traditionally cholelithiasis in children is classified as haemolytic or nonhaemolytic in origin. Nonhaemolytic cholelithiasis seems to be more frequent than haemolytic cholelithiasis at present. Aim: To find out the pattern of childhood cholelithiasis presenting in a tertiary level military hospital. Methods: This retrospective observational study was carried out in the Department of Paediatric Surgery, CMH Dhaka from January 2015 to December 2018. A total of 35 children with cholelithiasis were admitted in this hospital. Results: During the study period 35 children with cholelithiasis were admitted. Among them maximum children 31(88.6%) were in the age group of 6-12 years. Out of them 23(65.7%) were female and 12(34.3%) were male making a female to male ratio of 1.92:1. Twelve children (34.3%) were asymptomatic and 23(65.71%) were symptomatic. Among symptomatic group 10(28.6%) had biliary colic, 10(28.6%) had nonspecific abdominal pain and 3(13.0%) had acute abdominal pain. Out of these 35 children, only 4(11.4%) had link with haemolytic anaemia. Conclusion: Cholelithiasis in children is being recognized with increased frequency in recent years. The ratio of cholecystitis and cholelithiasis varies considerably in different countries and centres. Childhood cholelithiasis has less chance of complication and high rate of resolution. JAFMC Bangladesh. Vol 15, No 1 (June) 2020: 8-11
... Incidence of gallstone disease in India is 0.3% with less than 0.1% in the 0-10 year age group 10,11 . Males and females are equally affected in early childhood, but a clear female preponderance emerges in adolescence 12,13 . In this study, we observed male preponderance with a male: female ratio of 1.36. ...
... In Germany, guidelines by the German Societies for Digestive and Metabolic Diseases and for Surgery of the Alimentary Tract regulate the management of cholelithiasis in adults [8]. Separate treatment guidelines in the pediatric sector on the basis of evidence-based large-scale population studies are either lacking, outdated or represent expert opinions of distinct hospitals (e.g., Sweden [2], Brazil [9], India [10], USA [11], Egypt [12], Iran [13]). This is significant with regard to the timing of surgery. ...
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Background In contrast to adults, for whom guidelines on the cholelithiasis treatment exist, there is no consistent treatment of pediatric patients with cholelithiasis throughout national and international departments, most probably due to the lack of evidence-based studies. Methods We evaluated the German management of pediatric cholelithiasis in a dual approach. Firstly, a retrospective, inter-divisional study was established, comparing diagnostics and therapy of patients of the pediatric surgery department with the management of patients aged < 25 years of the visceral surgery department in our institution over the past ten years. Secondarily, a nation-wide online survey was implemented through the German Society of Pediatric Surgery. Results Management of pediatric patients with cholelithiasis was primarily performed by pediatricians in the retrospective analysis ( p < 0.001). Pediatric complicated cholelithiasis was not managed acutely in the majority of cases with a median time between diagnosis and surgery of 22 days (range 4 days–8 months vs. 3 days in visceral surgery subgroup (range 0 days–10 months), p = 0.003). However, the outcome remained comparable. The hospital’s own results triggered a nation-wide survey with a response rate of 38%. Primary pediatric medical management of patients was confirmed by 36 respondents (71%). In case of acute cholecystitis, 22% of participants perform a cholecystectomy within 24 h after diagnosis. Open questions revealed that complicated cholelithiasis is managed individually. Conclusions The management of pediatric cholelithiasis differs between various hospitals and between pediatricians and pediatric surgeons. Evidence-based large-scale population studies as well as a common guideline may represent very important tools for treating this increasing diagnosis.
... In fact, patients with ABCB11 mutations are at a higher risk of cholelithiasis. 9,10,19 While, Onal and his collages in their study revealed that vitamin D deficiency is suggested to be associated with gallbladder stasis, and a role for vitamin D supplementation is thought to have potential to prevent gallstones in this special population. 20 This may explain the occurrence of gallbladder stones in our patient as a result of vitamin D deficiency in early childhood, and that was not due to increased intake of vitamin D as it seems to be. ...
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Background: The gall bladder stones (GBSs) are common disease related to diet habit, obesity, hematological diseases, diabetes mellitus, and receiving total parenteral nutrition. GBS is a rare cause of hospitalization of pediatric patients but have been increasingly diagnosed in recent years due to widespread use of ultrasonography. The aim of this case report study is to determine the clinical presentation, risk factors, valuable diagnostic procedures, and outcome of laparoscopic management of cholelithiasis in children. Case report: Our case is a 9-year-old boy with empyemic gallbladder complaining of attacks of colicky epigastric pain associated with recurrent vomiting. On abdominal palpation, there is positive sign of deep tenderness at hypochondrium area and positive murphy sign. He has central obesity with body mass index of 29.9, skin folds >3.5 cm and waist circumference >90 cm. He has history of high cholesterol and fatty diet and fast food habit, prolonged intake of vitamin D, and positive family history. While no other associated risk factors was detected in our patient, all laboratory investigations was within normal ranges even for his lipid profile. Although empyema was present no leukocytosis was detected. Abdominal ultrasound showed the gall bladder wall is slightly thick surrounded by pericholycystic fluid, solitary GBS of 3 cm size and normal CBD. Post-operative histopathological examination revealed thick wall gallbladder with multiple tiny stones of cholesterol type. The patient was treated with laparoscopic cholecystectomy with promising outcome and no complications. Conclusion: Pediatric surgeons should consider cholecystolithiasis from differential diagnosis of abdominal pain associated with vomiting in children. Empyema of gallbladder should be considered once murphy sign is positive in such child patients. Child obesity, fatty diet, vitamin D deficiency, and family history are possible risk factors. Ultrasonography is the mainstay of diagnosis. Laparoscopic cholecystectomy is the appropriate management for symptomatic cholelithiasis in children.
... In line with our results, Dooki et al., [10] found in his study conducted upon 66 children with gall stones that the most common predisposing factors of cholelithiasis were hemolytic diseases, hepatobiliary diseases and cystic fibrosis. As well, Karami et al., [11] stated that hemolytic diseases, hereditary blood disorders, and cirrhosis were among the main causes of cholelithiasis in children. Also, Zhang et al., [12] conducted a study on the prevalence of gallstone disease in Chinese patients with liver cirrhosis. ...
... Out of all the cases of acute cholecystitis diagnosed in the pediatric population, approximately 50-70% are characterized as acalculous [1]. Factors that predispose the development of gallstones in children include hemolytic diseases, obesity, congenital heart diseases, short gut syndrome, inflammatory bowel disease, infection, ileal resection, and prolonged parenteral nutrition [2][3][4]. We present a case of gallbladder perforation secondary to cholelithiasis in a child with recent abdominal surgery and history of Crohn's disease. ...
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Gallbladder perforation is a rare occurrence in children. We report a case of gallbladder perforation in a 15-year-old boy with Crohn's disease currently being treated with immunosuppressive therapy and corticosteroids. He was successfully treated with percutaneous drainage and interval cholecystectomy.
... In a large population study on TI patients in Iran, 153 subjects were evaluated for thalassemia-related complications and cholelithiasis was reported in 25.5% of the participants 19 . This is while cholelithiasis has been reported in 0.1-0.3% of general pediatric population (20). This result was obtained while cholelithiasis was reported in 30-56% of TM patients in Italy 21,22 , 21.6% in the US 23 and 6-18% in Egypt 24,25 . ...
Article
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Background: Cholelithiasis and its predisposing factors are less characterized in thalassemia syndromes. In the present study, we assessed the prevalence of gallstones and related-risk factors among thalassemia major (TM) patients in south-east of Iran. Materials and Methods: The patients were recruited form a single center in Zabol city, south-east of Iran. Demographic and clinical information were retrieved from medical histories. Abdominal ultrasonography was performed to scrutinize gallstones and organ dimensions of liver, spleen, gallbladder and kidney. Results: The study participants (n=127) consisted of 50 (39.4%) males and 77 (60.6%) females. The mean age of the patients was 15.2±7.9 years. Cholelithiasis was observed in 11 (8.7%) patients. Cholelithiasis was significantly associated with age (P=0.002) and splenectomy (P=0.001). The patients with cholelithiasis received a significantly higher blood volume than patients without cholelithiasis (546±108.7 ml and 425.1±134.7 ml, respectively, P=0.007). There were significant differences between cholelithiasis and non- cholelithiasis TM patients regarding the length of right and left liver lobes (P=0.001), as well as the length of gallbladder (P=0.006). Ferritin level was not associated with cholelithiasis in our patients. In multivariate analysis, age older than 15 (OR=10.4, 95% CI: 1.2-86.3, P=0.02) and 30 years old (OR=42.6, 95% CI: 2.9-613, P=0.006), and splenectomy (OR=8.7, 95% CI: 2.1-35.4, P=0.002) were significant risk factors for cholelithiasis. Conclusion: Cholelithiasis is a relatively common complication among TM patients in our region. The most prominent risk factors of cholelithiasis were advanced age, splenectomy and large-volume blood transfusion.
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Objective: The most common etiology for gallstones in children is hemolytic diseases; however, the prevalence of nonhemolytic gallstones, which are mostly idiopathic, is increasing. Several studies concerning the treatment of gallstones with respect to the influence of extracorporeal shock wave lithotripsy (ESWL) have been conducted in adults, but not to the same extent in children. Therefore, this study attempted to examine the effects of lithotripsy on idiopathic gallstones in children. Materials and Methods: In this study, 12 children, all of whom were under 12 years of age and diagnosed with idiopathic gallstones, were treated with ESWL. The average age of the children examined in this study was 6.5 years (range 3-11 years). Patients were treated with 2500-3000 shockwaves per session. The number of shockwaves was 90 shocks/min and the impulse intensity ranged from 10 to 12 kV. The final goal was the fragmentation of stones in pieces with less than 3 mm in dimension. Patients were followed up for 6-30 months. Results: A total of 12 patients were treated with ESWL for 14 rounds. In three patients, complete fragmentation occurred within the first trial and was cleared. The nine remaining patients underwent ESWL 10 times in which an acceptable change in the gallstone's condition was not observed. Five of the patients underwent surgery. The chemical composition of the gallstones showed that the dominant element in them was calcium. Conclusions: Our findings show that performing ESWL can be effective in some children. Further studies with larger population are recommended. Furthermore, it seems increasing the voltage intensity and frequency as conducted in adults accompanied with biliary acids prescription can be effective in children.
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Cholelithiasis rarely occurs in children but the increased use of ultrasonography has led to increased detection of gallstones in patients. The epidemiology and predisposing factors of cholelithiasis vary in different populations. The aim of this study was to describe the clinical presentation, predisposing factors and to evaluate management and outcome of patients referred to Amirkola Children's Hospital jn Babol. This cohort study was performed on children with cholelithiasis referred during 2000 to 2011. Cholelithiasis was diagnosed with ultrasonography. The data was obtained based on history, physical exam, clinical and paraclinical investigations and analyzed by SPSS version 18. P-value <0.05 was considered being significant. From the 66 patients with cholelithiasis, 39 (59.1%) were males. The mean age at diagnosis was 6.6±4.5 years. The most common predisposing factor included ceftriaxone therapy (27.3%), hemolytic diseases (13.6%), hepatobiliary diseases (7.5%) and cystic fibrosis (7.5%). In 30.3% of patients, no predisposing factor was detected. The most common complaint was abdominal pain (67%). Among the patients in whom abdominal X-Ray was performed, only 20% had radiopaque gallstones; 6 (9%) patients underwent cholecystectomy. According to this study, ceftriaxone therapy and hemolytic diseases were the most common predisposing factors in children with cholelithiasis in our area and cholecystectomy had not been needed in most patients.
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Facilitation of biliary salts secretion represents the mainstay of treatment for progressive familial intrahepatic cholestasis (PFIC). The purpose of this study was to introduce a new approach for the treatment of progressive familial intrahepatic cholestasis (PFIC) to avoid ostoma. An 11-year-old girl with the diagnosis of PFIC underwent cholecystoappendicostomy with myotomy operation. Because of anastomosis stricture, she was reoperated with cholecystojejunocolic anastomosis and intussuscepted valve surgery. She was followed for 9 months. Despite disappointing outcomes of internal drainage with cholecystoappendicostomy, results of cholecystojejunocolic anastomosis with intussuscepted valve surgery were promising. The cholecystojejunocolic anastomosis with intussuscepted valve surgery could be considered as a forthcoming approach in the treatment of intrahepatic cholestasis.
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Extra-hepatic bile duct injuries in children following blunt abdominal trauma are rare; early diagnosis and treatment are imperative for a good outcome. The purpose of this report is to describe the management of problems encountered in children with bile duct injuries following blunt abdominal trauma. A three year-old girl presented with obstructive jaundice and vomiting following blunt abdominal trauma one month prior to referral. The child was sitting in her father's lap when the accident occurred. She was then examined by an emergency physician to assess the cause of vomiting. An abdominal ultrasonography was performed and revealed dilatation of the common bile duct. To the best of our knowledge, this is the first report of bile duct injury following blunt trauma and its emergency management.
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In order to compare gallstone disease data from India and Asian countries with Western countries, it is fundamental to follow a common gallstone classification. Gallstone disease has afflicted humans since the time of Egyptian kings, and gallstones have been found during autopsies on mummies. Gallstone prevalence in adult population ranges from 10 to 15 %. Gallstones in Western countries are distinguished into the following classes: cholesterol gallstones that contain more than 50 % of cholesterol (nearly 75 % of gallstones) and pigment gallstones that contain less than 30 % of cholesterol by weight, which can be subdivided into black pigment gallstones and brown pigment gallstones. It has been shown that ultrastructural analysis with scanning electron microscopy is useful in the classification and study of pigment gallstones. Moreover, x-ray diffractometry analysis and infrared spectroscopy of gallstones are of fundamental importance for an accurate stone analysis. An accurate study of gallstones is useful to understand gallstone pathogenesis. In fact, bacteria are not important in cholesterol gallstone nucleation and growth, but they are important in brown pigment gallstone formation. On the contrary, calcium bilirubinate is fundamental in black pigment gallstone formation and probably also plays an important role in cholesterol gallstone nucleation and growth.
Data
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In order to compare gallstone disease data from India and Asian countries with Western countries, it is fundamental to follow a common gallstone classi-fication. Gallstone disease has afflicted humans since the time of Egyptian kings, and gallstones have been found during autopsies on mummies. Gallstone preva-lence in adult population ranges from 10 to 15 %. Gallstones in Western countries are distinguished into the following classes: cholesterol gallstones that contain more than 50 % of cholesterol (nearly 75 % of gall-stones) and pigment gallstones that contain less than 30 % of cholesterol by weight, which can be subdivided into black pigment gallstones and brown pigment gall-stones. It has been shown that ultrastructural analysis with scanning electron microscopy is useful in the clas-sification and study of pigment gallstones. Moreover, x-ray diffractometry analysis and infrared spectroscopy of gallstones are of fundamental importance for an accurate stone analysis. An accurate study of gallstones is useful to understand gallstone pathogenesis. In fact, bacteria are not important in cholesterol gallstone nucleation and growth, but they are important in brown pigment gallstone formation. On the contrary, calcium bilirubi-nate is fundamental in black pigment gallstone forma-tion and probably also plays an important role in cholesterol gallstone nucleation and growth.
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AIM: To evaluate the management of Italian children with cholelithiasis observed at Pediatric and Surgical Departments linked to Italian Society of Pediatric Gastroenterology Hepatology and Nutrition. METHODS: One-hundred-eighty children (90 males, median age at diagnosis 7.3 years; range, 0-18 years) with echographic evidence of cholelithiasis were enrolled in the study; the data were collected by an anonymous questionnaire sent to participating centers. RESULTS: One hundred seventeen patients were treated with ursodeoxycholic acid; in 8 children dissolution of gallstones was observed, but the cholelithiasis recurred in 3 of them. Sixty-five percent of symptomatic children treated became asymptomatic. Sixty-four patients were treated with cholecystectomy and in only 2 cases a postoperative complication was reported. Thirty-four children received no treatment and were followed with clinical and echographic controls; in no case the development of complications was reported. CONCLUSION: The therapeutic strategies were extremely heterogeneous. Ursodeoxycholic acid was ineffective in dissolution of gallstones but it had a positive effect on the symptoms. Laparoscopic cholecystectomy was confirmed to be an efficacy and safe treatment for pediatric gallstones.
Article
Thirty-five cases of cholelithiasis diagnosed at a children's hospital over a 7.5-year period are reviewed and compared to 693 cases of pediatric gallstones reported in the literature. Symptomatology and associated medical history are more important in diagnosing cholelithiasis than are laboratory tests. Hemolytic disease is the most common associated condition in our series (46%) as well as in the literature (30%), but the frequency of the various associated conditions varies with age. Isolated gallstone disease does occur, particularly in the young infant. Jaundice is the most common symptom in children less than 1 year of age, being present in greater than 90 percent of symptomatic patients previously reported. Overall, the most common symptom in our series is vomiting (60%). Right upper quadrant pain in the absence of vomiting does not appear to be significant, as this occurred in only one patient (3%) in our series.