eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Cholecystitis: Treatment & Medication

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

Treatment

Medical Care

Medical care of the patient with acute cholecystitis centers around stabilization of the patient and preparation for surgery if the patient is a candidate. Administer intravenous (IV) fluids to correct any dehydration and continue as maintenance therapy. Standard regimens include 5% dextrose in 0.2% sodium chloride solution or 5% dextrose in 0.45% sodium chloride solution with 20 mEq of potassium chloride (KCl) per liter at a rate determined by standard pediatric calculations.

Patients who are at risk for vaso-occlusion, including those with sickle hemoglobinopathies, should receive hydration at 1.5 times maintenance dose. The patient should receive nothing by mouth (NPO), and a nasogastric tube should be placed to low-intermittent wall suction for evacuation of gastric contents. This step minimizes stimulation to the inflamed gallbladder and prepares the patient for general anesthesia. Administer pain medications; however, avoid morphine because of its spasmodic effects on the sphincter of Oddi.

Antibiotics with biliary excretion covering enteric pathogens may be administered to control infection. The combination of ampicillin, gentamicin, and clindamycin is a common and well-accepted regimen. In addition, cefoperazone has a broad spectrum of coverage and good biliary excretion. The use of antibiotics remains controversial. Some authors assert that antibiotics are not necessary in simple cases and should be reserved for persistent fever or worsening condition; however, Agrawal et al found a significant reduction in postoperative infection with the use of prophylactic preoperative antibiotic administration in elective cholecystectomy.10 Because of the high percentage of cases of acute cholecystitis that are complicated by bacterial colonization, clinicians should maintain a low threshold for the use of antibiotic therapy.

Removal of the gallbladder is the standard of care in patients with symptomatic gallstone disease, although some exceptions are noted. Critically ill children with acute acalculous cholecystitis may not tolerate anesthesia and operative conditions. These children should receive antibiotic therapy, hyperalimentation, and gastric decompression until their conditions improve. These patients may then undergo surgery if symptoms persist; however, many cases resolve with medical therapy alone. One author reported a 75% resolution of acute acalculous cholecystitis with the use of antibiotics, nasogastric suction, and hyperalimentation. Therefore, antibiotics may be sufficient in critically ill patients who do not tolerate anesthesia and who may be assisted by other procedures, such as cholecystotomy, if gallbladder drainage is necessary.

Observation is also recommended in infants with gallstone disease, especially those with hyperalimentation-associated gallstones. These gallstones often dissolve with maturation of the hepatobiliary system. The gallbladder should be removed with any sign of common duct obstruction, pancreatitis, or cholecystitis. Cholecystectomy should also be performed if gallstones persist longer than 1 year or if long-term hyperalimentation is anticipated, as in Crohn disease, pseudo-obstruction, or short-bowel syndrome. Medical care in chronic cholecystitis or other gallbladder disease is also supportive. Cholecystectomy is recommended in most patients with gallstone disease. Treatment should be aimed at control of any underlying conditions and preparation for surgery.

Children with sickle cell disease present a unique challenge because their hemoglobinopathy may cause perioperative and postoperative complications. These patients are susceptible to vaso-occlusive crises, pneumonia, sepsis, and pulmonary infarct, most likely secondary to hypoxia, dehydration, and acidosis in response to anesthesia.

Ware et al observed no complications when preoperative transfusion of packed RBCs were performed to obtain a hemoglobin A (Hgb A) ratio greater than 2:1 while the hematocrit level was maintained at 35-45%.11 This required 2 transfusions 2 weeks apart in most patients with partial volume exchange used for those with hemoglobin sickle cell (Hgb SC) or sickle beta-thalassemia (SB thalassemia) disease. The preparation involved with such improved outcomes suggests that planned elective surgery is beneficial to patients with sickle hemoglobinopathies.

Other medical management strategies include contact dissolution and biliary lithotripsy. Percutaneous transhepatic cholecystolitholysis involves the injection of a cholesterol solubilizer, such as methyl-tert -butyl ether, directly into the gallbladder.

The time between instillation and aspiration must be conscientiously limited to avoid leakage into the bile duct, causing abdominal pain and duodenitis. This method has been successful in a few children. Biliary lithotripsy has also been used with limited success. Similar to lithotripsy for nephrolithiasis, biliary lithotripsy uses shock waves to pulverize gallstones. Biliary lithotripsy causes fragmentation in most patients but rarely causes complete dissolution. Because fragments may still cause biliary colic and cholecystitis, additional oral therapy may be necessary. All management techniques that involve leaving the gallbladder in situ have 1-year recurrence rates of approximately 10% and 5-year recurrence rates of approximately 50%.

Biliary dyskinesia is increasingly diagnosed in children, and these patients respond favorably to cholecystectomy. As opposed to the adult population, the incidence of complicated gallstone disease appears less common in children because most present with symptomatic cholelithiasis without active inflammation, accounting for the very low rate of ductal complications. For that reason, surgical treatment of gallbladder disease (laparoscopic cholecystectomy) is now considered the most acceptable treatment modality in pediatric patients.

Surgical Care

The surgical options available are open cholecystectomy (OC) and laparoscopic cholecystectomy (LC). Although OC was considered the criterion standard 20 years ago, the laparoscopic approach is now accepted as the criterion standard and preferred procedure in almost all cases. Advantages of the laparoscopic approach include reduced pain and hospital stay and improved cosmetic results and patient satisfaction. Some concern remains regarding the previously reported higher risk of bile duct injury. Acute inflammation of the gallbladder was a concern, but many authors now agree that acute cholecystitis is not a contraindication; however, the surgeon must be experienced and well skilled with laparoscopic techniques. In addition, conversion to OC can always be performed in difficult cases. 

Some authors assert that LC is ideal in infants and children and should be the procedure of choice. In this case, surgical experience with laparoscopy and with infants is a must. Wide spacing of cannulas is helpful in small children to allow for visualization and adequate working distance. Also, with conscientious surgical technique, some authors believe that bile duct injury can be minimized. In general, OC is reserved for conversion and cases of prior major abdominal surgery. OC is accomplished through a right subcostal incision or a transverse abdominal incision if a splenectomy is also indicated. Laparoscopic entry involves 4 ports: 2 subcostal, 1 subxiphoid, and 1 umbilical.

The surgical course is usually routine. Patients can be admitted to the hospital the day of surgery and discharged within 48-72 hours. The average postsurgical hospital stay after LC is 36 hours, whereas patients undergoing OC typically need to stay in the hospital for 3 days. Continue hydration until the patient can tolerate a regular diet, usually the morning after LC. In either procedure, it is recommended to observe the patient postoperatively for complications, including fever, jaundice, ileus, pancreatitis, bile leak, or urinary retention. Jaundice or continued right upper quadrant pain may signify a retained common duct stone or biliary injury and should be investigated using endoscopic retrograde cholangiopancreatography (ERCP) or hepatoiminodiacetic acid (HIDA) scanning as soon as possible.

Technique for laparoscopic cholecystectomy in children

The technique for laparoscopic cholecystectomy in pediatric patients is very similar to the one described in adult patients; however, a few variables must be considered.12,13,14

First, the trocar placement is determined by patient size and position of the gallbladder and the liver. The authors usually start by placing a 12-mm trocar in the umbilical position. A small incision is made from the center of the umbilicus inferiorly, in order to expose the midline fascia at the umbilicus. Local anesthetic is infiltrated at that site. 

The authors' preferred approach is to place a STEP trocar (Covidien Surgical; Mansfield, MA) through that site using a Verees needle technique. Starting with a 5-mmSTEP trocar is recommended and, once the peritoneal cavity is insufflated with CO 2 , the trocar is upgraded to a 12-mm STEP placed through the same sleeve as the 5-mm trocar.

Typically the peritoneal cavity is insufflated with CO 2 using the following pressure limits: 
  • Teenaged patients who are obese - 16 mm Hg
  • Normal-sized, healthy teenaged patients - 14 mm Hg
  • Patients aged 8-12 years - 12 mm Hg
  • Patients younger than 7 years - 10 mm Hg
If the patient had any previous abdominal surgery or is significantly obese, the authors prefer to use an open technique for the initial trocar placement. In such cases, creating an opening on the inferior aspect of the umbilicus until the muscle fascia and the linea Alba can be visualized is important. Stay sutures of 2-0 Vicryl are placed on each side of the muscle fascia, which is than opened under direct visualization. Additional Vicryl sutures may be needed in order to elevate the fascia until the peritoneal membrane can be visualized and entered.

Once the peritoneum is open, a 12-mm trocar can be inserted under direct visualization, and the peritoneal cavity is insufflated with CO 2 . The authors perform most LCs with a 5-mm, 30 º- angled laparoscope. However, in patients who are significantly obese, a 10-mm trocar should be used to perform the cystic duct dissection. This is primarily due to the fact that the small 5-mm laparoscope does not generate enough light inside the large abdominal cavity of a patient who is obese and may compromise the surgeon's ability to clearly visualize all vital structures surrounding the cystic duct. Considering that most complications related to laparoscopic gallbladder surgery occur during the dissection and exposure of the cystic duct, one should never work under poor light and inadequate visualization at that point of the operation. Beginning the procedure with the 10-mm laparoscope in place via the 12-mm trocar is fairly easy, as is changing to a 5-mm laparoscope once the dissection and exposure of the cystic duct and artery are completed.

Second, subsequent trocar placement in children must be determined individually once the gallbladder fundus is visualized with the laparoscope. A 5-mm trocar is typically placed in the subxyphoid region. Another 5-mm trocar should be placed in the mid-right upper quadrant of the abdomen (at the level of the mid-clavicular line) in such a way to allow the introduction of a laparoscopic instrument used to manipulate the neck of the gallbladder. This trocar is usually placed about 2 cm below the costal margin. However, in small children, it must be placed closer to the costal margin.

The last trocar should be a 5-mm trocar placed laterally in the right upper quadrant. This trocar is used for placement of a grasping instrument, such as a McKernan grasping-locking forceps, that is placed on the fundus of the gallbladder for retraction. For that reason, the trocar should not be placed too far from the costal margin. Once the gallbladder fundus is grasped, it must be displaced towards the patient's right shoulder, above the right lobe of the liver. This maneuver allows for exposure of the neck of the gallbladder. One assistant should keep the fundus of the gallbladder pushed towards the patient's shoulder region at all times. This elevates the neck of the gallbladder together with the cystic duct and artery, facilitating dissection and exposure.

The third important step is the exposure and dissection of the neck of the gallbladder. If significant inflammatory changes are identified, the authors prefer to perform an intraoperative cholangiography to help define the anatomy of the cystic duct and its relationship to the gallbladder and common bile duct. The authors prefer to perform a cholangiography through the gallbladder. This can be easily performed by placing a percutaneous catheter in the gallbladder under laparoscopic visualization. The gallbladder is filled with water soluble dye, and radiographic images are obtained with live-fluoroscopy. This allows the surgeon to determine any points of biliary obstruction and if any evidence of common bile duct stones is present. In addition, it provides information about the length and relative location of the cystic duct, facilitating dissection and minimizing the risk of injury to the ducts.

The dissection for exposure of the cystic duct and artery is started at the neck of the gallbladder. Initially mobilizing the visceral peritoneum and any inflammatory adhesions away from the neck of the gallbladder is important. This can be easily performed using a hook with electrocautery. The authors usually have the surgeon manipulate the laparoscopic camera, with a hook or Maryland dissector in the right hand placed via the subxyphoid trocar. The assistant should be retracting the fundus of the gallbladder towards the right shoulder at all times and should also have a blunt grasper on the right hand to manipulate the neck of the gallbladder. This manipulation involves moving the neck towards the patient's right and left side, providing dynamic exposure for the surgeon. The assistant should never keep the neck of the gallbladder on a fixed and locked position.

Using careful dissection, the surgeon must achieve the so-called "critical view." This refers to the visualization of the cystic duct and artery as they enter the gallbladder. Dissecting towards the common bile duct and exposing the duct is not necessary. Once the point of entry of the cystic duct is clearly visualized on the gallbladder, the duct can be clipped and divided. The authors prefer to place one 5-mm clip on the cystic duct next to the gallbladder and two clips towards the common bile duct. Again, the dissection and exposure of the cystic duct is kept very close to the gallbladder, which should minimize the risk of injury to the common bile duct. The cystic artery can be simultaneously clipped with the cystic duct or can be separately clipped, depending on how close it is located next to the duct.

Completely dissecting the artery and fully exposing it is not necessary because this may lead to bleeding from small branches. In young children, cauterizing the artery is possible. Controlling the artery with a LigaSure or Harmonic scalpel is also possible. However, such devices are rarely necessary during LC. Once the cystic duct is divided with laparoscopic scissors, its lumen should be inspected to make sure that no evidence of any abnormalities suggests the presence of an injury to the common bile duct. At this point of the operation, the surgeon should use an electrocautery hook to divide the visceral peritoneum at the plane between the gallbladder and the liver. Again, the assistant moves the gallbladder back and forth, providing continuous exposure of that plane until the gallbladder is completely free.

If a hole is accidentally made in the gallbladder wall, the leakage of bile and gallstones can be controlled by placing the grasping instrument over the hole. Any stones that leaked should be removed using a suction irrigation device. Occasionally, a gallbladder is partially intrahepatic. In such cases, removing a wedge of liver tissue with the gallbladder is necessary. Electrocautery dissection at high settings should be enough for hemostasis. Once the gallbladder is completely disconnected from the liver, the authors move the laparoscope to the subxyphoid port and insert a 10-mm endopouch through the umbilical port. The gallbladder is placed inside the bag and brought into the trocar. In most cases, the gallbladder is too big to be removed through the 12-mm port. The authors prefer to enlarge the umbilical incision and expose the muscle fascia, which is than divided with electrocautery. This allows extraction of the pouch that contains the gallbladder. The fascia can than be reapproximated with Vicryl sutures. After the gallbladder is removed, the authors prefer to reinspect the liver bed to make sure that no evidence of bleeding or bile leaking is present. Any residual bile is suctioned. At this point, all trocars are removed under direct laparoscopic visualization, and the operation is completed. The fascia at the 5-mm trocar sites does not need to be closed, unless the patient is younger than 5 years.

Recent experience has demonstrated the feasibility of a mini-laparoscopic technique for removal of the gallbladder in pediatric patients. The laparoscopic operation can be achieved using 3-mm instruments and minimal use of ports. A 3-port mini-approach has been reported. However, remember that patient selection is essential when performing this operation with mini-instruments. One should not sacrifice good visualization and optimal exposure of the vital structures. The risk of iatrogenic injury to the common bile duct outweighs any benefit that can be achieved with mini-scopes and mini-instruments. Inflammation and adhesions, frequently seen in symptomatic patients, may limit the use of the mini-laparoscopic approach.

Consultations

Use a team approach to achieve proper care of the patient with cholecystitis. Consult a pediatric gastroenterologist and surgeon early in the treatment of the patient. The assistance of a dietitian may be very useful if observation without surgery is to be used. In addition, consulting a radiologist is helpful if percutaneous cholecystotomy is considered.

Diet

Dietary recommendations in gallbladder disease differ according to the stage of disease. The 2 available strategies include acute management and preventative measures. The patient with acute cholecystitis should receive NPO and undergo nasogastric evacuation of gastric contents. The goal in this stage of disease is to eliminate unnecessary stimulation to the biliary system and to reduce infectious exposure. Additionally, preparations can be more readily made for surgery.

No widely accepted dietary therapy exists for the prevention of cholecystitis; however, the contemporary Western diet and obesity have been implicated as predisposing factors in the development of gallstone disease. Certainly, diet and exercise are influential, and the West is infamous for poor dietary and exercising habits. In the Jamaican cohort study, Walker examined a population of patients with sickle cell disease similar to that examined by Winter et al in the United States. The progression of biliary sludge to cholecystitis and the need for cholecystectomy was significantly decreased in the Jamaican population. Walker theorized that dietary differences in the 2 countries were causal. These cultural influences affect the adolescent and adult populations.

Presumably, a decrease in cholesterol and fatty food consumption would lower risk of disease, but no specific data supporting this have been collected. Dietary restriction to achieve weight reduction may minimize risk in children with obesity. Weight loss should be controlled and gradual because rapid reduction may increase bile cholesterol saturation and gallbladder stasis, actually promoting stone formation. Dietary management of chronic gallbladder disease in the absence of surgery also follows this preventative approach with the added goal of preventing symptoms. Although biliary colic in children is less likely to directly correspond with fatty food consumption than in adults, still advise the patient to avoid high-fat meals. Finally, in patients with hyperalimentation-associated gallstones, administer low-dose enteral feedings, which may prevent stone formation by stimulating contraction of the gallbladder and reduction bile stasis.

Activity

Cholecystitis does not directly affect activity. Children should remain as active as their condition, comfort, and development allow. Postoperatively, activity recommendations correspond with the general precautions recommended abdominal surgery. Ambulation, as soon as tolerable, improves outcomes, although patients should restrict lifting to less than 5 pounds for several weeks.

Medication

Medical treatment of cholecystitis remains inadequate, especially in the pediatric population. The only treatments approved for use in children are open cholecystectomy (OC), laparoscopic cholecystectomy (LC), cholecystotomy, and endoscopic retrograde cholangiopancreatography (ERCP). The 2 oral medications that have been used with some success are chenodiol (chenodeoxycholic acid) and ursodiol (ursodeoxycholic acid). Both medications selectively inhibit hydroxymethylglutaryl-coenzyme A reductase (HMG-CoA reductase), thereby decreasing bile cholesterol supersaturation and lithogenicity. Chenodiol was shown to achieve complete dissolution of pure cholesterol gallstones in 15% of adult patients and partial dissolution in 28% of adult patients. However, the medications are expensive and cause adverse effects, including diarrhea and hepatotoxicity.

Combination treatment may be more effective and allow lower doses of each medication, causing fewer adverse effects. Although ursodiol was found to be unsuccessful in dissolving radiolucent gallstones in 10 children with cystic fibrosis (CF), it has been shown to increase hepatobiliary excretion and may be useful in a cytoprotective and preventative role.

Bile acids

Bile acids are used for the medical dissolution of cholesterol gallstones. Ursodiol and chenodiol both are orphan drugs and have been approved by the US Food and Drug Administration (FDA) for the dissolution of gallstones.


Ursodiol (Actigall, Urso)

Suppresses hepatic synthesis and secretion and intestinal absorption of cholesterol. Does not seem to significantly inhibit synthesis and secretion of endogenous bile acids or affect secretion of phospholipids into bile. Overall, increases concentration at which cholesterol saturation occurs and allows cholesterol to solubilize in an aqueous medium. Preferred over chenodiol because of its relative safety.

Adult

300 mg PO bid pc

Pediatric

30 mg/kg/d PO divided tid pc; not to exceed 600 mg/d
Adolescents: Administer as in adults

Bile acid sequestrants (eg, cholestyramine, colestipol) decrease absorption of bile acids; aluminum-based antacids may decrease absorption in a similar mechanism; estrogens, PO contraceptives, and clofibrate increase hepatic synthesis of cholesterol and can counteract effects

Documented hypersensitivity; calcified cholesterol gallstones, radiopaque gallstones, and radiolucent bile pigment stones (because of ineffectiveness)

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Hepatotoxicity not associated with ursodiol but has been related to other bile acids; monitor liver enzymes before use and during therapy; obtain ultrasonograms q6mo during therapy to monitor progress; adverse effects are rare; diarrhea is most commonly, noted in <1% of patients


Chenodiol (Chenix)

Acts in a similar fashion to ursodiol; however, its metabolite lithocholic acid is hepatotoxic and may cause hepatobiliary damage itself. Low-dose (<10 mg/kg/d) may actually increase the rate of cholecystectomy. Because of these effects, ursodiol is preferred.

Adult

Optimal dosage range: 13-16 mg/kg/d PO divided bid
250 mg PO bid for 2 wk initially; increase by 250 mg/d qwk until therapeutic doses achieved

Pediatric

Not recommended

Bile acid sequestrants (eg, cholestyramine, colestipol) decrease absorption of bile acids; aluminum-based antacids may decrease absorption in a similar mechanism; estrogens, PO contraceptives, and clofibrate increase hepatic synthesis of cholesterol and can counteract effects

Documented hypersensitivity; preexisting hepatobiliary dysfunction; calcified cholesterol gallstones, radiopaque gallstones, and radiolucent bile pigment stones (because of ineffectiveness)

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

May cause hepatotoxicity; mild transient elevations of aminotransferase, usually not associated with elevations in bilirubin or alkaline phosphatase, observed in 30% of patients; liver enzyme levels usually returned to normal within 6 mo, even with continued administration of the drug, however 2-3% of patients showed elevations of aminotransferase to 2-3 times normal and required therapy withdrawal
Patients with history of biliary pain before treatment have higher rates of cholecystectomy on low-dose chenodiol, but association not clearly causal; GI adverse effects most commonly include dose-related mild diarrhea, constipation, cramps, heartburn, nausea, vomiting, anorexia, dyspepsia, and flatulence; LDL levels may rise >10% with use, and a few patients showed mild decreases in WBC count

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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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