eMedicine Specialties > Pediatrics: General Medicine > Gastroenterology

Cholelithiasis

Author: Joshua R Friedman, MD, PhD, Assistant Professor of Pediatrics, University of Pennsylvania School of Medicine; Attending Physician, Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia
Coauthor(s): Melissa Crawford Kennedy, MD, Fellow, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia
Contributor Information and Disclosures

Updated: Apr 13, 2009

Introduction

Background

Gallbladder disease is one of the most common and costly digestive diseases that requires hospitalization in the United States. Gallbladder calculi are more common in the adult population and remain relatively uncommon in children; however, the incidence of cholelithiasis in children has recently increased. 

Transverse view of the gallbladder reveals multip...

Transverse view of the gallbladder reveals multiple stones, without gallbladder wall thickening, edema, or surrounding fluid accumulation.

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Transverse view of the gallbladder reveals multip...

Transverse view of the gallbladder reveals multiple stones, without gallbladder wall thickening, edema, or surrounding fluid accumulation.


Children may present with black pigment, cholesterol, calcium carbonate, protein dominant, or brown pigment stones. As in adults, treatment for simple cholelithiasis is largely symptomatic and laparoscopic cholecystectomy remains the criterion standard in treatment for symptomatic cholelithiasis.

Pathophysiology

Gallstones are typically classified as cholesterol, black pigment, and brown pigment stones; typically, only one type of stone forms at any given time. The distribution of gallstone types in children differs from the adult population with cholesterol stones being the most common type of stone in adults and black pigment stones being the most common type in children. Cholesterol stones are formed from cholesterol supersaturation of bile and are composed of 70-100% cholesterol with an admixture of protein, bilirubin, and carbonate. These account for most gallstones in adults but comprise only about 21% of stones in children.1  

Black pigment stones comprise 48% of gallstones in children. They are formed when bile becomes supersaturated with calcium bilirubinate, the calcium salt of unconjugated bilirubin. Black pigment stones are commonly formed in hemolytic disorders and can also develop with parenteral nutrition. Brown pigment stones are rare, accounting for only 3% of gallstones in children, and form in the presence of biliary stasis and bacterial infection. They are composed of calcium bilirubinate and the calcium salts of fatty acids and occur more often in the bile ducts than in the gallbladder. Calcium carbonate stones, which are rare in adults, are more common in children and account for 24% of stones in children. The remaining portion of gallstones in children are protein-dominant stones, which comprise about 5%.

The complications of cholelithiasis in children are similar to those in adults. Cholelithiasis primarily affects the gallbladder and may cause irritation of the gallbladder mucosa, resulting in chronic calculous cholecystitis and symptoms of biliary colic. If a gallstone obstructs the cystic duct, acute cholecystitis can occur, with distention of the gallbladder wall and possible necrosis and spillage of bile. If gallstones migrate from the gallbladder into the cystic duct and main biliary ductal system, further complications can occur such as choledocholithiasis, biliary obstruction with or without cholangitis, and gallstone pancreatitis.

Frequency

United States

Although gallbladder disease had traditionally been considered an adult condition, the prevalence has been rising in the pediatric population. A population-based study estimated the prevalence of gallstones and biliary sludge in children at 1.9% and 1.46%, respectively.2 This number seems to be increasing, and the true number of affected children may have previously been underestimated because patients with cholelithiasis can present with nonspecific abdominal pain.  Other factors affecting the increasing incidence of cholelithiasis in children include increased detection with increased use of ultrasonography, as well as the growing obesity epidemic.

The frequency of cholelithiasis in children with sickle cell disease is almost double that of the general population.3,4  Pigmented gallstones occur in approximately 50% of children with sickle cell disease by age 22 years.

Although approximately 80% of adults with gallstones were historically believed to be asymptomatic, more recent retrospective studies have found that only 33-40% of children are asymptomatic.

Mortality/Morbidity

The morbidity and mortality associated with gallstones are more commonly associated with cholecystitis or ascending cholangitis. The primary morbidity associated with uncomplicated cholelithiasis is chronic abdominal pain, which can be incapacitating.

Race

Although no racial predilection is noted, individuals of certain ethnic heritage have been identified to be at higher risk for developing gallstones, particularly the Pima Indians of North America and Scandinavians.

Sex

Prior to puberty, the sex ratio of cholelithiasis in children appears to be equal. However, after puberty, the frequency of cholelithiasis is significantly greater in females than in males and is comparable to the adult ratio of 4:1 female predominance.

Clinical

History

Gallstones in children are most commonly an incidental finding in patients with cholelithiasis but should be strongly considered in the workup of nonspecific intermittent abdominal pain with risk factors. Risk factors include chronic hemolysis, obesity, ileal disease, a family history of childhood gallstones, parity, and parenteral nutrition. Cholelithiasis should be considered in any symptomatic child with sickle cell or other hemolytic disease. Also, consider cholelithiasis in children with jaundice and low-grade elevations of transaminases. Older children may be able to localize their pain to the right upper quadrant (RUQ).

Physical

Perform a complete physical examination in children. Include auscultation, visualization, and, lastly, palpation of the abdomen in the examination. Pain in the RUQ is common. A Murphy sign (expiratory arrest with palpation in the RUQ) is thought to be pathognomonic. Also, note hepatomegaly and splenomegaly because they may be a clue to venous congestion or a hemolytic process that may be a predisposing factor for cholelithiasis. Obesity should also be noted on physical examination because this can be a risk factor for the development of cholesterol gallstones. Guidelines for the evaluation and treatment of childhood obesity have been established.5

Causes

Cholelithiasis in children has various causes related to predisposing factors. Hemolytic disease, hepatobiliary disease, obesity, prolonged parenteral nutrition, abdominal surgery, trauma, sepsis, and pregnancy all may lead to an increased incidence of gallstones in the pediatric population. Less prominent risk factors include acute renal failure, prolonged fasting, low-calorie diets, and rapid weight loss have been identified to increase the incidence of gallstones. Biliary pseudolithiasis, or reversible cholelithiasis, has been identified with the use of certain medications, primarily ceftriaxone.6

More on Cholelithiasis

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

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Further Reading

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Keywords

cholelithiasis, gallstones, gall stones, biliary colic, cholecystitis, choledocholithiasis, gall bladder calculi, gallbladder, chronic calculous cholecystitis, cystic duct, acute cholecystitis, biliary obstruction, cholangitis, biliary pancreatitis, chronic abdominal pain, stomach pain, treatment, diagnosis, pancreatitis, hemolytic disease, jaundice, splenomegaly, hepatomegaly, obesity, biliary pseudolithiasis, acute renal failure

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Contributor Information and Disclosures

Author

Joshua R Friedman, MD, PhD, Assistant Professor of Pediatrics, University of Pennsylvania School of Medicine; Attending Physician, Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia
Joshua R Friedman, MD, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association for the Study of Liver Diseases, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

Coauthor(s)

Melissa Crawford Kennedy, MD, Fellow, Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia
Disclosure: Nothing to disclose.

Medical Editor

Jorge H Vargas, MD, Professor of Pediatrics and Clinical Professor of Pediatric Gastroenterology, David Geffen School of Medicine, University of California at Los Angeles; Consulting Physician, Department of Pediatrics, University of California at Los Angeles Health System
Jorge H Vargas, MD is a member of the following medical societies: American Liver Foundation, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, and North American Society for Pediatric Gastroenterology and Nutrition
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 financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

B U K Li, MD, Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Director, Pediatric Fellowships and Gastroenterology Fellowship, Medical Director, Functional Gastrointestinal Disorders and Cyclic Vomiting Program, Medical College of Wisconsin; Attending Gastroenterologist, Children's Hospital of Wisconsin
B U K Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, and North American Society for Pediatric Gastroenterology and Nutrition
Disclosure: Nothing to disclose.

CME Editor

Steven M Schwarz, MD, FAAP, FACN, AGAF, Professor of Pediatrics, Children's Hospital at Downstate, SUNY-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 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; Centocor, Inc. Grant/research funds Independent contractor

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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