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Pediatric Gallstones (Cholelithiasis) Workup

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

Approach Considerations

The workup of cholelithiasis in pediatric patients is similar to that in adults. The goal is to demonstrate evidence of gall bladder or biliary tract disease. Laboratory tests should include a complete blood count, gamma-glutamyltransferase (GGT), amylase, urinalysis, direct and indirect bilirubin, alkaline phosphatase, and transaminase levels.

All laboratory results in simple cholelithiasis should be within reference ranges. They are of use in identifying more complex disease processes, including biliary obstruction and cholecystitis. Abnormal results on liver function tests or CBC count suggest infection, obstruction, or both.

Ultrasonography of the RUQ is the study of choice in patients with uncomplicated cholelithiasis. Plain radiography, radionuclide scanning, and cholangiopancreatography can also play a role in the assessment of cholelithiasis.

Go to Imaging in Cholelithiasis for more complete information on this topic.

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Abdominal Ultrasonography

Ultrasonography can be used to identify the location of the stone (as demonstrated in the image below, gallbladder wall thickening, the presence of gallbladder sludge, and pericholecystic fluid. Furthermore, an ultrasonographic Murphy sign (expiratory arrest with pressure from the sonographic probe in the RUQ) aids in the diagnosis of cholelithiasis.

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

Abdominal plain radiography in pediatric patients with cholelithiasis is seldom useful, because gallstones, with the exception of calcium carbonate stones, are not radio-opaque. However, radiography may be beneficial in identifying small-bowel obstruction or free air under the diaphragm.

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Radionuclide Scanning

Radionuclide scanning, such as with iminodiacetic acid (IDA) derivatives (eg, hepatoiminodiacetic acid [HIDA], diisopropyl iminodiacetic acid [DISIDA], and para-isopropyliminodiacetic acid [PIPIDA] scanning), is also used to assess gallbladder filling and bile excretion, particularly in response to cholecystokinin or a fatty meal.

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Cholangiopancreatography

In children with suspected hepatobiliary complications, magnetic resonance cholangiopancreatography (MRCP)[15] or endoscopic retrograde cholangiopancreatography (ERCP) can help delineate the anatomy of the extrahepatic and intrahepatic biliary tract, identify the presence of ductal stones, and provide a therapeutic mode of removing a stone or decompressing the biliary tract.[16, 17]

ERCP in the pediatric population has been associated with the same frequency of success and complications as in adults. As a noninvasive alternative, the MRCP has demonstrated promise in the evaluation of choledocholithiasis.

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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.

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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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