This document discusses gallstones in children. It describes the main types as cholesterol stones and pigment stones. Cholesterol stones are more common in obesity, ileal disease, etc. while pigment stones are more common in hemolytic diseases, cirrhosis, infections. Diagnosis is usually by ultrasound. Treatment involves surgery for symptomatic or complicated cases while smaller asymptomatic cases may be observed. Prevention focuses on managing risk factors like TPN, obesity, chronic diseases.
2. Pathogenesis
For gallstones of any type to develop, some or all of
the following need to occur
Alterations in the proportion of bile constituents
Nucleation
Changes in gallbladder motility
Infection (Infection appears to be important only for
brown pigment gallstone formation).
3. Classification
Cholesterol stones
Pigment stones
Black pigment stones
Brown pigment stones
In children, >70% of gallstones are the pigment
type, 15-20% are cholesterol stones, and the
remainder are composed of a mixture of
cholesterol, organic matrix, and calcium bilirubinate
4. Cholesterol Stones
More than 50% of cholesterol by weight
with variable amounts of proteins and calcium salts
This mainly occurs due to super saturation of bile salts
with cholesterol
Commonly seen in
Obesity
Ileal resection
Jejunoilael bypass
Ileal Crohn’s disease
7. Black Pigment Stones
50% are radiopaque, due to high content of calcium carbonate
and phosphate
Cholesterol concentration 10%-30%
Shiny, hard & spiculated
Commonly seen in
Chronic hemolytic anaemias like sickle cell anaemia, hereditary
spherocytosis etc
Cirrhosis & Chronic cholestasis
Total parenteral nutrition
Ceftriaxone therapy
Infants born to morphine abusers
8.
9. Brown Pigment Stones
Soft, soap-like or greasy in consistency
Seen in biliary infestations like biliary ascariasis
More commonly found in the extrahepatic ducts
and even in the intrahepatic ducts
12. Clinical Presentation
Typical biliary symptoms (40%-50%): right upper
quadrant or epigastric pain with or without nausea,
vomiting and fat intolerance.
Non-specific abdominal pain (20%-30%).
Acute abdomen (5%-10%): due to acute
cholecystitis, pancreatitis or cholangitis.
Asymptomatic (20%).
14. Diagnosis
Laboratory test results commonly are normal. The white blood cell
count may be normal. In a small fraction of patients, there is
transient mild elevation of serum bilirubin, aminotransferase, and
alkaline phosphatase levels.
Diagnosis is made using USG abdomen
A stone, as small as 1.5 mm, can be detected by ultrasonography.
The sensitivity and specificity of ultrasonography exceeds 95% for
gallbladder cholelithiasis, but only 50%-75% for choledocholithiasis
Axial CT may also be helpful in demonstrating stones
17. Medical Management
Nonsurgical therapy consists of
Administration of bile salts or
Extracorporeal shock wave lithotripsy.
Ursodeoxycholic acid and chenodeoxycholic acid are
two bile salts that have been used. Both of these bile
salts decrease cholesterol secretion into bile so that bile
becomes desaturated of cholesterol.
Extracorporeal shock wave lithotripsy has been used in
association with administration of bile acids to
disintegrate stones.
18. Prevention
Gallstones can be prevented by
Initiating children on TPN with early limited enteral
feeds.
Pancreatic supplements in cystic fibrosis.
Weight control in obese children.
Using choleretics in chronic cholestasis.