Gallstone disease
Key points
Increasing obesity in children - primary gallstones (GS) now more common than haematological disease
Biliary dyskinesia now described in children
LITH, UGT1A1 genes predispose
Stone types
Mixed pigment - brown - due to sepsis, biliary obstruction
Black pigment - Calcium bilirubinate - due to haemolytic diseases
Cholesterol - often a single stone, more common in obese females
Calcium carbonate - associated with abdominal procedure as neonate, cystic duct obstruction
Conditions predisposing to GS
Congenital heart disease - calcium bilirubinate stones
Caused by chronic cyanosis and thrombocytopenia
Bone marrow + stem cell transplant
Graft vs host disease disrupts enterohepatic circulation
Chemo/radiotherapy also reisk factors
Cystic fibrosis
Mucus blocking of bile ducts causes biliary stasis and stone formation
Trisomy 21
Likely due to foetal hypercholesterolaemia
Parenteral nutrition
Due to disruption of enterohepatic circulation
Acalculous cholecystitis
Caused by trauma, sepsis, diabetes
Can do cholecystostomy in critically unwell patients. Cholecystectomy after stabilisation
Acalculous mucocoele (gallbladder hydrops)
Causes:
Kawasaki syndrome (i.e. mucocutaneous lymph node syndrome)
Streptococcal pharyngitis
Hepatitis
Familial Mediterranean fever
Nephrotic syndrome
Management
Define if symptoms are definitely related to GS
Bogue et al 2010 Asymptomatic GS can be managed conservatively - only 5% risk of complications
Infants can be managed conservatively - 25% resolve, 75% asymptomatic
Ursodeoxycholic acid helpful in dissolution of small stones in patients not fit for surgery
Offer laparoscopic cholecystectomy to patients who likely have symptomatic GS
Perform liver function tests prior - if elevated, get MRCP or do on-table cholangiogram as it may indicate ductal stones
Gallbladder duplications - no need to excise if not complicated
Complications of cholecystectomy
Retained stones - perform ERCP (in centre where this is available)
No lower age limit for ERCP - successful in 1 year olds
Can do ERCP in patients with pancreatitis
CBD injuries cause major morbidity - involve experienced hepatobilary (HPB) surgeon. If small, repair +/- T tube
If more extensive may need reconstruction e.g choledochojejunostomy
Large bile leak not responding to drainage - perform percutaneous transhepatic cholangiogram - then repair by experienced HPB surgeon
References
Gollin, Gerald, et al. "Gallbladder Disease." Pediatric Surgery NaT, American Pediatric Surgical Association, 2020. Pediatric Surgery Library, www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT/829468/all/Gallbladder_Disease.
Bogue CO, et al. Risk factors, complications, and outcomes of gallstones in children: a single-center review. J Pediatr Gastroenterol Nutr. 2010