Gallstone disease in children

https://doi.org/10.1053/j.sempedsurg.2012.05.008Get rights and content

Gallstone disease in children is evolving, and for the previous 3 decades, the frequency for surgery has increased greatly. This is in part because of improved diagnostic modalities, but also changing pathology, an increased awareness of emerging comorbidities, such as childhood obesity, and other associated risk factors. This article outlines the pathophysiology, genetics, and predisposing factors for developing gallstones and includes a review of the literature on the current and more novel medical and surgical techniques to treat this interesting disease.

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:

  • 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

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