eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Cholecystitis: Follow-up

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

Follow-up

Further Outpatient Care

  • The surgeon should follow up with the patient 2 weeks after surgery to monitor wound healing and to ensure no postoperative complications are present.
  • The clinician should be sensitive to any indication of biliary injury or obstruction and investigate any such signs quickly.
  • The patient should be aware that common bile duct stones may still occur in the absence of the gallbladder.
  • Evaluate future abdominal pain in the right upper quadrant because it may represent residual or recurrent common bile duct stones.
  • If unrecognized, bile duct stones may lead to biliary obstruction and hepatocyte damage.

Transfer

  • Treat the pediatric patient with cholecystitis at a facility with the services of a pediatrician and a staff proficient in the care of children. A pediatric surgeon should be available, preferably one proficient at laparoscopic cholecystectomy (LC). In addition, appropriate radiologic and gastroenterologic procedures (eg, cholangiography, endoscopic retrograde cholangiopancreatography [ERCP]) should be readily available. If these resources are deficient, consider transfer to an appropriate institution. Outcomes for children who have cholecystitis and are given proper care are generally excellent, although complications can occur; the prognosis plummets with neglect. Clinicians caring for these children should be experienced in treating gallbladder disease and have all necessary resources at their disposal.

Deterrence/Prevention

  • The focus of prevention of cholecystitis is the minimization of controllable risk factors. Because most of these factors for pediatric cholecystitis are related to underlying disease processes, options are limited, but conscientious treatment by the primary provider, knowledge of risks, and close observation for symptoms are helpful.
  • Certain risks can be decreased. Weight control in the child with obesity may decrease the risk of cholelithiasis and many other long-term sequelae. The use of pancreatic enzymes and bile acid supplements in patients with CF decreases the saturation and lithogenicity of bile. Limited enteral feedings in children who require long-term hyperalimentation decrease the biliary hypofunction observed in prolonged fasting. The addition of ursodeoxycholic acid (Actigall) in settings of chronic biliary stasis may mitigate the potential for cholelithiasis to develop. Finally, seriously consider the risks associated with medications, (eg, oral contraception, Lasix, Rocephin, octreotide, cyclosporine) before using them in patients who are at risk.

Complications

  • Distinct complications can occur at any point in the course or treatment of gallbladder disease. They can be divided into complications of gallstones, inflammation, and treatment. At any of the 3 stages, disease may exacerbate preexisting medical conditions leading to cardiac, hepatic, pulmonary, or renal demise.
  • Gallstones may cause obstruction of the common bile duct, acute or chronic cholecystitis, cholangitis, gallbladder perforation, or pancreatitis. Choledocholithiasis occurs less often in children. Risk increases with age. Obstruction of the common bile duct may still accompany pediatric cholelithiasis, especially in the presence of congenital ductal narrowing or stenosis, and it may cause hepatocyte damage. Rule out common bile duct stones in the presence of any jaundice. Stones may also perforate the gallbladder, allowing bile leakage into the peritoneum, or create a cystoenteric fistula, possibly leading to a gallstone ileus. However, the most common complication of gallstones in children is pancreatitis, reported to occur in 8% of cases. The course is usually mild and resolves spontaneously with passage of the stone, which occurs in several days.
  • More danger occurs in the presence of inflammation. Acute infection and inflammation of the gallbladder or ductal system may lead to sepsis or local spread of disease. Perforation, abscess, empyema, infarction, or gangrene may develop in acute cholecystitis, causing peritonitis and threatening the patient's life. Chronic cholecystitis may lead to acute hydrops, acute cholecystitis, or, more insidiously, porcelain gallbladder. The well-known radiographic finding of porcelain gallbladder is caused by chronic calcium deposition in the wall of the gallbladder as a result of inflammation; it ominously leads to cancer in 50% of adults in whom it is found.
  • Procedure-related complications are predictable and include hemorrhage, bile duct injury, ileus, pancreatitis, and leakage from the newly created stump. Risks from anesthesia are also noted. In addition, wound infections, abscess, or cholangitis may complicate the postoperative course.

Prognosis

  • Isolated cholecystitis generally has an excellent prognosis if diagnosed and treated appropriately. Children can be expected to return to presurgical functioning soon after cholecystectomy, especially after a laparoscopic procedure. The greatest indicator for poor prognosis is the underlying disease process itself. Cholecystitis that is treated is usually well tolerated. Acute acalculous cholecystitis has higher morbidity and mortality rates; however, because it often occurs in patients who are critically ill, these statistics are also most likely related to the underlying disease process.

Patient Education

  • Patient education can be focused on prevention, observation, timely treatment, and information about the intraoperative procedure. Preventative measures include diet and weight management. In addition, educate patients with cystic fibrosis (CF) about compliance with pancreatic enzyme and bile acid supplementation. At-risk patients, whether because of chronic disease of cultural and/or genetic risk factors, should be aware of signs and symptoms of cholecystitis and gallstone disease. This enables them to seek timely medical attention and avoid complications of acute cholecystitis. Finally, educate all patients undergoing operative procedures about preoperative and postoperative care and the expectations and risks of surgery.
  • For excellent patient education resources, see eMedicine's Liver, Gallbladder, and Pancreas Center and Cholesterol Center. Also, visit eMedicine's patient education article, Gallstones.

Miscellaneous

Special Concerns

  • Infants with cholecystitis may present with irritability, jaundice, and acholic stools. Because of young age and differing presentation, consider congenital bile duct anomalies, such as biliary atresia and paucity of intrahepatic bile ducts. Acalculous cholecystitis usually occurs in children with preexisting systemic illness and, therefore, may be masked by other conditions and analgesics. Be sensitive to the possibility of cholecystitis if systemic infection and multiple risk factors are present.
 


More on Cholecystitis

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