Cholelithiasis

Pediatric Cholelithiasis

After feeling the synapses in my brain start to misfire while contemplating the multitude of potential medical problems and drug interactions that my adult patients present with, I relish being able to evaluate a pediatric patient who has no chronic medical problems and is on no medications.  Straight forward presentations and clear-cut diagnoses; that is what is always seen in the Peds ED.  Right?  Well, if that were completely true, then I would have had a much harder time writing weekly Morsels over the past 3-4 years.

Unfortunately, in recent years, conditions that were once considered “adult” illnesses are now increasing in incidence in children.  We have discussed how the prevalence of Kidney Stones in children is increasing, and not to be outdone, gallstones are are no longer simply an adult consideration.

Basics of Gallstones

  • Current estimates have incidence ~ 1.9%
  • Rise in childhood obesity, diabetes, and terrible diets do play a role in this increase.
  • Frequency of cholelithiasis in children with hemolytic anemias is almost twice that of the general population!

Types of Stones

  • Brown Pigment Stones

    • Rare
    • Associated with infections.
  • Cholesterol Stones
    • Most common in adults
    • Account for ~21% of gallstones in kids
    • Associated with obesity, estrogen/progesterone therapy, ethnicity, and family history.
  • Black Pigment Stones
    • Most common in children (~48% of gallstones in kids)
    • Seen primarily with hemolytic disease or prolonged TPN use
  • Calcium Carbonate Stones
    • Rare in adults
    • ~24% of gallstones in children
    • Often associated with systemic illnesses.

Patients at Risk

  • Hemolytic Disease
    • Incidence of cholelithiasis in sickle cell disease is ~50%!
    • 15-30% are diagnosed before age 10!!
  • Cystic Fibrosis
  • Abnormal Biliary Anatomy
  • Hepatobiliary Disease
  • Crohn’s Disease
    • Or other condition that affects the terminal ileum
  • Systemic Infection / Sepsis
  • Congenital Heart Disease
    • Increased hemolysis
  • Drugs
    • Oral Contraceptives (also Pregnancy)
    • Antibiotics (ceftriaxone is one notable agent)
    • Antirejection Drugs (Cyclosporin, azathioprine)
  • Obesity
  • Family History

When to Consider It

Like many other significant conditions in pediatric patients, cholelithiasis and its complications may not present the same way as we are accustomed to in older patients.

  • In those <1 year – jaundice may be the only clue.
  • Toddlers may present with nonspecific vomiting.
  • ~1/4 of kids with gallstones will have nonspecific abdominal pain.
    • Many of these patients had hemolytic disease
    • Nonspecific abdominal pain in a patient with Sickle Cell Disease – before you attribute it solely to a vaso-occlusive crisis make sure you consider a biliary etiology!
  • Murphy sign is often not as easy to illicit in children.

Evaluation

  • Normal LFTs, Lipase, and WBC do not rule out the condition.
  • Patients with either physical exam or lab values concerning for cholelithiasis should have an ultrasound performed.
  • Patients with normal physical exam and lab values, but concerning risk factors should be informed of the potential for gallstones, but are safe for non-emergent imaging.

So, while it is often announced that “kids aren’t just little adults,” it is becoming increasingly apparent that we must consider adult diseases in the kids in our EDs… I guess kids just want to grow up to be like their parents.

 

Poffenberger CM, Gausche-Hill M, Ngai S, Myers A, Renslo R. Cholelithiasis and its complications in children and adolescents: update and case discussion. Pediatr Emerg Care. 2012 Jan;28(1):68-76

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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