Acute Cholecystitis

Acute CholecystitisWhen caring for children, we are all prepared for evaluating abdominal pain as it seems like every condition leads can cause belly pain. Fortunately, this means the odds favor it not being caused by a critical condition; however, it therefore mandates that we remain vigilant for those subtle presentations of more ominous conditions. Previously, we’ve discussed important conditions to keep on our Ddx lists (ex, Pancreatitis, Cholelithiasis, Malrotation, Appendicitis, HSP, Intussusception, Ovarian Torsion, Testicular Torsion), but there is another one that we need to consider that may be easily overlooked, due to the age of the patient- Acute Cholecystitis:

 

Acute Cholecystitis: Bascis

  • Cholecystitis = inflammation of the gallbladder (as the name would imply).
    • Can be Acute or Chronic
      • Acute is less common than Chronic in children.
      • Chronic cholecystitis is likely under-appreciated though. [Blackwood, 2017]
    • Can be associated with Stones (Calculous) or Not (Acalculous)
      • Calculous:
        • Cystic duct become impacted by stone leading to gallbladder distention and edema with biliary stasis and bacterial overgrowth. [Guralnick, 2009]
        • Needs to be treated surgically.
      • Acalculous:
        • Most frequent form of acute cholecystitis in children (unlike adults) [Poddighe, 2015]
        • Mortality rate estimated to be >30%. [Poddighe, 2015]
          • May be treated conservatively, but may require surgery. [Poddighe, 2015]
          • Risk factors for mortality = anemia, thrombocytopenia, gallbladder sludge, hepatitis, and sepsis plus hepatitis. [Lu, 2017]
  • Common Pathologic Components of Cholecystitis: [Poddighe, 2015]
    • Gallbladder ischemia
      • Related to severe Dehydration (ex, SHOCK), Sepsis, Cardiovascular disease or surgery.
      • Arterial occlusion for vasculitis or diabetes.
    • Bile stasis
      • From prolonged fasting, obstruction, TPN, IV narcotics
      • Static bile can lead to a chemical irritation of the gallbladder.
    • Direct trauma
  • Often diagnosed based with Ultrasound
    • Increased gallbladder wall thickness (>3-4 mm)
    • Pericholecystic fluid
    • Distented gallbladder
    • Sludge (or stones)
    • Ultrasonographic Murphy sign

 

Acute Cholecystitis: Acalculous

  • In the CRITICALLY ILL patient: [Poddighe, 2015]
    • Often considered after alterations in bloodwork.
      • Findings consistent with cholestasis and liver dysfunction.
      • Often these patients are too ill to communicate discomfort.
    • Seen most commonly with:
      • Major Surgery (especially cardiovascular)
      • Major Burns
      • Multiple Trauma
      • Severe Systemic infections (ex, Sepsis)
  • In otherwise HEALTHY patients: [Poddighe, 2015]
    • Acalculous cholecystitis is more common than in the critically ill.
    • Patients may present with nonspecific and variable constellation of symptoms (ex, Abdominal pain, Fever Nausea/vomiting, Jaundice)
    • It is not just a young adult issue: [Poddighe, 2015]
      • Cases of in adolescents as well as school-aged children and even as young as 2 years of age.
    • Often lack the pathophysiological aspects and risk factors associated with the acute ill patients. [Poddighe, 2015]
    • Most cases are related to infections: [Lu, 2017]
      • Yeast
      • Parasites
      • Bacteria
        • Brucella spp., C. jejuni, C. burnetti, Leptospira spp., Salmonella spp., V. cholera
        • Staph aureus, Strep spp.
      • Viruses (most prevalent causative agents) [Poddighe, 2015]
        • Hep A and B
        • CMV
        • Mycoplasma
        • Influenza A
        • EBV [Poddighe, 2015; Alkhoury, 2015; Branco, 2015]
          • More than 30% of cases are associated with EBV! [Poddighe, 2015]
          • Viral acute acalculous cholecystitis has a good prognosis and is almost always managed conservatively.
    • Can also be associated with other systemic diseases: [Lu, 2017; Poddighe, 2015]

 

Moral of the Morsel

  • Not all kid belly pain is benign. Think of cholecystitis, even in kids.
  • Never say it’s “just a virus.” Viruses can cause lots of problems.
  • Mono doesn’t just harm the spleen! Keep acalculous cholecystitis on the Ddx for abdominal pain in a child with suspected/proven EBV infection.

 

References

Lu YA1, Chiu CH2, Kong MS1, Wang HI3, Chao HC1, Chen CC4. Risk factors for poor outcomes of children with acute acalculous cholecystitis. Pediatr Neonatol. 2017 Mar 25. PMID: 28499592. [PubMed] [Read by QxMD]

P Blackwood B1,2, Grabowski J1. Chronic cholecystitis in the pediatric population: an underappreciated disease process. Gastroenterol Hepatol Bed Bench. 2017 Spring;10(2):125-130. PMID: 28702136. [PubMed] [Read by QxMD]

Alkhoury F1, Diaz D1, Hidalgo J2. Acute acalculous cholecystitis (AAC) in the pediatric population associated with Epstein-Barr Virus (EBV) infection. Case report and review of the literature. Int J Surg Case Rep. 2015;11:50-52. PMID: 25932972. [PubMed] [Read by QxMD]

Branco L1, Vieira M1, Couto C2, Coelho MD1, Laranjeira C1. Acute Acalculous Cholecystitis by Epstein-Barr Virus Infection: A Rare Association. Infect Dis Rep. 2015 Dec 22;7(4):6184. PMID: 26753086. [PubMed] [Read by QxMD]

Shihabuddin B1, Sivitz A. Acute acalculous cholecystitis in a 10-year-old girl with cystic fibrosis. Pediatr Emerg Care. 2013 Jan;29(1):117-21. PMID: 23283281. [PubMed] [Read by QxMD]

Saito JM1. Beyond appendicitis: evaluation and surgical treatment of pediatric acute abdominal pain. Curr Opin Pediatr. 2012 Jun;24(3):357-64. PMID: 22450248. [PubMed] [Read by QxMD]

Guralnick S1. Cholelithiasis and cholecystitis. Pediatr Rev. 2009 Sep;30(9):368-9; discussion 369. PMID: 19726705. [PubMed] [Read by QxMD]

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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2 Responses

  1. Lisa Malyemezian says:

    My daughter at the age of 11 began complaining of acute severe right upper quad pain. She was convinced she was going to die! I’m a nurse, with no pediatric expertise and also not one to run to the ER! This pain continued for close to 1 hour when I decided we need to go, this is not normal. One thing you should know, she has beta Thalassemia intermedia. This episode of pain abruptly resolved and she went from writhing in pain to, I’m fine now. My mind immediately thought gallbladder. I did a bit of research on pediatric gb dx and thought maybe not. We decided to wait and see if she ever had this occur again. Well… it did, along with jaundice and palpable splenomegly. Not once were we told this is not uncommon with beta Thalassemia, and with know experience in peds, I didn’t get pushy. The final attack was so severe we did head to the ER. While enrout, pain again abruptly resolved. The ER md came in took a hx at which time I shared everything I had, he said she seems just fine now, did not draw 1 drop of blood and sent us home. I had enough! Took her straight to her pedi as soon as the doors opened blood tests were performed, I received a call about 4 hours later from the pedi who informed me, your daughter may be in or going into liver failure and instructed us to go to the large children’s hospital here in Houston now! I lost count at the number of residents we saw and answered questions repeatedly for about 6 hours. They were all lovely, but I had to suggest the gb ultrasound, no one ever even mentioned it. Needless to say. H r gb was full of stones and surgery was advised. I apologize for being so long winded, but I don’t want to leave gaps. I was pretty upset as this was my suspicion at the onset of the initial onset of her pain, and was kind of blown off by multiple physicians, discounting my suggestion. The night my daughter was admitted her lft’s were greater than 500, nearly 600. Is this common to hear in children with genetic hemolytic disorders? To me, this should have been the first thing that was ruled out, but was never even suggested. Quite concerning, but being fed up, and tired of seeing my child writh in pain, I insisted on the ultrasound, and sure enough, what I suspected all along. The splenomegaly was solely attributed to the beta Thalassemia and never worked up further. Very distressing and puzzling to me. There is some liver damage, and spleen remains large, but once the go was removed the pain was too, never to return. Is this common in pediatric acute abdominal pain with complete hx (beta Thalassemia)? She has only slightly yellow eyes now, and is fine, but I shutter to think what might have been had I not had a bit of knowledge and mothers intuition.

    Any thoughts would be appreciated.

    • Sean Fox says:

      I’m sorry to hear of your daughter’s pain, but I am glad she is improving.

      Gallbladder disorders are UNUSUAL in children overall, but there are children with specific conditions that place them at greater risk for gallbladder conditions and hemolytic disorders are on such condition that increases the risk. Since gallbladder disorders are so unusual in children, the diagnosis of them can be very challenging and may take a few evaluations, so I would say that your story is, itself, not unusual. I am glad the condition was discovered and encourage you to continue to collaborate with your group of physicians to ensure the best care possible.

      All the best,
      sean

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