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Pediatric Cholecystitis Clinical Presentation

  • Author: Steven M Schwarz, MD, FAAP, FACN, AGAF; Chief Editor: Carmen Cuffari, MD  more...
Updated: Jul 21, 2016


Symptoms of cholelithiasis often precede those of cholecystitis, although patients may have acute cholecystitis on initial presentation. Cholelithiasis causes biliary colic. Patients may complain of intermittent abdominal pain of inconsistent severity in the right upper quadrant, with possible radiation to the scapular region of the back, or pain may be diffuse or localized to the epigastrium.

Discomfort is more likely to be nonspecific in infants and younger children. Patients of this age group often present with irritability, jaundice, and acholic stools.

The classic history of patients with gallstones is postprandial right upper quadrant pain associated with nausea and vomiting, but this is usually observed only in older children. Jaundice in pediatric cholelithiasis is much more frequent than in adults and can occur in the absence of gallstone obstruction of the common bile duct. Most likely, the stone causes inflammation of the ductal tissue, creating an edematous obstruction to bile flow.

Patients with chronic cholecystitis usually present similarly to patients with biliary colic, with an intermittent and indolent history of pain. Therefore, differentiation must be made on the basis of findings from the physical examination and diagnostic tests.

Acute cholecystitis pain resembles biliary colic but is usually more severe and constant, lasting for several days. The pain may begin as a vague discomfort; however, as inflammation spreads and affects the surrounding peritoneum, the pain localizes to the right upper quadrant.

Patients often report a recent history of nausea, vomiting, anorexia, and a low-grade fever. Onset of symptoms usually occurs approximately 1 week prior to presentation, although the patient may report years of the less severe symptoms of biliary colic and chronic cholecystitis.


Physical Examination

The physical examination in acute cholecystitis usually reveals right upper quadrant tenderness. The classic triad is right upper quadrant pain, fever, and leukocytosis. The patient may have abdominal guarding and a positive Murphy sign (ie, arrest of inspiration on deep palpation of the gallbladder in the right upper quadrant of the abdomen). Omental adherence to the inflamed gallbladder combined with distension may create a palpable mass between the 9th and 10th costal cartilages.

The ductal system may become inflamed, causing cholangitis. In 50% of these cases, the examiner may find a Charcot triad. This combination of right upper quadrant pain, fever, and jaundice indicates obstruction of the common bile duct and the presence of acute cholangitis. The Charcot triad is considered to represent a medical emergency, and patients require immediate intervention.

Performing a physical examination may be the only way to distinguish biliary colic from chronic cholecystitis. In chronic cholecystitis, the patient usually complains of tenderness to palpation in the right upper quadrant; however, the differentiation may be trivial, given the high likelihood of chronic cholecystitis in the presence of recurring biliary colic.

Contributor Information and Disclosures

Steven M Schwarz, MD, FAAP, FACN, AGAF Professor of Pediatrics, Children's Hospital at Downstate, State University of New York Downstate Medical Center

Steven M Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American Association for Physician Leadership, New York Academy of Medicine, Gastroenterology Research Group, American Gastroenterological Association, American Pediatric Society, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Society for Pediatric Research

Disclosure: Nothing to disclose.


Andre Hebra, MD Chief, Division of Pediatric Surgery, Professor of Surgery and Pediatrics, Medical University of South Carolina College of Medicine; Surgeon-in-Chief, Medical University of South Carolina Children's Hospital

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, Florida Medical Association, Society of American Gastrointestinal and Endoscopic Surgeons, Children's Oncology Group, International Pediatric Endosurgery Group, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Carmen Cuffari, MD Associate Professor, Department of Pediatrics, Division of Gastroenterology/Nutrition, Johns Hopkins University School of Medicine

Carmen Cuffari, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition, Royal College of Physicians and Surgeons of Canada

Disclosure: Received honoraria from Prometheus Laboratories for speaking and teaching; Received honoraria from Abbott Nutritionals for speaking and teaching.

Additional Contributors

Jeffrey J Du Bois, MD Chief of Children's Surgical Services, Division of Pediatric Surgery, Kaiser Permanente, Women and Children's Center, Roseville Medical Center

Jeffrey J Du Bois, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, California Medical Association

Disclosure: Nothing to disclose.


Melissa Miller, MD Department of Surgery, Medical University of South Carolina College of Medicine

Melissa Miller, MD is a member of the following medical societies: American Medical Association and American Medical Student Association/Foundation

Disclosure: Nothing to disclose.

  1. Akiyoshi T, Nakayama F. Bile acid composition in brown pigment stones. Dig Dis Sci. 1990 Jan. 35(1):27-32. [Medline].

  2. Stephen AE, Berger DL. Carcinoma in the porcelain gallbladder: a relationship revisited. Surgery. 2001 Jun. 129(6):699-703. [Medline].

  3. Baldwin M, Eisenman RE, Prelipp AM, Breuer RI. Ascaris lumbricoides resulting in acute cholecystitis and pancreatitis in the Midwest. Am J Gastroenterol. 1993 Dec. 88(12):2119-21. [Medline].

  4. Kong MS, Chen CY. Risk factors leading to ceftriaxone-associated biliary pseudolithiasis in children. Chang Keng I Hsueh. 1996 Mar. 19(1):50-4. [Medline].

  5. Schaad UB, Wedgwood-Krucko J, Tschaeppeler H. Reversible ceftriaxone-associated biliary pseudolithiasis in children. Lancet. 1988 Dec 17. 2(8625):1411-3. [Medline].

  6. Weinstein S, Lipsitz EC, Addonizio L, Stolar CJ. Cholelithiasis in pediatric cardiac transplant patients on cyclosporine. J Pediatr Surg. 1995 Jan. 30(1):61-4. [Medline].

  7. Callahan J, Haller JO, Cacciarelli AA, et al. Cholelithiasis in infants: association with total parenteral nutrition and furosemide. Radiology. 1982 May. 143(2):437-9. [Medline].

  8. Heubi JE, O'Connell NC, Setchell KD. Ileal resection/dysfunction in childhood predisposes to lithogenic bile only after puberty. Gastroenterology. 1992 Aug. 103(2):636-40. [Medline].

  9. Tsakayannis DE, Kozakewich HP, Lillehei CW. Acalculous cholecystitis in children. J Pediatr Surg. 1996 Jan. 31(1):127-30; discussion 130-1. [Medline].

  10. [Guideline] Guralnick S, Serwint J. Cholelithiasis and cholecystitis. Pediatr Rev. 2009 Sep. 30(9):368-9; discussion 369. [Medline].

  11. Friesen CA, Roberts CC. Cholelithiasis. Clinical characteristics in children. Case analysis and literature review. Clin Pediatr (Phila). 1989 Jul. 28(7):294-8. [Medline].

  12. Bennion LJ, Knowler WC, Mott DM, et al. Development of lithogenic bile during puberty in Pima indians. N Engl J Med. 1979 Apr 19. 300(16):873-6. [Medline].

  13. Imhof M, Raunest J, Ohmann C, Roher HD. Acute acalculous cholecystitis complicating trauma: a prospective sonographic study. World J Surg. 1992 Nov-Dec. 16(6):1160-5; discussion 1166. [Medline].

  14. Tse F, Liu L, Barkun AN, Armstrong D, Moayyedi P. EUS: a meta-analysis of test performance in suspected choledocholithiasis. Gastrointest Endosc. 2008 Feb. 67(2):235-44. [Medline].

  15. Giljaca V, Gurusamy KS, Takwoingi Y, et al. Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones. Cochrane Database Syst Rev. 2015. (2):CD011549:[Medline].

  16. Agrawal CS, Sehgal R, Singh RK, Gupta AK. Antibiotic prophylaxis in elective cholecystectomy: a randomized, double blinded study comparing ciprofloxacin and cefuroxime. Indian J Physiol Pharmacol. 1999 Oct. 43(4):501-4. [Medline].

  17. Suell MN, Horton TM, Dishop MK, Mahoney DH, Olutoye OO, Mueller BU. Outcomes for children with gallbladder abnormalities and sickle cell disease. J Pediatr. 2004 Nov. 145(5):617-21. [Medline].

  18. Ware R, Filston HC, Schultz WH, Kinney TR. Elective cholecystectomy in children with sickle hemoglobinopathies. Successful outcome using a preoperative transfusion regimen. Ann Surg. 1988 Jul. 208(1):17-22. [Medline].

  19. Lugo-Vicente HL. Trends in management of gallbladder disorders in children. Pediatr Surg Int. 1997 Jul. 12(5-6):348-52. [Medline].

  20. Siddiqui S, Newbrough S, Alterman D, Anderson A, Kennedy A Jr. Efficacy of laparoscopic cholecystectomy in the pediatric population. J Pediatr Surg. 2008 Jan. 43(1):109-13; discussion 113. [Medline].

  21. Sigman HH, Laberge JM, Croitoru D, et al. Laparoscopic cholecystectomy: a treatment option for gallbladder disease in children. J Pediatr Surg. 1991 Oct. 26(10):1181-3. [Medline].

  22. St Peter SD, Keckler SJ, Nair A, et al. Laparoscopic cholecystectomy in the pediatric population. J Laparoendosc Adv Surg Tech A. 2008 Feb. 18(1):127-30. [Medline].

  23. Holcomb GW 3rd, Morgan WM 3rd, Neblett WW 3rd, et al. Laparoscopic cholecystectomy in children: lessons learned from the first 100 patients. J Pediatr Surg. 1999 Aug. 34(8):1236-40. [Medline].

  24. Walker TM, Hambleton IR, Serjeant GR. Gallstones in sickle cell disease: observations from The Jamaican Cohort study. J Pediatr. 2000 Jan. 136(1):80-5. [Medline].

Diagram illustrating the technique for laparoscopic cholecystectomy. The gallbladder is retracted with grasping 5-mm laparoscopic instruments, and clips are applied over the cystic duct and artery.
Photograph of a gallbladder filled with numerous small cholesterol stones.
Operative photograph illustrating the position of small (5 mm, 10 mm) trocars in the abdomen of a 12-year-old child undergoing laparoscopic cholecystectomy. By using this technique, the surgeon can avoid large incisions and remove the gallbladder safely.
Photograph illustrating the role of endoscopic retrieval of common bile duct stones. The picture shows a balloon placed via the endoscope into the ampulla for extraction of a cholesterol stone that was occluding the common bile duct.
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