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Pediatric Gallstones (Cholelithiasis) Treatment & Management

  • Author: Melissa Kennedy, MD; Chief Editor: Carmen Cuffari, MD  more...
 
Updated: Nov 19, 2015
 

Approach Considerations

Treatment for simple cholelithiasis is symptomatic. Surgical removal of asymptomatic gallstones is currently not standard practice.

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Asymptomatic Patients

Expectant management with periodic clinical and ultrasonographic surveillance is appropriate for asymptomatic cholelithiasis.

An exception is in children with sickle cell anemia, in whom laparoscopic cholecystectomy is currently recommended for asymptomatic gallstones, in order to prevent potential complications of cholelithiasis, which tend to be more common in children with sickle cell anemia.[18]

Ursodeoxycholic acid therapy

Ursodeoxycholic acid can be useful in the medical management of cholelithiasis.[19] One study in which pediatric patients received 25 mg/kg/d of ursodeoxycholic acid for a median period of 13 months demonstrated resolution of clinical discomfort in 83.7% of patients. However, complete disappearance of gallstones was observed in only 7.2%, and the cholelithiasis recurred in 50% of these patients. All children did complete the therapy with no adverse effects.

Ursodeoxycholic acid has not been approved by the US Food and Drug Administration for use in pediatric patients. Nevertheless, it has a long history of use as adjunctive therapy in the management of adolescents with cystic fibrosis and in infants and children with hereditary cholestasis syndromes, biliary atresia, and cholestasis associated with parenteral nutrition.

The primary disadvantage with ursodeoxycholic acid therapy is the high incidence of gallstone recurrence. Therefore, this treatment is not recommended in patients with symptomatic cholelithiasis and is indicated only for patients either unfit or unwilling to undergo surgical intervention.

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Symptomatic Patients

Laparoscopic cholecystectomy is currently the criterion standard in the treatment of symptomatic cholelithiasis. It has been proven to be safe and effective in children, with a low rate of postoperative complications.[2, 20, 21]

One multicenter study reported recurrence of symptoms after cholecystectomy (postcholecystectomy syndrome) in only 4.7% of patients.

Indications for laparoscopic cholecystectomy in cholelithiasis include symptoms of biliary colic or chronic abdominal pain or the presence of cholecystitis.

Removal of the gallbladder in asymptomatic children with cholelithiasis is not standard practice, with the exception of those with sickle cell anemia. Laparoscopic cholecystectomy has also been demonstrated to be safe and effective in patients with sickle cell disease.[13] In addition, because gallbladder sludge is frequently documented in patients with sickle cell anemia and most patients with sickle cell disease who have biliary sludge go on to develop gallstones, elective cholecystectomy has been recommended for those patients with evidence of biliary sludge, with or without stones.

Surgical complications of laparoscopic cholecystectomy include common bile duct injury and bile leaks, as well as complications of hemolytic disease in patients who are at risk. Postoperative complications such as biliary tract obstruction tend to be more common in patients with sickle cell disease.[22]

Laparoscopic cholecystectomy with intraoperative cholangiography has demonstrated promise as an alternative to endoscopic retrograde cholangiopancreatography (ERCP) in patients with obstructive common bile duct stones (choledocholithiasis).[23]

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Diet

A decrease in the consumption of fatty foods and controlled weight reduction in patients with obesity may be effective in preventing the development of cholesterol stones.[7]

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Activity

In prospective cohort studies, Leitzmann et al found that an increase in exercise reduced symptomatic gallstones in women and men by approximately 20%.[24, 25] This reduction may be extrapolated to the pediatric population.

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Complications

Complications of concern include cholecystitis and ascending cholangitis.

With migration of gallstones from the gallbladder, through the cystic duct, and into the main biliary ductal system, more ominous complications may occur, including choledocholithiasis, biliary obstruction with or without cholangitis, gallstone ileus, biliary hepatitis, and biliary pancreatitis.

Postcholecystectomy syndrome involves the persistence or recurrence of symptoms experienced prior to surgery and may include new symptoms. The incidence of postcholecystectomy syndrome in children is not currently known.[6]

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Consultations

Consultation with a general surgeon is appropriate in patients with symptomatic cholelithiasis or with evidence of cholecystitis.

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Contributor Information and Disclosures
Author

Melissa Kennedy, MD Attending Physician, Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia

Melissa Kennedy, MD is a member of the following medical societies: American Academy of Pediatrics, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Coauthor(s)

Joshua R Friedman, MD, PhD Adjunct Professor of Pediatrics, Perelman School of Medicine at the University of Pennsylvania

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, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Received salary from Johnson & Johnson for employment.

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.

B UK Li, MD Professor of Pediatrics, Division of Gastroenterology, Hepatology and Nutrition, Medical College of Wisconsin; Attending Gastroenterologist, Director, Cyclic Vomiting Program, Children’s Hospital of Wisconsin

B UK Li, MD is a member of the following medical societies: Alpha Omega Alpha, American Gastroenterological Association, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

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

Jorge H Vargas, MD Professor of Pediatrics and Clinical Professor of Pediatric Gastroenterology, University of California, Los Angeles, David Geffen School of Medicine; 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, Latin American Society of Pediatric Gastroenterology, Hepatology & Nutrition, American Society for Gastrointestinal Endoscopy, American Society for Parenteral and Enteral Nutrition, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Alexandre F Migala, DO, Hildegardo Costa, MD, and Richard D Warren, MD, to the development and writing of the source article.

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