You are in: eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology CholelithiasisArticle Last Updated: Jun 19, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Alexandre F Migala, DO, Staff Physician, Department of Emergency Medicine, Denton Regional Medical Center Alexandre F Migala is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Osteopathic Association, Association of Military Osteopathic Physicians and Surgeons, and Texas Medical Association Coauthor(s): Hildegardo Costa, MD, Fellow in Pediatric Gastroenterology and Nutrition, Instructor, Department of Pediatrics, State University of New York Health Sciences Center at Brooklyn; Richard D Warren, MD, Staff Physician, Department of Emergency Medicine, Darnall Army Community Hospital Editors: Jorge Vargas, MD, Professor, Department of Pediatrics, Division of Pediatric Gastroenterology, University of California at Los Angeles School of Medicine; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; B U K Li, MD, Professor of Pediatrics, Division of Gastroenterology and Nutrition, Children's Hospital of Wisconsin, Medical College of Wisconsin; Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, State University of New York, Downstate Medical Center College of Medicine; Distinguished Lecturer, New York Medical College, School of Public Health; Steven M Altschuler, MD, President and CEO, Children's Hospital Foundation, Children's Hospital of Philadelphia Author and Editor Disclosure Synonyms and related keywords: cholelithiasis, gallstones, biliary colic, cholecystitis, choledocholithiasis, gall bladder calculi, gallbladder, chronic calculous cholecystitis, cystic duct, acute cholecystitis, biliary obstruction, cholangitis, biliary pancreatitis, chronic abdominal pain, stomach pain INTRODUCTIONSection 2 of 10
  BackgroundGallbladder calculi are relatively uncommon in children. However, the incidence of cholelithiasis has been increasing recently. Children may harbor cholesterol gallstones, black- or brown-pigmented stones, or mixed-type gallstones. A study by Stringer et al demonstrated a high incidence of calcium carbonate stones in children that are exceptionally rare in the adult population. PathophysiologyComplications that occur in adults with this condition may also occur in children. Cholelithiasis primarily affects the gallbladder. Gallstones may cause irritation and inflammation of the gallbladder mucosa, resulting in chronic calculous cholecystitis and symptoms of biliary colic. If a stone obstructs the cystic duct, acute cholecystitis can occur, with distension of the gallbladder wall and the possibility of necrosis and spillage of gallbladder contents. With migration of gallstones from the gallbladder, through the cystic duct, and into the main biliary ductal system, more ominous complications may occur. These include choledocholithiasis, biliary obstruction with or without cholangitis, and biliary pancreatitis. FrequencyUnited StatesCurrently, the incidence of cholelithiasis in children is estimated to be 0.15-0.22%. This number seems to be increasing, and the true number of affected children may have always been underestimated because patients with cholelithiasis can present with a nonspecific abdominal pain. Another factor that may be adding to the increasing incidence is the rise in teenage pregnancies. The frequency of cholelithiasis in children with sickle cell disease is almost double that of the general population. The incidence of patients with identified gallstones who eventually develop symptoms is relatively low. A 1992 National Institutes of Health consensus conference on gallstones concluded that approximately 10% of patients with gallstones will develop symptoms in the first 5 years after diagnosis. In 1995, The Group for Epidemiology and Prevention of Cholelithiasis reported that initially asymptomatic patients with cholelithiasis had a 25.8% probability of developing symptoms within 10 years and a yearly incidence of 0.5-3% after 10 years. Mortality/MorbidityThe morbidity and mortality associated with gallstones are more commonly associated with cholecystitis or ascending cholangitis. Cholelithiasis may lead to morbidity as chronic abdominal pain, which can be incapacitating. RaceAlthough no racial predilection exists, individuals of certain ethnic heritage have been identified to be at higher risk for developing gallstones, particularly the Pima Indians of North America and Scandinavians. SexThe frequency of cholelithiasis in children is significantly greater in females than in males and is comparable to the adult ratio, with up to 4:1 female predominance. CLINICALSection 3 of 10
HistoryGallstones in children are most commonly an incidental finding, but strongly consider them during the workup of those with nonspecific intermittent abdominal pain with risk factors. Also, consider cholelithiasis in those with jaundice and low-grade elevations of transaminases and transpeptidase. Older children may be able to localize their pain to the right upper quadrant (RUQ). PhysicalPerform a complete physical examination in children. Include auscultation, visualization, and lastly, palpation in the abdominal examination. Pain in the RUQ is common. A Murphy sign (expiratory arrest with palpation in the RUQ) is thought to be pathognomonic. Also, note hepatomegaly and splenomegaly because they may be a clue to venous congestion or hemolytic processes that may predispose a patient to gallstones. CausesThe causes of cholelithiasis are multiple and relate to the risk factors. Trauma, sepsis, prolonged total parenteral nutrition (TPN), hepatobiliary disease, hemolytic diseases, abdominal surgery, and pregnancy all may lead to an increased incidence of gallstones in the pediatric population. In addition, acute renal failure, prolonged fasting, low-calorie diets, and rapid weight loss have been identified to increase the incidence of gallstones. Sickle cell disease has been identified as an independent risk factor associated with an increase in the frequency of cholelithiasis. Biliary pseudolithiasis has been identified with the use of certain medications, primarily ceftriaxone. DIFFERENTIALSSection 4 of 10
Cholecystitis Cholestasis Gallbladder Disease Jaundice, Neonatal Pancreatitis and Pancreatic Pseudocyst
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| Drug Name | Ursodiol (Actigall, Ursodamor, Ursofalk, Ursogal) |
|---|---|
| Description | Also called ursodeoxycholic acid. Indicated for radiolucent noncalcified gallbladder stones <20 mm in diameter when conditions preclude cholecystectomy. Suppresses hepatic cholesterol synthesis and secretion and also inhibits intestinal absorption. It appears to have little inhibitory effect on synthesis and secretion into bile of endogenous bile acids and does not appear to affect secretion of phospholipids into bile. After repeated doses, reaches steady-state bile concentrations in about 3 wk. Cholesterol is insoluble in aqueous media, but it can be solubilized in at least 2 different ways in the presence of dihydroxy bile acids. In addition to solubilizing cholesterol in micelles, ursodiol acts by dispersing cholesterol as liquid crystals in aqueous media. The overall effect of ursodiol is to increase the concentration level at which saturation of cholesterol occurs. The various actions of ursodiol combine to change the bile of patients with gallstones from cholesterol-precipitating to cholesterol-solubilizing bile, thus resulting in bile conducive to cholesterol stones dissolution. Although not approved by the FDA, ursodiol has been used in combination with chenodeoxycholic acid and in conjunction with extracorporeal shock-wave lithotripsy for the dissolution of gallstones. Available in 250-mg and 300-mg caps. An extemporaneous liquid formulation may be compounded for pediatric use. |
| Adult Dose | 8-10 mg/kg/d PO divided bid/tid |
| Pediatric Dose | Not established; limited data exist; administer as in adults |
| Contraindications | Documented hypersensitivity; calcified cholesterol stones; radiopaque stones; radiolucent bile pigment stones; required cholecystectomy (eg, unremitting acute cholecystitis, cholangitis, biliary obstruction, gallstone pancreatitis, biliary-gastrointestinal fistula) |
| Interactions | Decreased effect with aluminum-containing antacids, cholestyramine, colestipol, clofibrate, and PO contraceptives |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Ursodiol has not been associated with liver damage; however, a metabolite (lithocholic acid, a naturally occurring bile acid and ursodiol metabolite) is known to be liver toxic and congenital or acquired sulfation deficiency may increase the risk; monitor liver enzymes at baseline and as clinically indicated thereafter |
These agents decrease inflammatory responses and systemically interfere with events leading to inflammation.
| Drug Name | Diclofenac (Voltaren, Cataflam) |
|---|---|
| Description | Designated chemically as 2-[(2,6-dichlorophenyl) amino] benzene acetic acid, monosodium salt, with an empirical formula of C14 H10 Cl2 NO2 NA. One of a series of phenylacetic acids that has demonstrated anti-inflammatory and analgesic properties in pharmacological studies. Believed to inhibit the enzyme cyclooxygenase, which is essential in the biosynthesis of prostaglandins. Can cause hepatotoxicity; hence, liver enzymes should be monitored in the first 8 wk of treatment. Rapidly absorbed; metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation. Delayed-release, enteric-coated form is diclofenac sodium, and immediate release form is diclofenac potassium. Has relatively low risk for bleeding GI ulcers. |
| Adult Dose | 25 mg PO bid/tid If well tolerated, increase by 25 or 50 mg at weekly intervals until satisfactory response is obtained or total daily dose of 150-200 mg PO is reached Higher doses generally do not increase effectiveness |
| Pediatric Dose | <12 years: Not established >12 years: Administer as in adults |
| Contraindications | Documented hypersensitivity; do not administer into CNS or give to patients with peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or those at high risk of bleeding |
| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding) may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Pregnancy category D during third trimester; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; low WBC counts rarely occur and usually return to normal in ongoing therapy; discontinuation of therapy may be necessary if persistent leukopenia, granulocytopenia, or thrombocytopenia is present |
| Drug Name | Indomethacin (Indocin) |
|---|---|
| Description | Rapidly absorbed. Metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation. Inhibits prostaglandin synthesis. |
| Adult Dose | 25-50 mg PO bid/tid 75 mg SR PO bid; not to exceed 200 mg/d |
| Pediatric Dose | <2 years: Not established >2 years: 1-2 mg/kg/d PO divided bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d |
| Contraindications | Documented hypersensitivity; GI bleeding or renal insufficiency |
| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
| Pregnancy | B - Usually safe but benefits must outweigh the risks. |
| Precautions | Pregnancy category D during third trimester; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur; discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia is present |
Article Last Updated: Jun 19, 2006
