eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Cholecystitis: Differential Diagnoses & Workup

Author: Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina
Coauthor(s): Melissa Miller, MD, Department of Surgery, Medical University of South Carolina
Contributor Information and Disclosures

Updated: Nov 18, 2008

Differential Diagnoses

Appendicitis
Hepatitis B
Biliary Atresia
Hepatitis C
Colitis
Irritable Bowel Syndrome
Constipation
Pancreatitis and Pancreatic Pseudocyst
Gastroesophageal Reflux
Pneumonia
Hepatitis A
Small-Bowel Obstruction

Other Problems to Be Considered

The differential diagnosis of cholecystitis is based on the presenting symptoms of abdominal pain in the right upper quadrant (patients with any of the diseases listed above may present with right upper quadrant pain). In the pediatric population, consider the following conditions in addition to the ones listed above:

  • Biliary colic
  • Cholangitis
  • Rupture of the gallbladder
  • Peptic ulcer disease
  • Renal colic
  • Gastritis
  • Pleurisy
  • Fitz-Hugh and Curtis syndrome (gonococcal perihepatitis)
  • Hepatic abscess
  • Abdominal tumor
  • Pyelonephritis

Workup

Laboratory Studies

  • In assessing for cholecystitis, appropriate laboratory studies include a CBC count, gamma-glutamyltransferase (GGT) assessment, amylase measurement, urinalysis, direct and indirect bilirubin tests, alkaline phosphatase measurement, and transaminase levels.
  • In acute cholecystitis, the WBC count is elevated, with a predominance of polymorphonuclear cells and bands. Bilirubin, alkaline phosphatase and GGT levels rise secondary to a blocked biliary system.
  • The traditional cholestatic picture involves direct hyperbilirubinemia, with a direct-to-indirect ratio approaching 1:1. Amylase may be elevated even in the absence of obstructive pancreatitis. In addition, transaminases may show mild elevation but not a significant increase, unless obstruction has been severe enough to cause hepatocyte damage.
  • Transaminase levels are more likely to rise early in patients with obstruction of the common bile duct.

Imaging Studies

  • Plain abdominal radiography may be used for initial screening in abdominal pain. Calcifications representing radiopaque gallstones may be observed in the gallbladder or ductal system. Radiopaque gallstones contain more calcium bilirubinate and are more common in the pediatric population, especially in infants and children. In addition, complications such as porcelain gallbladder and emphysematous cholecystitis may be visible on radiographs, although these complications are rare in children.
  • Abdominal ultrasonography has become the diagnostic tool of choice in evaluating cholelithiasis. The accuracy of abdominal ultrasonography in depicting gallstones is estimated to be more than 95%, but its reliability in the accurate diagnosis of acute cholecystitis is more limited. Ultrasonographic findings in acute cholecystitis include a discrete echodensity representing the gallstone, the presence of sludge, and, possibly, ductal anomalies or dilation. The gallbladder may be dilated with thickened walls. Imhof et al found gallbladder wall thickness of more than 3.5 mm to be a reliable independent diagnostic indicator of cholecystitis.9 Gallstones are often in a dependent position in the gallbladder and may move as the patient changes position. The reliability of ultrasonography is well established with both opaque and lucent gallstones. Results are immediate, and accessibility is usually excellent.
  • Oral cystography has been used in the past, but is now largely ignored because of the refinement of ultrasonography. Oral cystography involves the ingestion of contrast material that is secreted in the bile. Lack of visualization of the gallbladder indicates cholelithiasis. This procedure is limited by liver dysfunction and malabsorption. In addition, the contrast tablets have been associated with emesis and diarrhea, further complicating effectiveness.
  • The most accurate tool in the diagnosis of acute cholecystitis is biliary scintography, otherwise known as the hepatic 2,6-dimethyliminodiacetic acid or hepatoiminodiacetic acid (HIDA) scanning. This procedure involves the intravenous injection of substances labeled with technetium 99m, taken into the hepatocytes, and excreted into the biliary system. Normal hepatic uptake without gallbladder visualization is diagnostic, but false positive results occur with decreased biliary function secondary to prolonged fasting and the use of hyperalimentation. Morphine augmentation of this test has been shown to decrease false positive results. Induced spasm of the sphincter of Oddi increases biliary pressure and enhances gallbladder filling. This test may be unnecessary, however, because the clinical diagnosis and treatment are determined by the symptoms and presence of gallstones or sludge. Ultrasonography has proved its usefulness in depicting gallstones, does not rely on contrast, and, therefore, maybe
    safer.
  • Other imaging techniques that can be used in the diagnosis of cholecystitis include MRI and CT, especially in cases in which ultrasonography is not helpful. Ultrasonographic results may be compromised by ileus, surgical incisions, and coexisting diseases, especially those found in patients who are critically ill. MRI and CT may be more sensitive than ultrasonography in detecting inflammation within and around the gallbladder. In addition, the presence of other sources of abdominal sepsis are more easily discovered and treated by means of MRI and CT.

Other Tests

  • Other tests associated with the diagnosis and treatment of cholecystitis include cholecystokinin (CCK) stimulation, intraoperative cholangiography, and endoscopic retrograde cholangiopancreatography (ERCP). CCK stimulation may be used during other imaging studies, such as cholescintigraphy. Gallbladder dyskinesia after CCK administration is diagnostic of gallbladder hypofunction and may be useful in discerning acalculous or chronic cholecystitis and acute inflammation.
  • Intraoperative cholangiography, whether intravenous or percutaneous, is widely used for the visualization of the gallbladder and ductal system. However, cholangiography can be time-consuming and an added expense to the patient, although some data show no statistical difference in operative time with and without its use. Consider cholangiography for any risk of obstruction of the common bile duct. Indications are a history of jaundice, pancreatitis, dilated common bile duct, and the presence of small gallstones. The benefits of using cholangiography have not been proven for routine cholecystectomy, routine screening for congenital anomalies, or assessment of the common bile duct for obstruction in the absence of clinical suspicion.
  • If the patient displays signs and symptoms of choledocholithiasis, ERCP may also be used preoperatively for exploration of the common bile duct. This procedure is both diagnostic and therapeutic because it may be used for stent placement, basket retrieval, or papillotomy to allow passage of gallstones; however, available choledochoscopes may be too large for small patients.

Procedures

  • One alternative to cholecystectomy is percutaneous transhepatic cholecystostomy. In this approach, thread a catheter directly into the gallbladder and place it to allow gravity drainage. Cholecystostomy is especially useful in acalculous cholecystitis and in seriously ill patients with simple gallstones in whom obstruction of the common bile duct is ruled out. Because cholecystectomy is the standard of care for cholecystitis, cholecystostomy is usually reserved for seriously ill patients who may not tolerate surgery.
  • Choledocholithiasis complicates the picture of cholecystitis and usually requires adjunctive procedures to cholecystectomy. If obstruction of the common bile duct is suspected preoperatively, perform ERCP before surgery with papillotomy, stent placement, or basket retrieval. If gallstones are found intraoperatively, several techniques can be used. The common bile duct can be flushed with saline or opened and explored. Additionally, an endoscope or nephroureteroscope may be used intraoperatively for basket retrieval.

Histologic Findings

  • The histology of the inflamed gallbladder is fairly straightforward. Acute cholecystitis shows changes similar to that of any acute inflammation. Edema, leukocytic infiltration, and vascular congestion are prominent. Inflammation may progress to abscess formation, gangrenous necrosis, and perforation, especially in acalculous cholecystitis. Chronic cholecystitis shows long-term inflammatory changes, with lymphocytes, plasma cells, and macrophages scattered throughout the mucosa. Subserosal fibrous tissue forms and may extend into the subepithelial layer with increasing disease severity. As the mucosa proliferates, epithelium may become buried in crypts known as Rokitansky-Aschoff sinuses.
  • Over time, chronic obstruction and inflammation may lead to the deposit of calcium within the gallbladder wall, causing the porcelain gallbladder, which is visible on flat plate imaging of the abdomen. Another variation is xanthogranulomatous cholecystitis in which chronic inflammation leads to a shrunken nodular gallbladder with many foci of necrosis and hemorrhage. This condition may be confused with malignancy but is actually benign. Hydrops of the gallbladder may also develop with chronic obstruction. This is characterized by a distended lumen and atrophic walls. Obstruction of the common bile duct may cause histologic change in nearby organs. Ductal hyperplasia ensues from obstruction and distension, and periportal fibrosis in the liver may occur with hepatic bile flow obstruction. Gallstones may also cause transient acute pancreatitis, resulting in characteristic histologic changes in the pancreas.

More on Cholecystitis

Overview: Cholecystitis
Differential Diagnoses & Workup: Cholecystitis
Treatment & Medication: Cholecystitis
Follow-up: Cholecystitis
Multimedia: Cholecystitis
References
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References

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

  2. 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. Aug 1999;34(8):1236-40. [Medline].

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

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

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

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

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

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

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

  10. 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. Oct 1999;43(4):501-4. [Medline].

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

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

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

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

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

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

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

  18. Bumgarner SD, Evans ML. Clinical care map for the ambulatory laparoscopic cholecystectomy patient. J Perianesth Nurs. Feb 1999;14(1):12-6. [Medline].

  19. Cappell MS, Waye JD, Farrar JT, Sleisenger MH. Fifty landmark discoveries in gastroenterology during the past 50 years. A brief history of modern gastroenterology at the millennium: Part I. Gastrointestinal procedures and upper gastrointestinal disorders. Gastroenterol Clin North Am. Mar 2000;29(1):223-63, viii. [Medline].

  20. Colombo C, Bertolini E, Assaisso ML, et al. Failure of ursodeoxycholic acid to dissolve radiolucent gallstones in patients with cystic fibrosis. Acta Paediatr. Jun-Jul 1993;82(6-7):562-5. [Medline].

  21. Colombo C, Castellani MR, Balistreri WF, et al. Scintigraphic documentation of an improvement in hepatobiliary excretory function after treatment with ursodeoxycholic acid in patients with cystic fibrosis and associated liver disease. Hepatology. Apr 1992;15(4):677-84. [Medline].

  22. Crawford JM. The liver and biliary tract. In: The Pathologic Basis of Disease. 1994:884-8.

  23. Crowther RS, Soloway RD. Pigment gallstone pathogenesis: from man to molecules. Semin Liver Dis. Aug 1990;10(3):171-80. [Medline].

  24. Davidoff AM, Branum GD, Murray EA, et al. The technique of laparoscopic cholecystectomy in children. Ann Surg. Feb 1992;215(2):186-91. [Medline].

  25. Diehl AK. Epidemiology and natural history of gallstone disease. Gastroenterol Clin North Am. Mar 1991;20(1):1-19. [Medline].

  26. Gebhard RL, Prigge WF, Ansel HJ, et al. The role of gallbladder emptying in gallstone formation during diet-induced rapid weight loss. Hepatology. Sep 1996;24(3):544-8. [Medline].

  27. Gilger MA. Diseases of the gallbladder. In: Pediatric Gastrointestinal Disease: Pathophysiology, Diagnosis, Management. Mosby; 1999:651-9.

  28. Giurgiu DI, Roslyn JJ. Treatment of gallstones in the 1990s. Prim Care. Sep 1996;23(3):497-513. [Medline].

  29. Griffen WO Jr, Bivins BA, Rogers EL, et al. Cholecystokinin cholecystography in the diagnosis of gallbladder disease. Ann Surg. May 1980;191(5):636-40. [Medline].

  30. Hawkins PE, Graham FB, Holliday P. Gallbladder disease in children. Am J Surg. May 1966;111(5):741-4. [Medline].

  31. Hes FJ, de Jong TP, Bax NM, Houwen RH. Urinary tract infections and cholelithiasis in early childhood. J Pediatr Gastroenterol Nutr. Oct 1995;21(3):319-21. [Medline].

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

  33. Hikasa Y, Nagase M, Tanimura H, et al. Epidemiology and etiology of gallstones. Nippon Geka Hokan. Sep 1 1980;49(5):555-71. [Medline].

  34. Holcomb GW Jr, Holcomb GW 3d. Cholelithiasis in infants, children, and adolescents. Pediatr Rev. Mar 1990;11(9):268-74. [Medline].

  35. Irish MS, Pearl RH, Caty MG, Glick PL. The approach to common abdominal diagnosis in infants and children. Pediatr Clin North Am. Aug 1998;45(4):729-72. [Medline].

  36. Kalliafas S, Ziegler DW, Flancbaum L, Choban PS. Acute acalculous cholecystitis: incidence, risk factors, diagnosis, and outcome. Am Surg. May 1998;64(5):471-5. [Medline].

  37. Kullman E, Dahlin LG, Hallhagen S, et al. Trends in incidence, clinical findings and outcome of acute and elective cholecystectomy, 1970-1986. Eur J Surg. Nov 1994;160(11):605-11. [Medline].

  38. Lau GE, Andrassy RJ, Mahour GH. A 30-year review of the management of gallbladder disease at a children's hospital. Am Surg. Aug 1983;49(8):411-3. [Medline].

  39. Lennard TW, Farndon JR, Taylor RM. Acalculous biliary pain: diagnosis and selection for cholecystectomy using the cholecystokinin test for pain reproduction. Br J Surg. May 1984;71(5):368-70. [Medline].

  40. MacMillan RW, Schullinger JN, Santulli TV. Cholelithiasis in childhood. Am J Surg. Jun 1974;127(6):689-92. [Medline].

  41. McEvoy CF, Suchy FJ. Biliary tract disease in children. Pediatr Clin North Am. Feb 1996;43(1):75-98. [Medline].

  42. McSherry CK, Glenn F. The incidence and causes of death following surgery for nonmalignant biliary tract disease. Ann Surg. Mar 1980;191(3):271-5. [Medline].

  43. Morris JS, Gallo GA, Scheuer PJ, Sherlock S. Percutaneous liver biopsy in patients with large bile duct obstruction. Gastroenterology. Apr 1975;68(4 Pt 1):750-4. [Medline].

  44. Nilsson S. Gallbladder disease and sex hormones. A statistical study. Acta Chir Scand. Sep 1966;132(3):275-9. [Medline].

  45. Ostrow JD. The etiology of pigment gallstones. Hepatology. Sep-Oct 1984;4(5 Suppl):215S-222S. [Medline].

  46. Pitcher GJ, Azmy AF. Cholelithiasis in paediatric renal transplant patients: implications for screening and management. Br J Urol. Aug 1996;78(2):316-7. [Medline].

  47. Podda M, Zuin M, Battezzati PM, et al. Efficacy and safety of a combination of chenodeoxycholic acid and ursodeoxycholic acid for gallstone dissolution: a comparison with ursodeoxycholic acid alone. Gastroenterology. Jan 1989;96(1):222-9. [Medline].

  48. Raunest J, Imhof M, Rauen U, et al. Acute cholecystitis: a complication in severely injured intensive care patients. J Trauma. Apr 1992;32(4):433-40. [Medline].

  49. Reif S, Sloven DG, Lebenthal E. Gallstones in children. Characterization by age, etiology, and outcome. Am J Dis Child. Jan 1991;145(1):105-8. [Medline].

  50. Salen G, Tint GS, Shefer S, et al. Oral dissolution treatment of gallstones with bile acids. Semin Liver Dis. Aug 1990;10(3):181-6. [Medline].

  51. Sarli L, Pietra N, Franze A, et al. Routine intravenous cholangiography, selective ERCP, and endoscopic treatment of bile duct stones before laparoscopic cholecystectomy. Gastrointest Endosc. Aug 1999;50(2):200-8. [Medline].

  52. Schoenfield LJ, Lachin JM. Chenodiol (chenodeoxycholic acid) for dissolution of gallstones: the National Cooperative Gallstone Study. A controlled trial of efficacy and safety. Ann Intern Med. Sep 1981;95(3):257-82. [Medline].

  53. Schrefer J, ed. Mosby's GenRx 2000: A Comprehensive Reference For Generic and Brand Name Drugs. 10th ed. Mosby; 2000.

  54. Shapiro N, Poe M. Sickle cell disease: an anesthesiological problem. Anesthesiol. 1955;16:771-80.

  55. Suell MN, Horton TM, Dishop MK, et al. Outcomes for children with gallbladder abnormalities and sickle cell disease. J Pediatr. Nov 2004;145(5):617-21. [Medline].

  56. Svanvik J, Pellegrini CA, Allen B, et al. Transport of fluid and biliary lipids in the canine gallbladder in experimental cholecystitis. J Surg Res. Oct 1986;41(4):425-31. [Medline].

  57. Tagge EP, Tarnasky PR, Chandler J, et al. Multidisciplinary approach to the treatment of pediatric pancreaticobiliary disorders. J Pediatr Surg. Feb 1997;32(2):158-64; discussion 164-5. [Medline].

  58. Ternberg JL, Keating JP. Acute acalculous cholecystitis. Complication of other illnesses in childhood. Arch Surg. May 1975;110(5):543-7. [Medline].

  59. Thistle JL, May GR, Bender CE, et al. Dissolution of cholesterol gallbladder stones by methyl tert-butyl ether administered by percutaneous transhepatic catheter. N Engl J Med. Mar 9 1989;320(10):633-9. [Medline].

  60. Thompson JS. The role of prophylactic cholecystectomy in the short-bowel syndrome. Arch Surg. May 1996;131(5):556-9; discussion 559-60. [Medline].

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

  62. Walker TM, Serjeant GR. Biliary sludge in sickle cell disease. J Pediatr. Sep 1996;129(3):443-5. [Medline].

  63. Weinsier RL, Wilson LJ, Lee J. Medically safe rate of weight loss for the treatment of obesity: a guideline based on risk of gallstone formation. Am J Med. Feb 1995;98(2):115-7. [Medline].

  64. Winter SS, Kinney TR, Ware RE. Gallbladder sludge in children with sickle cell disease. J Pediatr. Nov 1994;125(5 Pt 1):747-9. [Medline].

  65. Wosiewitz U, Schenk J, Sabinski F, Schmack B. Investigations on common bile duct stones. Digestion. 1983;26(1):43-52. [Medline].

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Further Reading

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Keywords

cholecystitis, acute cholecystitis, chronic cholecystitis, acalculous cholecystitis, calculous cholecystitis, gallbladder inflammation, gall bladder inflammation, gallstones, gall stones, gallbladder disease, Escherichia coli, Klebsiella, Kawasaki disease, periarteritis nodosa, chronic bile stasis, lymph node hypertrophy, biliary sludge, hemolytic anemia, cystic fibrosis, CF, obesity, hepatic disease, diabetes mellitus, sickle cell disease, immunocompromise, sickle cell disease, hemoglobin C disease, thalassemia, prematurity, congenital anomalies, necrotizing enterocolitis, abdominal surgery, sepsis, bronchopulmonary dysplasia, hemolytic disease, malabsorption, hepatobiliary disease, Charcot triad, glucose-6-phosphate dehydrogenase deficiency, G-6-PD deficiency, typhoid fever, scarlet fever, measles

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Contributor Information and Disclosures

Author

Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina
Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Melissa Miller, MD, Department of Surgery, Medical University of South Carolina
Melissa Miller, MD is a member of the following medical societies: American Medical Association and American Medical Student Association/Foundation
Disclosure: Nothing to disclose.

Medical Editor

Jeffrey J DuBois, MD, Consulting Staff, Division of Pediatric Surgery, Kaiser Permanente, North Sacramento Medical Center
Jeffrey J DuBois, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, California Medical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

CME Editor

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 Schwarz, MD, FAAP, FACN, AGAF is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, American Gastroenterological Association, American Pediatric Society, Gastroenterology Research Group, New York Academy of Medicine, North American Society for Pediatric Gastroenterology and Nutrition, and Society for Pediatric Research
Disclosure: TAP Pharmaceuticals Honoraria Speaking and teaching; Curemark, LLC Consulting fee Board membership

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, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

 
 
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