1. Cholecystitis in Overweight
Mexican American Children
Myths and Facts
Francisco J Cervantes MD
Laredo Pediatrics & Neonatology PA
Ancestral Health Symposium, Atlanta GA.
August 2013
WWW.LaredoPediatrics.com

2. A Rational Approach
During 2001 we recommended the SAD Diet
(Standard American Diabetes Association) low fat,
high Carbs. It didn't work
August 2002: Modified Diet, basically: lower sugar
intake, more protein and vegetables, diet drinks
or water. Blood work and diet recommended at
school to Overweight kids and close f/u
September 2003: Results of First 1000 classified
patients
April 2004: Update to 3000 patients

3. Patient Distribution by Age and BMI

4. Screening
• CMP, GGT, Lipid profile, Liver Function Test:
Alkaline phosphatase, ALT, AST, Bilirubin,
• HbA1c, Insulin, THS and T4
• Biometric information; Weight, Height, BMI,
Waist and hip circumference and Percentage of
body fat
• Blood pressure
• Ultrasound of the liver if altered liver enzymes, or
complaining of RUQ pain or discomfort

5. Facts About Diabetes
 80% in our children has at least 1 close
relative with diabetes
10% has one of the parents with diabetes
1% has both parents with diabetes
Mexican American have poor tolerance to
carbohydrates
As the intake of carbohydrates increases so
are the levels of insulin, visceral fat and
acanthosis.
THE GOOD NEWS: IT IS REVERSIBLE!!

6. MAXIMUM DAILY TOLERANCE OF CARBOHYDRATES
IN MEXICAN AMERICAN CHILDREN
50 – 100 GRAMS OF CARBOHYDRATES
3 Fruits (10X 3 = 30 grams)
a banana accounts for 30 to 40 grams
1 cup plain cereal = 30 grams
2 to 3 glasses of 8 oz of regular milk = 30 grams
( Regular = 10; 2% 11; Skim 15 grams)

7. Criteria for screening for liver disease
• Persistent Overweight BMI 85 to 90 %tile
• BMI above 95 %tile
• Rapid Increase in BMI no matter where it
starts
• Family history of Lipid disorder, liver or
gallbladder disease and Diabetes
• RUQ or epigastric discomfort

8. Local Experience
•2555 patients, about equally divided,
boys (1230, 48.1%) and girls (1325, 51.9%)
•First generation American-born children of
Hispanic descend.
•Patients were followed because of changes in
BMI then the discovery of the fatty liver and
subsequently Gallbladder disease.
• All patients have at least one metabolic screen.
•BMI groups normal BMI 75, 85, 95,97 and ≥99
WWW.Laredopediatrics.com

10. Liver Enzymes and BMI in Boys

11. Liver Enzymes in Children with Normal BMI

13. Causes of GB disease in Children
History of cardiac or abdominal surgery
Prolonged parenteral nutrition
Hemolytic disease
Hepatobiliary obstructive disease
Obesity
Rapid decreases in weight
Systemic Infection
Acute renal failure
Prolonged fasting
Low calorie diet
Certain medications
Organ transplant

14. women—especially pregnant, use of hormone replacement
therapy, or birth control pills (decrease gallbladder movement)
people over age 60 (As people age, the body tends to secrete more
cholesterol into bile)
American Indians (Pima Indians of Arizona, 70% of women have
gallstones by age 30)
Mexican Americans
overweight or obese ( Bile salts Cholesterol GB emptying
people who fast or lose a lot of weight quickly
people with a family history of gallstones (possible genetic link)
people with diabetes (high levels of fatty acids called triglycerides)
people who take cholesterol-lowering drugs
Who is at risk for gallstones?
The Classic 4 F’s still apply: Female, Fertile, Forty, Fat

15. Signs and Symptoms
• Typical symptoms of RUQ pain, nausea, vomiting.
• Tenderness to palpation or mass at RUQ
• Leukocytosis and jaundice
• The pain and tenderness are less localized in younger
children
• Epigastric pain mimic RUQ pain
• Epigastric pain or discomfort postprandial
• Atypical presentation: Sleep apnea and sleep
disturbance

18. Fact about GB polyps
Resembling growth in the gall bladder wall
True polyps are abnormal accumulation of mucous membrane
tissues that would normally be shed by the body
Main types of polyps
Cholesterol Polyp/Cholesterosis
Cholesterosis with fibrous dysplasia
Adenomyomatosis
Hyperplastic cholecystosis
Adenocarcinoma
It affects 5% of adult, the causes uncertain, but there is a
correlation between increase age, and presence of Gall stone.
The polyps are detected by abdominal ultrasound performed for
another reason

19. Cholesterosis might contribute to the
formation of the GB polyps

20. Figure 1. Focal hepatic steatosis.
Prasad S R et al. Radiographics 2005;25:321-331
©2005 by Radiological Society of North America

21. Screening Criteria for Gallbladder
Disease in Children
•Acute or persistent epigastric or non-specific
abdominal pain, postprandial
•Rapid decline in BMI
•Family history of Gall bladder disease
•persistently elevated GGT or Total Bilirrubin

22. Normal Findings of HB Scan
• Hepatocytes take up the
radiopharmaceutical in minutes after
injection
• Hepatic ducts seen in fifteen minutes
• Gallbladder seen within 45 to 60 minutes
• GB Ejection Fraction >40
• Small intestine seen by 30 minutes

27. Liver Size in Children

28. Liver Size by BMI Groups

29. Hepatomegaly and Fatty Liver
NL
Fatty Liver
Ultrasound

30. Surgical Gallbladder Cases
• 404 in 4,000,000 in 4 years = 1 in 40,000 per
year at Texas Children’s Houston (2005-2008)
73% women
• 11 in 2000 in 1 yr = 1 in 200 per year at Laredo
Pediatrics (2010 -2011) 63% women
• 8 other reported at local pediatric meetings

35. Conclusion
•Incidence of Gallbladder disease is on the rise on
overweight children.
•Gallbladder disease should be in the differential
diagnosis of any pediatric patient who presents with
localized pain in the epigastric, RUQ or ill-defined,
Jaundice or dyspepsia and asymptomatic patients with
BMI of ≥85
•Consider Liver ultrasound as primary tool over
more expensive and invasive procedures
•HB Scan helps identify adequate GB function